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Projekt Druckansicht

Koordination sozialer und medizinischer Dienste für ältere Menschen im internationalen Vergleich: wie Organisationen auf Vermarktlichung reagieren

Fachliche Zuordnung Empirische Sozialforschung
Förderung Förderung von 2017 bis 2022
Projektkennung Deutsche Forschungsgemeinschaft (DFG) - Projektnummer 370386280
 
Erstellungsjahr 2023

Zusammenfassung der Projektergebnisse

This project provides a cross-national analysis of coordination problems in healthcare and elderly care systems. We focus on four European welfare states with well-developed but differently institutionalized healthcare (HC) and long-term-care (LTC) systems: Germany, the Netherlands, Sweden, and Switzerland. The empirical data are drawn from official records and from interviews with major stakeholder organizations in the four countries. When reaching old age, many people become dependent on social support. Their opportunities and resources are limited in many cases. Potential support networks tend to decline. At the individual level, this lack of resources and capabilities in old age has always existed and was often more severe in the past. At the societal level, the high dependency of large groups of older people is a more recent phenomenon, which has been predicted in many ways, but arrangements to cope with the consequences of these challenges have not been made to a sufficient extent. Coordination between healthcare and long-term care systems is a major challenge in all mature welfare states, exacerbated by demographic aging. The number of people over the age of 80 has strongly increased and will continue to grow. Modern societies have realized the need of social care systems already in the early 1990s. The German social care system, for example, was institutionalized in 1995, more than a hundred years after the introduction of social health insurance. Of course, elderly care homes, home care, and other arrangements had been set up long before, and the poor houses dating back to the 18 th century provided shelter for many old and poor people (Alber, 1982; Bahle, 2007). Over a long time, the pressure to take political action grew. The burden on traditional forms of support, in particular the family, increased. At the same time, families’ capacities to care for older family members decreased. Women, who as partners, daughters and daughters-inlaw had shouldered much of the social care for family members for decades, increasingly entered the labor market. Their time resources therefore declined. Besides the family, the second institution responsible for fragile older people was the healthcare system. Older people sometimes spent longer time in hospital than medically necessary if they were not able to care for themselves but social or family care after the hospital stay could not be arranged. We do not address in this book, however, the great importance of religious associations, which for centuries have provided various services to older people. Today, many of these institutions, such as elderly care homes, are part of the long-term care system, and we include these associations and organizations in our analysis but without discussing their important historical role (see, for instance, Alber, 1982; Bahle, 2007). After the set-up of LTC systems, transitions of clients between different healthcare and social care organizations have remained critical junctures in the process of care. Examining these processes and the relationships between the organizations involved is at the core of this comparative book. These critical pathways can be analyzed from various angles, with the field of health service research being the most established one. The question of how this process is coordinated and which actors are mainly responsible for ensuring that individuals receive the right treatment at the right time has been less studied. And there are even fewer comparative studies that focus on studying the view of organizations with respect to this book’s guiding question of who is and should be responsible for coordinating the process of care for older people. Coordination is a structural challenge that requires an institutional answer. In general, and independent of the particular context of action, institutionalization processes are the result of problems that are not solved by existing institutions and are therefore externalized (Lepsius, 2017; Wendt, 2017). Externalization of care for older people to another context of social action always takes place when the care requirements cannot be met within the institution of the family. Processes of institutionalization and de-institutionalization always follow the change in values in the society. Values such as women’s rights, which include financial independence and labor market participation, reduce women’s time resources for the care of close family members. These changes are partly in conflict with values and beliefs that support the acceptance of traditional care within the family. Furthermore, it is uncertain whether these developments correspond to the wishes and needs of older people in need of care. A second phase of extensive institutional change started when services that did not involve medical care were increasingly externalized from the hospital. Long hospital stays were partly the consequence of a lack of care outside the hospital, so patients not in need of medical treatment often received social care in the hospital. The process of reducing the length of hospital stays already started in the mid-1970s, and this externalization process accelerated with the introduction of diagnosis-related group (DRG) systems, which began in most European countries in the 1990s (Schmid et al., 2010; Wendt, 2013). The pressure to develop new institutional solutions outside the healthcare system therefore increased. Social care systems, in contrast to healthcare systems, are not designed to cure and restore health. Values important to social care systems range from providing the basic needs of daily living to enabling older people to lead independent and self-determined lives. The value conflicts in the newly institutionalized social care systems have not yet been solved, and it is not predictable which values will finally prevail. A value of great importance for the institutionalization of social care systems is aging in place: the deep wish of most elderly to live in their homes until they die. Earlier discharge from hospital is therefore consistent not only with the economic forces that have increased with the introduction of DRG systems but also with the values and perceptions of the group of older people as well as of the society at large. Furthermore, older people have a strong desire not to become a burden on close family members. The institutionalization and professionalization of elderly care, therefore, seems to correspond to the changing values in modern societies. Besides discharge processes from hospital, we focus on home care. Both contexts of social action, the transition from hospital care to home care and integrated care of older people at home, require intensive, comprehensive, and flexible coordination. The needs and wishes of the people in care are highly diverse because they depend on patients’ social and health conditions as well as on their resources and potential support networks. Coordination is not only a question of better aligning the HC and the LTC system. The service package for elderly persons is complex even if provided within one single system. It usually combines social and health-related care as well as supplementary services such as housekeeping or meals-on-wheels, often provided by different actors operating in different regulatory contexts and at different times. The inherent complexity of these services is the key to understand why coordination is a problem in all countries. For this reason, it is insufficient to analyze coordination by exclusively looking at formal institutional arrangements or policies at the macro level. Coordination is in fact a set of practices that come into play during the process of active service provision. Analyzing the role of actors and how they respond to changing institutional structures is important to better understand how the coordination of HC and LTC services actually takes place in different countries. High coordination requirements can also be the consequence of institutional barriers established by previous institutions. For the long-term care system, these powerful institutions are the family and the healthcare system. In an institutional context in which support from family members is reduced, additional care outside the family is required at an early stage but without necessarily going beyond the quality of care provided within the family. Therefore, care workers with comparably low qualifications can potentially be employed, as it is the case with personal carers. Such developments increase the coordination requirements because these services need to be adjusted to services provided by more professionalized healthcare personnel. At the same time, semi-skilled social care workers will not be able to fulfill coordination tasks for which high qualifications are required. The HC system is a highly developed institution with established professions and hierarchies. For LTC systems, the institutional precedence of healthcare systems has assets and drawbacks. It is a possible advantage that the processes of care and their requirements, as well as the existing gaps and therefore the responsibilities of the LTC system, are largely predefined by the healthcare system. In principle, a precise identification of the tasks and responsibilities of the LTC system helps to assess the number and qualifications of the required LTC workforce. This assessment, however, is undertaken from the perspective of the HC system, which, with its focus on curing, follows different guiding principles than the LTC system, with its focus on caring. Other possible disadvantages of the institutional precedence of HC systems are related to often strict hierarchies in the field of healthcare, with the medical profession at the top. Institutional borders between HC and LTC due to different values and interests of the actors involved are further reinforced by different modes of financing. At the same time, the earlier developed HC system often seeks to expand hierarchies established in its own context of action toward the LTC system. An institutional core of many HC systems with relevance for LTC systems is the establishment of general practitioners as gatekeepers with comprehensive coordination responsibilities. If gatekeepers are institutionalized, they are—except in cases of emergency—the first point of contact and therefore the primary care doctors coordinate other healthcare services for their patients and, if necessary, transfer patients to specialist care inside or outside the hospital. Primary care doctors or primary care centers collect and coordinate much information with relevance to their patients’ health. In such an institutional context, which some of the countries studied here have set up, the GP is a potential candidate for coordinating care processes between HC and LTC systems. At the same time, healthcare systems in which the GP has a strong position often have lean hierarchies, and other professions such as nurse practitioners have been established. Higher levels of qualification among nurses have the effect that other professionals besides medical doctors can take over coordination tasks in HC and LTC. Interestingly, digitalization in healthcare and social care is often more developed in healthcare systems with strong primary care institutions and gatekeeping than in healthcare systems with free choice of doctors and direct access to different general practitioners and specialists (Bertelsmann Stiftung, 2018). Establishing an actor or organization with comprehensive coordination responsibilities, in this case the primary care doctor or center, seems to foster processes in which further coordination tools and responsibilities are defined. In our four-country comparison, we analyze whether this pattern can also be identified in infrastructures outside the healthcare system. Coordination of healthcare and social care services is not an end in itself. The primary goal is to harmonize processes of care in a way that they meet the wishes and needs of older people. Whether coordination is successful could be analyzed by studying older people’s satisfaction with existing services in HC and LTC. However, it is important to keep in mind that the target group and its particular needs, for instance in the case of dementia, are not easy to assess. Secondly, satisfaction studies have to take into account historically developed expectations (Wendt, Mischke, & Pfeifer, 2011), and therefore even highly effective systems sometimes generate lower levels of satisfaction than systems with lower quality that has improved in recent years. This is one reason why we decided to assess the responsibilities for coordination in the care process of older people through interviews with the organizations in charge of care. These expert interviews constitute the empirical basis of our comparative volume. This perspective also requires an understanding of the respective context, and higher quality service provision could also raise expectations by providers, with the result of negative assessments by organizations if progress is lacking. To be able to include and analyze different institutional contexts at the system level, we selected HC and LTC systems with common features but also specific institutional differences. In Germany, a health insurance system was established in which the medical profession has had a dominant position already in the early 20 th century. The healthcare system is characterized by a strict hierarchy, and other occupational groups are subordinated to medical doctors. The principle of primary care doctors with strong gatekeeping is not fully established, and the number of general practitioners is small compared to specialists. There is a strict separation, also in financial terms, between inpatient and outpatient healthcare, which negatively affects continuity of patient care already within the healthcare system. The LTC system has been institutionalized in 1995 according to the model of the health insurance system. The German LTC system is characterized by a large number of service providers that are small in size and compete with each other on the care market. At the same time, care of older people is influenced by conservative elements of the German welfare state. The family receives a high level of support, and in line with the principle of subsidiarity, mutual help within the family is fostered and demanded. The number of people working in the LTC system is comparatively small. On average, they are well qualified but without strong academization and without the possibility of reaching a professional level similar to medical doctors in the healthcare system. In the Netherlands, the healthcare system developed in parallel with the German one for many years. The primary care doctor model and gatekeeping, however, were institutionalized quite early. The primary care physician collects and forwards necessary information in the healthcare system and decides about necessary further treatments inside or outside the hospital. General practitioners not only have comprehensive responsibilities but are also large in number. The number of specialists is comparatively small, and they mainly work in hospitals, with only few working in an outpatient practice. In hospitals, inpatient and outpatient specialist treatment takes place, and if general medicine is involved, hospitals cooperate with primary care doctors or centers. The processes of patient transfer within the healthcare system are therefore less complex than in Germany. The LTC system in the Netherlands is financed from social insurance contributions for HC and LTC as well as other public and private resources, depending on the care provided. While residential care is mainly organized within the LTC system, home care is mainly financed by the health insurance funds and organized by district nurses, and home help services are financed and organized by the municipality. LTC personnel is on average well qualified. While in Germany none of the involved professions seems to be the obvious coordinator of HC and LTC services, in the Netherlands there are two: general practitioners in the HC system and district nurses in the LTC system. In Switzerland, private insurance was predominant in healthcare for many years. Since 1996, insurance is mandatory but is still mainly provided through private insurance companies and financed through per capita premiums with public subsidies in case of financial need. Health insurance today is strongly publicly regulated and since 2011 includes nursing care, but with capped benefits only. Since health insurance is mandatory and publicly regulated, the OECD counts most expenditure in this sector as public. And since nursing care benefits are capped, the share of private out-of-pocket payments in LTC is among the highest in the OECD. Nonetheless, the LTC sector is highly developed in terms of personnel and is also among the most professionalized systems in the OECD. Like in Germany, healthcare is dominated by specialists who, in outpatient care, primarily work in smaller units. Gatekeeping is supported by financial incentives, which is why the primary care doctor principle is more established than in Germany. Depending on the particular insurance contract, however, patients may have direct access to specialists and free choice of doctors. Within the healthcare system, coordination through primary care doctors, therefore, is restricted or rather depends on the insurance. In Sweden, the healthcare system is based on public organization and tax financing to a much larger extent. Gatekeeping and primary care doctors are firmly established, and these doctors have coordination responsibilities for processes of healthcare outside the hospital. Municipalities are not only responsible for primary care but also for organizing the LTC system. They manage the system at the local level and operate as first points of contact for persons in need. Services can be provided either directly as part of local social services or by private companies working on behalf of municipalities (contracting out services). Personal carers with comparatively low qualifications represent the vast part of LTC personnel. Primary care doctors and nurse practitioners in the HC system as well as higher qualified nurses in the LTC system could take over coordination tasks

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