Health and social care planning in collaboration in older persons’ homes: the perspectives of older persons, family members and professionals

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Health and social care needs of older persons with multiple diseases are often extensive, complex and changing over time 1. Several different occupations are involved in the care, but the collaboration is not unproblematic 2. As care of older persons is increasingly provided outside hospitals and nursing homes, the interfaces between health and social care as well as between primary and community care have become an obstacle for an integrated care that fulfils the needs of older persons at home 6. Interprofessional care planning has been proposed to overcome the risk of fragmentation and to contribute to person‐centred care 3. To achieve person‐centred care and get a deeper understanding of the older person's situation, a dialogue between the older persons, family members and professionals is necessary 3. Previous research has problematised interprofessional collaboration 2, but there is less studies on how the older person themselves, their family members and the professional experiences the interprofessional care planning meetings in older peoples home. This study will therefore highlight these perspectives.
A number of different concepts concerning interprofessional care plannings are used: advanced care planning is used to describe end‐of‐life care, when the older persons no longer can make own decisions 8. Discharge planning is used to describe the planning for the care after discharge from the hospital 9. Other concepts describing plannings, at the hospital or in older persons’ home, are coordinated care planning 13, comprehensive care planning 14, family meeting 16 and care planning 17. In addition, a model for care and support planning aimed at adults with care and support needs was developed in UK in response to the requirements by the government 19. The UK model has much in common with a Swedish model under development although the latter is directed only at persons with complex health problems and many providers involved. In this study we used the term health and social care planning in collaboration (HSCPC) to highlight that this planning concerned both medical and social care needs provided by professionals representing different occupations and organisations. The HSCPC was organised as a meeting that focused on dialogues between older persons, their family members and different professionals in older persons homes. Research concerning care plannings has also varied and the study foci has been; the content of the plan 14, the collaboration between health care professionals 2, the meeting13 and older persons needs as expressed by themselves 12. Since planning the care at the hospital is not optimal, initiatives have been taken to perform the discharge planning at home a few days after discharge 2. However, little research has focused differences and similarities between older persons’, family members’ and professionals’ views on the care planning meeting at home.
In Sweden, organisational affiliations vary, physicians belong to primary health care, while social workers, homecare aides, registered nurses and rehabilitation therapists are employed by the municipality. As professions and organisations have their own legislations, values, responsibilities and budgets 3, this system carries the risk of fragmentation and lack of continuity 4. The integration between health and social care for older persons is challenging. In a study 23 strategies to develop integrated care in nine European countries were investigated, and it was pointed out that some strategies were provided in standalone organisations while others were cross‐agency integration initiatives. The problem with improving the interface between health and social care has been described as ‘one of the most prominent shortcomings in European health and welfare systems’ 26. Lack of common legislation and joint budgets are barriers to an integrated service delivery 23.
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