MODELS OF CARE IN THE UNITED STATES, CANADA AND DENMARK Alan Johns

Abstract The recent introduction of new funding ar-

rangements in nursing homes in Australia combined with other changes arising out of the Nursing Homes and Hostels Review have significantly raised the level of debate on a whole range of issues concerning the care of. the elderly in this country. It is useful therefore, .to consider alternative models of care to that operating in Australia as a basis for improving our current continuum of care. The models chosen from the United States, Canada and Denmark all have assessment procedures that aim to reduce the need for early and inappropriate institutionalisation. The benefits are obvious in maintaining an elderly person in their own home and environment for as long as possible, given appropriate co-ordination of personnel involved in service delivery.

Introduction The Commonwealth Department of Community

Services Nursing Homes and Hostel Review’ has ushered in a new era in the care of the elderly in Australia.

Implied in the Review is a radical transference of funding from nursing homes, both capital and recur- ring, to hostels and home and community care. Whilst there is a broad consensus amongst service providers that this transference is both welcome and timely, there is certainly not a consensus about the degree to which this should occur. For example, how many more hostel beds at the ex-

pense of sufficient nursing home beds? How much home and community care at the expense of increased staffing in hostels as residents become more dependent as a result of persons being maintained longer in their own homes?

Combined with this scenario are the new funding ar- rangements for nursing homes in Australia which commenced on July lst, 1987. The two components of these new arrangements, Standard Aggregated Module (S.A.M.), consisting of infrastructure costs such as cleaning, laundry, catering and administra- tion, and Nursing and Personal Care (N.P.C.), con- sisting of nursing and paramedical staffing costs plus workcare costs (yet to be finalised), have created a uniform fee aimed at, according to the Com- monwealth, giving nursing home proprietors greater management flexibility to use resources effectively in the interests of residents and efficiency of the nursing home.*

Whether or not this flexibility is just another way of reducing Commonwealth funding without actually saying so, depends to a large extent on which State you come from. In Victoria, for example, a recent survey by Coopers, Lybrand and W.D. Scott indicates that between 60% and 70% of- deficit-financed nursing

homes will be adversely affected by the new funding arrangements.’

When one also considers the recent introduction of the Home and Community Care Program and the not so recent Regional Geriatric Assessment Teams, plus other initiatives by the Commonwealth, such as in- creasing resident participation in decisions affecting their lives, then it is easy to understand concerns as to whether we have got it or will get it ‘right’.

It is against this background that it may be useful to consider some alternative models of care operating overseas.

Whilst overseas models will always have peculiarly local characteristics which are not always easily transferable to Australia, it is important to look, learn and adopt where appropriate.

The models presented were ones that were found particularly interesting when visiting the United States, Canada, England, the Netherlands, Denmark and Sweden between June and September, 1985.

The three models chosen have parallels in that they endeavour to maintain an elderly person’s right to re- main independent for as long as possible, given ap- propriate services to achieve that aim. All of them have assessment procedures which reduce the need for early institutionalisation. All of them also rely on maximum co-operation between agencies and person- nel involved in service delivery.

1. Nursing Home Pre-Admission Screening Program,

2. Continuing Care Program, Manitoba, Canada 3. Denmark’s Integrated Approach to Long Term

The three models are:

Virginia, USA

Care

Virginia Nursing Home Pre-Admission Screening Program

This Program was established in May, 1977 by the Virginia State Department of Health. Major goals are to delay or avoid unwanted or inappropriate nursing home placements and to control Medicaid expen- ditures. Medicaid is a public-funded assistance scheme to low income earners. The Program was the first Statewide pre-admission screening and referral pro- gram in the United States. It is still used as a national model and has gained recognition both at the Federal and State legislative levels.

A pilot project was initially established.in 1976 in Virginia to test the need for a pre-admission screening program. Several problems were considered. These in- cluded:- the pressures placed on hospital discharge planners and local departments of ‘welfare by a com- bination of families, physicians and government re- quirements to find readily available funded services for elderly and disabled persons who could not con- tinue to live independently; and the fact that elderly

Australian Journal on Ageing, Vol. 6, No. 4. November 1987 19

and disabled persons and their families were often unaware of community based services. In addition, the fragmentation of community based services, and the difficulty of threading through the maze of communi- ty services were also a problem.

Analysis of these problems led State Medicaid staff to a possible solution; could a local interdisciplinary team review the appropriateness of nursing home placement prior to admission and thereby enhance the use of community based services for elderly and disabled persons? Such a team had to be knowledgeable about local resources that could be mobilised tQ meet the needs of the individuals screened.

The pilot project tested the basis for a nursing home pre-admission screening program. A Nursing Home Screening Certificate was developed for use in the pro- gram. The form was completed on each individual screened, and although simple in format, included medical, nursing and social information to create a picture of the ‘total’ person.

Screeniiig Committees Screening committees are the cornerstone of the

Program. These committees, situated within local health districts throughout the State, consist of a physician, a nurse, and a social worker from the local health or welfare departments. The committees work closely with other community agencies offering ser- vices to the elderly and disabled. In some areas, other agencies which participate on the committee include an area office on ageing, a mental health clinic, a private home health agency, a ministerial association. nursing homes, and homes for adults.

As stated earlier, the main purpose of the Program is to delay or avoid unwanted and/or inappropriate nursing home placements through evaluation and referral. This approach is based on the importance of individual needs and exploration of available com- munity services to meet those needs. Local screening committees are expected, therefore, to:-

(i) evaluate the medical, nursing and social con- ditions of the applicants;

(ii) decide what services are required; (iii) determine whether necessary services are

available in the community; (iv) make placement recommendations; and (v) refer the applicant to any required communi-

ty services. In reaching their decisions, committees are re-

quested to take into account the total person, in- cluding social, medical and emotional factors, formal and informal support systems, and quality of living circumstances. Nursing home admission only occurs if local services cannot support the person at home.

An important feature of the Program is that Medicaid reimbursement for a nursing home stay would only be paid if an applicant had been screened. Approximately 20% of all those screened since the Program’s inception have been not certified for nurs- ing home placement.

Program Benefits After eight years of operation, the general consen-

sus from officials I spoke to in Richmond (Virginia) was that the Program had achieved its aims. The Pro- gram was seen to be cost effective in saving the State approximately US$l ,OOO,OOO a year because of reduc- ed institutional costs through Medicaid payments. Benefits in social values were seen as very positive. In- appropriate and often unwanted nursing home placements have been delayed or avoided through bet- ter use of community resources. The emphasis placed on the human factor and the need for support and communication with other agencies are keys to the Program’s success.

Manitoba’s Continuing Care Program Manitoba has a population of one million people

spread over a vast province. Slightly more than half of the population live in Winnipeg. I visited four of the seven regions in Manitoba over a period of two weeks. After speaking to many officials during that period and observing at first hand the services provided to elderly persons, it is my belief that the continuing care program in Manitoba is an excellent model worthy of consideration for implementation in our own long term care program.

The Manitoba Continuing Care Program, created in 1975, is the oldest province-wide, centrally co- ordinated, universal home care program in Canada. The program is centrally administered and co- ordinated by the Office of Continuing Care establish- ed within the Department of Health but decentralized in delivery. Continuing Care Responsibility

The Office of Continuing Care has responsibility for the co-ordination, standards and policy recom- mendations for the Continuing Care Program, of which Home Care is one part and Personal Care Home Placement is the other. In Manitoba, it is possi- ble to assess a person for care, then to determine if care needs can be met most appropriately through Home Care or through placement in a Personal Care Home (Nursing Home). An integrated assessment pro- cedure, whereby the same people determine the level of placement required for entrants to Personal Care Homes; the designated alternative level of placement for Home Care clients were Home Care not available; and the amounts and types of s,ervices to be provided through Home Care, ensures a consistent standard of placement decision judgements throughout the range of the Continuing Care Program. This integrated pro- cess, which allows access to the Personal Care Homes or to Home Care only on the basis of assessed need and appropriateness of care, produces cost efficiencies in the system.

The Program is delivered through the Department’s seven regional offices, five rural health centres, plus the Winnipeg region, which includes four co- crdinating hospitals and what is called short term ser- vices (under 60 days) through the Victorian Order Of Nurses (similar to our Royal District Nursing Service).

20 Australian Journal on Ageing, Vol. 6, No. 4 . November 1987

Personal Care Homes are funded through the Manitoba Health Services Commission out of general revenue through what is called an insured service. Pro- prietary homes (about a quarter of all Manitoba’s nur- sing homes) are paid on a daily rate negotiated annual- ly. Residents pay a fixed fee, currently 70% of the old age pension. Assessment Responsibility and Care Plan

Whilst the Office of Continuing Care is responsible for the quality and standard of assessments for care in a Personal Care Home, the criteria for assessment are determined by the Manitoba Health Services Commis- sion. Both the Office of Continuing Care and the Commission are jointly responsible for general policy formation in respect to establishing priorities and management of waiting lists. Assessment, including clinical, health functioning and social functioning components, determines the care needs of applicants for Personal Care Home placement. The need for care in a Personal Care Home is determined by an assess- ment panel.

The Assessment Panel is a group of health profes- sionals responsible for assessing the need of in- dividuals for Personal Care Home placements. The panel would usually include a doctor, nurse, social worker and the Regional Continuing Care Co- ordinator. Wherever possible, the panel is held in the area where the applicant resides, includes a profes- sional who has had contact with the applicant and may also include a representative from Personal Care Homes in an area or region and/or others as ap- propriate. e.g. family. In one region visited, a representative from the Personal Care Home where a prospective applicant might be placed was always in- cluded on the panel.

No person may enter a Personal Care Home without the case being reviewed by the Panel. Continuing Care Case Co-ordinators are responsible for the co- ordination of assessments. They are also responsible for presenting the case at a panel where placement may be indicated, for working with the client/family through the assessment/placement process, including the monitoring for change and reassessment minimally every six months for those awaiting placement. The Regional Continuing Care Co-ordinator is responsi- ble, within formulated policy, for ensuring that assessments are completed, for the operation of the panel, for the performance of functions to ensure ap- propriate management of waiting lists and placement including authorisation of bed-holding and for the identification of needs arising in the region. The Regional Director, who oversees the whole program. is responsible for ensuring that policy as laid down by the Health Services Commission is carried out.

Once a person has been admitted to the program, a care plan is developed. The plan identifies the goals to be achieved and types of services required. If presenta- tion of a panel is necessary, then a review of both medical and social information is made. Approved ap- plicants are given two Personal Care Homes to choose

from. If forced to enter a different Home from that chosen, perhaps to free a hospital bed, or simply because a bed in the chosen facility might not be available, then they are put on a waiting list for the Home of their choice. Levels of Care

The assessment procedure also determines the in- dividual’s level of care. Level of care refers to a per- son’s degree of dependency on nursing staff time for activities of daily living, and basic nursing care to maintain functioning. Manitoba recognises four levels of nursing home care. Level 1 assumes that residents will need no more than 30 minutes of daily nursing at- tention. Level 2 aSsumes partial dependence on nurs- ing time for a minimum average of two hours per day. Levels 3 and 4 indicate maximum dependence on nurs- ing time for a number of designated categories and assumes nursing care of 3% hours per day.

Benefits and Outcomes A decade of the Continuing Care Program has in-

dicated that the average cost of providing home care services is considerably less than the average cost that institutional placement would have been for those clients placed in a nursing home if home care had not been available. Although the ratio of nursing home beds in Manitoba is relatively high (114 beds per lo00 persons aged 75 and over, 1983), this is due largely to the accrued excess of minimal-care Level 1 beds in facilities which are not suitable for more impaired clients. These Level 1 beds, we would call them hostel beds, are disappearing because of the increase of Home Care services enabling people to remain in- dependent. There is little doubt that professionals working in the field believe the program works. The key to the success of the program is adequate funding, clearly defined policies and goals, and co-ordination across the range of service providers.

Denmark: An Integrated Approach To Long-term Care

It was a pleasure to observe at first hand the very high commitment Danish authorities have towards aged care. Danish people expect and demand that their elderly be treated with respect and dignity and to be given at least the opportunity of having a choice of how they will spend the remaining years of their lives. Certainly, one of the reasons for this is the high rates of personal income tax Danish citizens pay compared to Australia. But it is a choice the Danes make, and despite a slow-down in the growth of the economy over the past decade, the will of the people is not to reduce substantially its commitment to care of the elderly.

The provision of services for the elderly in Denmark is a municipal obligation. Each municipality must work out a plan for the social and health needs of the area, including services for elderly people, for a five- year period. These plans are revised annually and sent to the National Board of Social Welfare in

Australian Journal on Ageing, Vol. 6, NO. 4. November 1987 21

Copenhagen which revises and comments on the plans before reporting back to the various municipalities. Generally, the plans do not have to be approved by the central authorities, but they form the basis for a dialogue between local and central authorities and provide the central authorities with an opportunity to contribute to the basis for local decisions by pro- viding, for instance, cross-municipal analyses and comparisons. The plans offer both local and central authorities better long-term possibilities of co- ordination.

Whilst I visited five municipalities, the Odense local authority area in the municipality of Funen was where I spent the majority of my time and, therefore, the following comments apply exclusively to that area. However, the thrust and general policies towards aged care in other municipalities are very similar. Odense Municipality

Odense had a population of 170,000, of whom 32,000 (19%) were over the age of 60 in 1985. The primary aim of the support system for the elderly is to assist them to continue to live in their own homes, or, where necessary, to offer a place in a nursing home or sheltered housing to those no longer able to remain at home.

Of the 32,000 aged 60 and over, 6% were in nursing homes 2% in sheltered flats and 17% were considered to be ‘.at risk’.

Odense has approximately 1200 home helpers visiting 4300 homes for up to six hours a day. Help is given with cleaning, cooking, shopping and ordinary care. A special evening service is provided to put frailer persons to bed. Home helpers undergo a seven- week training course before undertaking visits. In ad- dition to home help, 80 nurses give either nursing treatment or general care on the request of a doctor. About 4000 elderly people avail themselves of this ser- vice every year.

Elderly people are encouraged to live in their own homes for as long as possible. The general principle is that pensioners pay no more than 15% of their income on rent; subsidies in the form of rent support are available provided the dwelling meets with minimum standards and the recipient’s aggregate income is below a certain limit. Other important support systems include structural conversions and electronic surveillance systems.

Housing for elderly people in Odense revolves around a number of schemes. So-called ‘pensioner dwellings’ are small, compact, easy to manage flats, available at manageable rents. These are usually two- room flats of 60 square metres in size. The dwelling is made for handicapped people so that the person can stay in the same dwelling, even if considerable care needs arise.

Another form of housing is sheltered housing. These are self-containtd flats adapted for persons with permanent disabilities. There are around 500 flats of this nature. Usually, they are 65 square metres placed in groups of around 40 unitsrA call system is installed

in the dwelling which is linked to a central point where care is available 24 hours a day. This central point may either be within a complex, i.e. a room inside a com- mon area, or external, i.e. at a nursing home which services the individual dwellings.

The other form of housing is nursing homes. Ad- mission to a nursing home is dependent on screening by the local social services department’s assessment committee which includes a consultant in geriatric medicine. Both nursing homes and sheltered housing are extremely well furnished. Nursing homes are vir- tually all designed and funded to allow residents their own room. Residents are encouraged to furdish their room with their own furniture and personal posses- sions. All rooms are at least 13 square metres and have their own toilet and bathroom. The average age of residents is around 82 years, with an average life ex- pectancy of 32 months. Future Developments

What are likely to be future developments in the care of the elderly in Denmark? Whilst nursing homes and sheltered housing will continue to be an important part of long term care, official policy aims to reduce institutionalised elders from currently 6% down to 3% over the next decade.

One of the ways this will be achieved is through 24-hour home care. A research study in 1979 based around a 24-hour mobile care centre proved there were benefits both economically and in consumer satisfac- tion. The system, now expanded throughout Den- mark, works in the following way: subscribers are equipped with an emergency call set of a two-way communication model which is linked either with special 24-hour emergency offices at the municipal social service centre, at a nursing home, or at the local fire brigade. At all times, these central units are in con- tact via radio with a mobile care centre, a car complete with a nurse, assistant nurse and medical supplies. This is a 24-hour arrangement that runs according to a pre-determined schedule so that the clients can count on regular visiting hours unless the route is changed as a result of an acute call, registered via the call system. Danish Technology

Other forms of technology have also been used suc- cessfully over the past decade and will improve in sophistication. For example, alarm buttons in all rooms; horizontal strings which can be activated in places where people might fall. A passive system has also been developed. When a person steps on a thin mat, a clock will be zero-set. If a longer period elapses without the mat being stepped on than the period for which the clock is programmed, the alarm will automatically go off and the central security then pro- ceeds to phone the elderly person or, if necessary, will call. Another innovation is an alarm system which automatically opens door locks so that security per- sonnel can get in quickly in cases where the elderly per- son is incapable of opening the door. Marketing of ad- vanced telephone systems with automatic calls are also coming on to the market, as are T V telephones.

22 Australian Journal on Ageing, Vol. 6, No. 4. November 1987

This technology plus research justifies Danish claims to redcuce admissions to nursing homes. Not only is it cheaper, it is also offering a real alternative to Danish elderly persons in remaining independent with 24-hour care.

CONCLUSION The Danish model has messages for aged care ser-

vices throughout Australia. For policy implications under the Aged Or Disabled Persons’ Homes Act, a concerted effort should be made through long-term care agencies and other concerned organisations to urge the Commonwealth Government to both increase capital subsidies to allow more single rooms, and to in- crease the minimum size of rooms in nursing homes. These two issues would both decrease the degree of in- stitutionalisation, and increase the residents’ in- dependence and privacy. In terms of Home Care ser- vices, the Home and Community Care Program pro- vides real hope for the future and would allow some of the things that have been happening in Denmark for a decade to become a reality here in Australia.

In conclusion, there are elements in all of the three models presented that Australian service providers will be familiar with. The difference is, I would argue, that the co-ordination in these models, particularly Manitoba and Denmark, is far superior than here in Australia.

Whether or not the barriers to improved co- ordination can be broken down to give aged persons the sort of services they should have as their right, will depend on many factors. Those factors, and the reasons why they exist, are matters for further exploration.

Alan Johns Manager, South Port Community Nursing Home, Albert Park, Victoria.

FOOTNOTES

I . Department of Community Services. Nursing Homes & Hostels Review, A.G.P.S.. Canberra, May 1986.

2. Department of Community Services, Victorian Director, March 1987, Melbourne.

3. Coopers & Lybrand, W. D. Scott; Conrullancy Study On Nursing Home Coslr On Behalf Of The Voluntary Care Association of Vic- toria. April 1986, Melbourne.

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