Home help services in Sweden: responsiveness to changing demographics and needs

Revisiting the Nordic long-term care model for older people-still equal?

With the extensive long-term care services for older people, the Nordic countries have been labelled 'caring states' as reported (Leira, Welfare state and working mothers: the Scandinavian experience, Cambridge University Press, Cambridge, 1992). The emphasis on services and not cash benefits ensures the Nordics a central place in the public service model (Anttonen and Sipilä, J Eur Soc Policy 6:87-100, 1996). The main feature of this ideal model is public social care services, such as home care and residential care services, which can cover the need for personal and medical care, as well as assistance with household chores. These services are provided within a formally and professionally based long-term care system, where the main responsibility for the organization, provision and financing of care traditionally lays with the public sector. According to the principle of universalism (in: Antonnen et al. (eds), Welfare state, universalism and diversity, Elgar, Cheltenham, 2013), access to benefits such as home care and residential care is based on citizenship and need, not contributions nor merit. Also, care services should be made available for all and generally be used by all, with no stigma associated. Vabø and Szebehely (in: Anttonen (ed), Welfare State, universalism and diversity, Edward Elgar Publishing, London, 2012)) further argue that the Nordic service universalism is more than merely issues of eligibility and accessibility, in that it also encompasses whether services are attractive, affordable and flexible in order to meet a diversity of needs and preferences. However, recent decades have seen a continuous tendency towards prioritization of care for the most frail, contributing to unmet need, informalization of care and privatization in the use of topping up with market-based services. These changes have raised questions about increasing inequalities within Nordic long-term care systems. We investigate in the article what effect changes have for equality across social class and gender, for users and informal carers. The article is based on analysis of comparable national and international statistics and a review of national research literature and policy documents.

Determinants of home care utilization among the Swedish old: nationwide register-based study

Since the 1990s, Sweden has implemented aging-in-place policies increasing the share of older adults dependent on home care instead of residing in care homes. At the same time previous research has highlighted that individuals receive home care at a higher age than before. Consequently, services are provided for a shorter time before death, increasing reliance on family and kin as caregivers. Previous studies addressing how homecare is distributed rely primarily on small surveys and are often limited to specific regions. This study aims to ascertain how home care services are distributed regarding individual-level factors such as health status, living arrangements, availability of family, education, and socioeconomic position. To provide estimates that can be generalized to Sweden as a whole, we use register data for the entire Swedish population aged 65 + in 2016. The study's main findings are that home care recipients and the amount of care received are among the oldest old with severe co morbidities. Receiving home care is slightly more common among women, but only in the highest age groups. Childlessness and socioeconomic factors play a small role in who receives home care or not. Instead, the primary home care recipients are those older adults living alone who lack direct support from family members residing in the same household.

Care workers under pressure - A comparison of the work situation in Swedish home care 2005 and 2015

As in many Western countries, eldercare services in Sweden have changed dramatically over recent decades. Population ageing, ageing-in-place policies, pressures to contain costs and organisational reforms linked to New Public Management are challenging public home care. There is, however, limited knowledge about how the job content and working conditions have changed in the Swedish home care across this period. This article aims to analyse and compare the work situation in the Swedish home care in 2005 and 2015. The analysis is based on the international Nordcare survey and draws on the subsample of respondents working in Swedish home care 2005 and 2015 (n = 371). The data were analysed with bivariate and multivariate methods. The results suggest that, overall, the work situation of home-care workers was worse in 2015 compared to 2005. For example, those surveyed in 2015 reported meeting a larger number of clients per day, receiving less support from their supervisors, and having less time to discuss difficult situations with colleagues and considerably less scope to affect the planning of their daily work. Care workers in 2015 were also more mentally exhausted than those surveyed in 2005. In addition, the workers in 2015 experienced an accumulation of work-related problems. Deteriorating working conditions could be related to cutbacks and organisational reforms, and evidence suggests that home-care workers are paying a high price for ageing-in-place policies. Improvements of the work situation in home care are necessary not only to ensure the quality of care for older people, but also to ensure workers' well-being and to recruit and retain care workers, and thus, to meet the future needs for home care in an ageing society.

Spousal care-giving arrangements in Europe. The role of gender, socio-economic status and the welfare state

Spouses (and partners) are the most important source of care in old age. Informal care for frail spouses is provided by both sexes and across all socio-economic backgrounds and welfare policy contexts. There are, however, interesting differences as to whether spouses care alone, receive informal support from other family members or formal support from professional helpers, or outsource the care of their spouse completely. The present article contributes to the literature by differentiating between solo spousal care-giving and shared or outsourced care-giving arrangements, as well as between formal and informal care support. Moreover, we show how care-giving arrangements vary with gender, socio-economic status and welfare policy. Adding to previous research, we compare 17 countries and their expenditures on two elder-care schemes: Cash-for-Care and Care-in-Kind. The empirical analyses draw on the most recent wave of the Survey of Health, Ageing and Retirement in Europe (SHARE) data from 2015. Our results show that men have a higher propensity to share care-giving than women, albeit only with informal supporters. As expected, welfare policy plays a role insofar as higher expenditure on Cash-for-Care schemes encourage informally outsourced care-giving arrangements, whereas Care-in-Kind reduce the likelihood for informally shared or outsourced care-giving arrangements. Moreover, the influence of these welfare policy measures differs between individuals of different socio-economic status but not between men and women.

Horizontal and vertical targeting: a population-based comparison of public eldercare services in urban and rural areas of Sweden

The concepts of target efficiency can be used to assess the extent to which service provision is in line with the needs of the population. Horizontal target efficiency denotes the extent to which those deemed to need a service receive it and vertical target efficiency is the corresponding extent to which those who receive services actually need them. The aim of this study was to assess the target efficiency of the Swedish eldercare system and to establish whether target efficiencies differ in different geographical areas such as large urban, midsize urban and rural areas. Vertical efficiency was measured by studying those people who received eldercare services and was expressed as a percentage of those who received services who were functionally dependent. To measure horizontal target efficiency, data collected at baseline in the longitudinal population study SNAC (Swedish National study on Aging and Care) during the years 2001-2004 were used. The horizontal efficiency was calculated as the percentage of functionally dependent persons who received services. Functional dependency was measured as having difficulty with instrumental activities of daily living (IADL) and/or personal activities of daily living (PADL). Services included long-term municipal eldercare services (LTC). Horizontal target efficiency for the public LTC system was reasonably high in all three geographical areas, when using dependency in PADL as the measure of need (70-90 %), but efficiency was lower when the less restrictive measure of IADL dependency was used (40-50 %). In both cases, the target efficiency was markedly higher in the large urban and the rural areas than in the midsize urban areas. Vertical target efficiency showed the same pattern-it was almost 100 % in all areas for IADL dependency, but only 50-60 % for PADL dependency. Household composition differed in the areas studied as did the way public long-term care was provided to people living alone as compared to those co-habiting.

Changes in commitment to change among leaders in home help services

PURPOSE

The purpose of the this study was to explore the development of commitment to change among leaders in the home help services during organizational change and to study this development in relation to workload and stress. During organizational change initiatives, commitment to change among leaders is important to ensure the implementation of the change. However, little is known of development of commitment of change over time.

DESIGN/METHODOLOGY/APPROACH

The study used a qualitative design with semi-structured interviews with ten leaders by the time an organizational change initiative was launched and follow-up one year later. Thematic content analysis was used to analyze the interviews.

FINDINGS

Commitment to change is not static, but seems to develop over time and during organizational change. At the first interview, leaders had a varied pattern reflecting different dimensions of commitment to change. One year later, the differences between leaders' commitment to change was less obvious. Differences in commitment to change had no apparent relationship with workload or stress.

RESEARCH LIMITATIONS/IMPLICATIONS

The data were collected from one organization, and the number of participants were small which could affect the results on workload and stress in relation to commitment to change.

PRACTICAL IMPLICATIONS

It is important to support leaders during organizational change initiatives to maintain their commitment. One way to accomplish this is to use management team meetings to monitor how leaders perceive their situation.

ORIGINALITY/VALUE

Qualitative, longitudinal and leader studies on commitment to change are all unusual, and taken together, this study shows new aspects of commitment.

The importance of leadership style and psychosocial work environment to staff-assessed quality of care: implications for home help services

Work in home help services is typically conducted by an assistant nurse or nursing aide in the home of an elderly person, and working conditions have been described as solitary with a high workload, little influence and lack of peer and leader support. Relations between leadership styles, psychosocial work environment and a number of positive and negative employee outcomes have been established in research, but the outcome in terms of quality of care has been addressed to a lesser extent. In the present study, we aimed to focus on working conditions in terms of leadership and the employee psychosocial work environment, and how these conditions are related to the quality of care. The hypothesis was that the relation between a transformational leadership style and quality of care is mediated through organisational and peer support, job control and workload. A cross-sectional survey design was used and a total of 469 questionnaires were distributed (March-April 2012) to assistant nurses in nine Swedish home help organisations, including six municipalities and one private organisation, representing both rural and urban areas (302 questionnaires were returned, yielding a 65% response rate). The results showed that our hypothesis was supported and, when indirect effects were also taken into consideration, there was no direct effect of leadership style on quality of care. The mediated model explained 51% of the variance in quality of care. These results indicate that leadership style is important not only to employee outcomes in home help services but is also indirectly related to quality of care as assessed by staff members.

Horizontal and vertical target efficiency – a comparison between users and non-users of public long-term care in Sweden

The extent to which a system of services is in tune with the needs of the population can be expressed in terms of target efficiency, which includes horizontal target efficiency – the extent to which those deemed to need a service receive it – and vertical target efficiency – the corresponding extent to which those who receive a service actually need it. Vertical efficiency can be measured by looking only at those receiving services. To measure horizontal target efficiency in a population, one must have access to population surveys. Data were taken from the baseline survey of the Swedish National Study on Ageing and Care (SNAC study). The results show that more than 80 per cent of those dependent in personal activities of daily living in the studied geographic areas were users of public long-term care (LTC). Dependency in instrumental activities of daily living was identified as the most important predictor of using LTC. Vertical target efficiency was 83–95 per cent depending on age, gender and type of household, if need was defined as dependency in instrumental activities of daily living. It was considerably lower, 35–61 per cent when defined as dependency in personal daily activities. Overall, long-term target efficiency in Sweden must be regarded as high. Few persons who need public LTC services fail to receive them.

Long-term care: common issues and unknowns

All industrialized countries are grappling with a common problem—how to provide assistance of various kinds to their rapidly aging populations. The problem for countries searching for models of efficient and high-quality long-term care (LTC) policies is that fewer than a dozen countries have government-organized, formal LTC policies. Relatively new surveys focused on the elderly populations of about 25 countries could become the basis for research on which LTC policy design choices have desired outcomes for individuals and society and might be replicable in other countries. As in earlier decades when U.S. researchers created the Current Population Survey (CPS) modules and the Survey of Income and Program Participation to answer policy questions, researchers and policy analysts are now at a point where a concerted effort is needed to generate questions that international comparative research on LTC could answer as well as the data needed to address the questions.

Home care in Europe: a systematic literature review

BACKGROUND

Health and social services provided at home are becoming increasingly important. Hence, there is a need for information on home care in Europe. The objective of this literature review was to respond to this need by systematically describing what has been reported on home care in Europe in the scientific literature over the past decade.

METHODS

A systematic literature search was performed for papers on home care published in English, using the following data bases: Cinahl, the Cochrane Library, Embase, Medline, PsycINFO, Sociological Abstracts, Social Services Abstracts, and Social Care Online. Studies were only included if they complied with the definition of home care, were published between January 1998 and October 2009, and dealt with at least one of the 31 specified countries. Clinical interventions, instrument developments, local projects and reviews were excluded. The data extracted included: the characteristics of the study and aspects of home care 'policy & regulation', 'financing', 'organisation & service delivery', and 'clients & informal carers'.

RESULTS

Seventy-four out of 5,133 potentially relevant studies met the inclusion criteria, providing information on 18 countries. Many focused on the characteristics of home care recipients and on the organisation of home care. Geographical inequalities, market forces, quality and integration of services were also among the issues frequently discussed.

CONCLUSIONS

Home care systems appeared to differ both between and within countries. The papers included, however, provided only a limited picture of home care. Many studies only focused on one aspect of the home care system and international comparative studies were rare. Furthermore, little information emerged on home care financing and on home care in general in Eastern Europe. This review clearly shows the need for more scientific publications on home care, especially studies comparing countries. A comprehensive and more complete insight into the state of home care in Europe requires the gathering of information using a uniform framework and methodology.

Should the provision of home help services be contained?: validation of the new preventive care policy in Japan

Background

To maintain the sustainability of public long-term care insurance (LTCI) in Japan, a preventive care policy was introduced in 2006 that seeks to promote active improvement in functional status of elderly people who need only light care. This policy promotes the use of day care services to facilitate functional improvement, and contains the use of home help services that provide instrumental activity of daily living (IADL) support. However, the validity of this approach remains to be demonstrated.

Methods

Subjects comprised 241 people aged 65 years and over who had recently been certified as being eligible for the lightest eligibility level and had began using either home help or day care services between April 2007 and October 2008 in a suburban city of Tokyo. A retrospective cohort study was conducted ending October 2009 to assess changes in the LTCI eligibility level of these subjects. Cox's proportional hazards model was used to calculate the relative risk of declining in function to eligibility Level 4 among users of the respective services.

Results

Multivariate analysis adjusted for factors related to service use demonstrated that the risk of decline in functional status was lower for users of home help services than for users of day care services (HR = 0.55, 95% CI: 0.31-0.98). The same result was obtained when stratified by whether the subject lived with family or not. Furthermore, those who used two or more hours of home help services did not show an increase in risk of decline when compared with those who used less than two hours.

Conclusions

No evidence was obtained to support the effectiveness of the policy of promoting day care services and containing home help services for those requiring light care.