Needs assessment in long-term care: expression of national principles for priority setting in service allocation.

BACKGROUND: Long-term care services for older adults are characterised by increasing needs and scarce resources. Political strategies have led to the reorganisation of long-term care services, with an increased focus on "ageing in place" and efficient use of resources. There is currently limited research on the processes by which resource allocation decisions are made by service allocators of long-term care services for older adults. The aim of this study is to explore how three political principles for priority setting in long-term care, resource, severity and benefit, are expressed in service allocation to older adults. METHODS: This qualitative study uses data from semi-structured individual interviews, focus groups and observations of service allocators who assess needs and assign long-term care services to older adults in Norway. The data were supplemented with individual decision letters from the allocation office, granting or denying long-term care services. The data were analysed using reflexive thematic analysis. RESULTS: The allocators drew on all three principles for priority setting when assessing older adults' long-term care needs and allocating services. We found that the three principles pushed in different directions in the allocation process. We identified six themes related to service allocators' expression of the principles: (1) lowest effective level of care as a criterion for service allocation (resource), (2) blanket allocation of low-cost care services (resource), (3) severity of medical and rehabilitation needs (severity), (4) severity of care needs (severity), (5) benefit of generous service allocation (benefit) and (6) benefit of avoiding services (benefit). CONCLUSIONS: The expressions of the three political principles for priority setting in long-term care allocation are in accordance with broader political trends and discourses regarding "ageing in place", active ageing, an investment ideology, and prioritising those who are "worse off". Increasing attention to the rehabilitation potential of older adults and expectations that they will take care of themselves increase the risk of not meeting frail older adults' care needs. Additionally, difficulties in defining the severity of older adults' complex needs lead to debates regarding "worse off" versus potentiality in future long-term care services allocation. TRIAL REGISTRATION: Not applicable.

Service Allocators' Experiences of Ethical Dilemmas and Strategies in Long-Term Care: A Qualitative Study.

The provision of long-term care services for older adults is characterised by increasing needs and scarce resources, leading to ethical dilemmas. This qualitative study explored the ethical dilemmas experienced by healthcare professionals when allocating long-term care services to older adults and the strategies used to handle ethical dilemmas. Data from semi-structured individual interviews, focus group interviews, and observations of service allocators assessing needs and assigning long-term care services to older adults were analysed using content analysis. The overarching theme was the struggle for safe and equitable service allocation. The identified dilemmas were: (i) Struggles with A Just Allocation of Services due to Limited Time and Trust, (ii) Pressure on Professional Values Concerning Safety and Dignity, and (iii) Difficulties in Prioritising One Group Over Another. The strategies to deal with ethical dilemmas were: (i) Assessing Needs Across the Entire Municipality, (ii) Ensuring Distance to Service Recipients, (iii) Working as a Team, and (iv) Interprofessional Decision-Making. Scarce resources, organisational limitations, and political expectations drive the ethical dilemmas in long-term care service allocation. An open public discussion regarding the acceptable minimum standard of long-term care is needed to reduce the ethical pressure on service allocators.

Allocation of Adult Day Care Services to Different User Groups: A Register-Based Cross-Sectional Study.

The international policy of active ageing emphasises activities and social relations for long-term care recipients, for example through adult day care. Knowledge about who are allocated such services is, however, sparse. We aimed to investigate characteristics that contribute to determine allocation of adult day care for care recipients with and without dementia. This study selected all 250 687 individuals who received long-term care services on 31 December 2019 from the Norwegian Register for Primary Health Care. We added municipal level data from the Municipality-State-Reporting register and a national survey. Multilevel analyses comparing allocation of adult day care services to other services found that municipal clustering was around 20%. Care recipients who lived alone had higher odds of receiving adult day care, while the odds of receiving adult day care decreased as age increased. Disability level and gender were also significantly associated with allocation of adult day care, but in different directions for different user groups. As the unrestricted revenues of municipalities increased, the odds of allocating adult day care to people without dementia decreased. Other municipality characteristics did not significantly impact the allocation of adult day care. In conclusion, individual characteristics were more influential in allocation of adult day care than municipality characteristics, and the results uncovered clear differences between care recipients with and without dementia.

Forming Nursing Home Practices That Support Quality of Care for Residents. A Qualitative Observational Study.

Background: Residents of nursing homes are increasingly frail and dependent. At the same time, there are increased demands for quality of care and social life for individual residents. In this article, we explore how care workers contribute to quality of care and social life in shared living rooms in nursing homes. Methods: An ethnographically inspired design was applied, and a purposive sample of six units for long-term care in three nursing homes in Norway was included in the study. Data were collected by participant observation, including informal conversations with the staff and residents, and the data were analyzed using thematic analysis. Results: The analysis identified three main themes: working within the given context, creating care practices and organizing activities. The empirical findings demonstrate that care work focuses on meeting both the residents' physical and social needs and aiming for high-quality care and social life for the residents in nursing homes. Conclusion: The results of this study illustrate that nursing home practices are focused on residents as a group. However, care workers take advantage of personal skills and resources to work towards person-centred care within the given context. The quality of care is recognized in terms of how care workers meet individual residents' needs. The quality of care seems highly related to the capability and skills of individual care workers.

The influence of individual and municipality characteristics on allocation of long-term care services: a register-based cross-sectional study.

BACKGROUND: Variation in service allocation between municipalities may arise as a result of prioritisation. Both individual and societal characteristics determine service allocation, but previous literature has often investigated these factors separately. The present study aims to map variation in allocation of long-term care services and investigate the extent to which service allocation is associated with characteristics related to the individual care recipient and the municipality. METHODS: This cross-sectional study used register data from the Norwegian Registry for Primary Health Care on all 250 687 individuals receiving municipal health and care services in Norway on 31 December 2019. These individual level data were paired with municipal level data from the Municipality-State-Reporting register and information on the care models in Norwegian long-term care services, derived from a nationwide survey. Multilevel analyses were used to identify individual and municipal factors that were associated with allocation of home care, practical assistance and long-term stay in institutions. RESULTS: In total, 164 634 people received home care services and 97 380 received practical assistance per 31 December 2019. Furthermore, 64 404 received both types of home-based services and 31 342 people had a long-term stay in an institution. Increased disability was strongly associated with being allocated more hours of home care and practical assistance, as well as allocation of a long-term institutional stay. The amount of home care and practical assistance declined with increasing age, but the odds of institutional stay increased with age. Care recipients living alone received more home-based services, and women had higher odds of a long-term institutional stay. Significant associations between the proportion of elderly in nursing homes and allocation of a long-term institutional stay and more practical assistance emerged. Other associations with municipalities' structural characteristics and care service models were weak. CONCLUSIONS: The influence of individual characteristics outweighed the contribution of municipality characteristics, and the results point to a limited influence of municipality characteristics on allocation of long-term care services.

Modes and models of care delivery in municipal long-term care services: a cross-sectional study from Norway.

BACKGROUND: Numerous forces drive the evolution and need for transformation of long-term care services. Decision-makers across the globe are searching for models to redesign long-term care to become more responsive to changing health and care needs. Yet, knowledge of different care models unfolding in the long-term care service landscape is limited. The objective of this article is twofold: 1) to identify and characterise models of care in Norwegian municipal long-term care services based on four different modes of service delivery: Specialised municipal services, Assistive technology, Planning and coordination, and Health Promotion and Activity, and 2) to analyse whether the identified care models vary with regard to municipal characteristics, more specifically 'population size' and 'income'. METHODS: We adopted a cross-sectional approach and used data from a web-based survey conducted in 2019 to identify and characterize models of care in Norwegian long-term care services, based on four modes of service delivery. The questionnaire was developed through a comprehensive review of national healthcare policy documents and previous research and amended in collaboration with a user panel. A set of questions from the questionnaire were used to create four modes of service delivery. Hierarchical cluster analysis was used to cluster the municipalities based on the mean scores of the modes to identify care models. RESULTS: In total, 277 municipalities (response rate 66%) completed the survey. The four modes made it possible to identify four care models that differ on the level of Specialised municipal services, Assistive technology, Planning and coordination, and Health Promotion and Activity. Additionally, the models differed regarding municipal population size (p < 0.001) and income (p = 0.006). CONCLUSIONS: We put forward a theoretical description of the variety of ways long-term care services are provided, offering a way of simplifying complex information which can assist care providers and policymakers in analysing and monitoring their own service provision and making informed decisions. This is important to the development of services for current and future care needs.

Quality of Municipal Long-Term Care in Different Models of Care: A Cross-Sectional Study From Norway.

The quality of care remains a critical concern for health systems around the globe, especially in an era of unprecedented financial challenges and rising demands. Previous research indicates large variation in several indicators of quality in the long-term care setting, highlighting the need for further investigation into the factors contributing to such disparities. As different ways of delivering long-term care services likely affect quality of care, the objectives of our study is to investigate (1) variation in structure, process and outcome quality between municipalities, and (2) to what extent variation in quality is associated with municipal models of care and structural characteristics. The study had a cross-sectional approach and we utilized data on the municipal level from 3 sources: (1) a survey for models of care (2) Statistics Norway for municipal structural characteristics and (3) the National Health Care Quality Indicator System. Descriptive statistics showed that the Norwegian long-term care sector performs better (measured as percentage or probability) on structure (85.53) and outcome (84.86) quality than process (37.85) quality. Hierarchical linear regressions indicated that municipal structural characteristics and model of care had very limited effect on the quality of long-term care. A deeper understanding of variation in service quality may be found at the micro level in healthcare workers' day-to-day practice.

Social and Gender Differences in Informal Caregiving for Sick, Disabled, or Elderly Persons: A Cross-Sectional Study.

Introduction: Informal caregivers are in increasing demand to provide care for sick, disabled, and elderly persons in the years to come, also in the Nordic welfare states. Informal caregivers can provide different types of care, such as personal care, supervision, and practical help, and previous research has shown that women take on a heavier care burden than men. However, structural differences in care tasks and caregiver burden in the Norwegian population is an under-researched area of study. Objective: The study objective is to explore different types of informal care and caregivers in the Norwegian population and assess how different types of caregivers are distributed across socio-demographic groups. Methods: A cross-sectional population survey was conducted in 2014. A random sample of 20,000 people above 16 years of age was drawn from the national population register. The net sample consisted of 4,000 individuals, giving a response rate of 20.2%. Data were collected using telephone interviews. We used descriptive statistics, crosstabulations with chi-square tests and multinomial regression analyses. Results: Fifteen and seven percent of the respondents reported that they regularly helped persons with special care needs outside and inside their own household, respectively. Women were more likely than men to give personal care, whereas men were overrepresented among caregivers providing practical help only. The mean age of caregivers providing practical help only was significantly lower than for caregivers providing personal care. Conclusion: Our results indicate that women take on a heavier care load, both by providing more personal care then men and in that they spend more time caring. It is important that nurses and other healthcare professionals in community care have knowledge about structures of inequality in informal caregiver tasks and burden so that they can better identify opportunities for improved coordination between formal and informal care.

Nurses' assessments of horizontal collaboration in municipal health and care services for older adults: A cross-sectional study.

Interprofessional and interorganizational collaboration is considered key to achieving high-quality care and positive patient outcomes, but there is limited research into how nurses working in nursing homes and home care services perceive collaboration with other municipal health and care service providers and how their assessments of collaboration vary with individual characteristics and context. The objective of this study was to map variation in nurses' assessments of horizontal collaboration with core care services for older adults, specifically nursing homes, home care services, general practitioners, the allocation office and physio- and occupational therapy services. The study draws on findings from a nationwide cross-sectional survey on posthospital care for older adults, conducted among nurses working in nursing homes and home care services in Norway (N = 3717). Nurses were asked to assess collaboration with these five services. Independent variables were workplace, age, years at current workplace, part-time work, postgraduate education, and municipality size. Statistical analyses were conducted using descriptive statistics and analysis of variance (ANOVA). A majority of nurses evaluated horizontal collaboration as good. Collaboration with the home care services was evaluated as best, while collaboration with general practitioners was evaluated as least good. The study showed that workplace and municipality size were important for nurses' assessments of collaboration. Generally, nurses in smaller municipalities evaluated collaboration as better than nurses in larger municipalities. That workplace and municipality size impact on nurses' evaluations of collaboration in municipal care services for older adults is important knowledge for leaders and policy-makers aiming to improve patient care and teamwork.

Games of uncertainty: the participation of older patients with multimorbidity in care planning meetings - a qualitative study.

BACKGROUND: Active patients lie at the heart of integrated care. Although interventions to increase the participation of older patients in care planning are being implemented in several countries, there is a lack of knowledge about the interactions involved and how they are experienced by older patients with multimorbidity. We explore this issue in the context of care-planning meetings within Norwegian municipal health services. METHODS: This qualitative study drew on direct observations of ten care-planning meetings and an interview with each patient right after the meeting. Following a stepwise-deductive induction approach, the analysis began inductively and then considered the interactions through the lens of game theory. RESULTS: The care-planning interactions were influenced by uncertainty about the course of the disease and how to plan service delivery. In terms derived from game theory, the imaginary and unpredictable player 'Nature' generated uncertainty in the 'game' of care planning. The 'players' assessed this uncertainty differently, leading to three patterns of game. 1) In the 'game of chance', patients viewed future events as random and uncontrollable; they felt outmatched by the opponent Nature and became passive in their decision-making. 2) In the 'competitive game', participants positioned themselves on two opposing sides, one side perceiving Nature as a significant threat and the other assigning it little importance. The two sides negotiated about how to accommodate uncertainty, and the level of patient participation varied. 3) In the 'coordination game', all participants were aligned, either in viewing themselves as teammates against Nature or in ascribing little importance to it. The level of patient participation was high. CONCLUSIONS: In care planning meetings, the level of patient participation may partly be associated with how the various actors appraise and respond to uncertainty. Dialogue on uncertainty in care-planning interventions could help to increase patient participation.

Towards specialised and differentiated long-term care services: a cross-sectional study.

BACKGROUND: Numerous forces drive the evolution and need for transformation of long-term care services. During the previous decade, primary health care has assumed increased responsibility for developing and providing care services, but there is still limited knowledge about how European care service systems are evolving to address new tasks and patients. Based on data from Norwegian municipalities, this study aims to (1) describe the availability of specialised services in Norwegian nursing homes and home care services and (2) analyse whether structural factors, like population size and/or centrality, are associated with the availability of specialised services in nursing homes and home care. METHODS: This is a cross-sectional study of survey data. An online survey was designed specifically for this study. Its questions were developed from a comprehensive review of the literature and in partnership with a user panel. One representative from all of Norway's 422 municipalities were invited to answer the survey from February to April 2019. In total, 277 municipalities completed the survey (response rate 66%). Chi-square analysis and Fisher's exact test were used to test the associations between different categorical variables. RESULTS: Specialised care services were highly prevalent. For example, there were nursing home units specialising in dementia care (89%) and rehabilitation (81%) and home care teams for dementia care (79%) and reablement (76%). Approximately two-thirds of our sample were categorised as having high availability of specialisation in nursing home and home care services. The larger, more central municipalities had higher availability of specialisation compared to medium-sized and small, less central municipalities. CONCLUSIONS: Our study indicates that a majority of nursing homes and home care services provide specialised and differentiated services that serve patient groups of different ages and diagnoses. Municipalities' population size and centrality are associated with availability of specialised services in nursing homes and home care services.

The Development of a New Care Service Landscape in Norway.

Demographic changes, as well as the transfer of medical and caring tasks from specialist to primary care in Norwegian municipalities, have led to changes in care service delivery. So far, we have limited knowledge of how this affects the design of the care services. Based on a semi-structured questionnaire survey, this article presents the development of a new care service landscape in Norway, where municipalities increasingly set up specialized care services for different patient groups and their care needs. This leads to a continuum of care service models from a generalist approach to highly specialized care services. Larger municipalities typically have a higher degree of specialization, indicating that volume is an important prerequisite for specialization. Similarly, a higher degree of specialization corresponds to higher formal competencies in the workforce. To understand the development of the services and the impact on care service delivery, further research is required.

A nation-wide cross-sectional study of variations in homecare nurses' assessments of informational continuity - the importance of horizontal collaboration and municipal context.

BACKGROUND: Numerous studies have revealed challenges associated with ensuring informational continuity in municipal care services for older adults with comprehensive, prolonged and complex care needs. Most research is qualitative and on the micro-level. The aim of the current study is to map variation in homecare nurses' assessments of available information in the municipalities' documentation system and investigate the extent to which these assessments are associated with perceived quality of collaborations and with municipal context. METHODS: We used data from a nationwide web-based survey among 1612 nurses working with older adults (65+) in homecare services in Norway. Responses from individual homecare nurses were linked with municipal-level data from the public registers. Data were analysed with descriptive statistics and multilevel regression analyses. RESULTS: Information on the recipients' medications and medical condition was considered most often available (42.8 and 20.0% responding very often/always), whereas information related to psychosocial needs and future follow-up was perceived less available (4.5 and 6.7% responding very often/always). Homecare nurses' perceptions of the quality of collaboration with the GP and the allotment office were independently and positively associated with assessments of informational continuity (ß =0.86 and ß =0.96). A modest share of the total variation (8%) in assessments of informational continuity was at the structural level of municipality. Small municipalities (< 5000 inhabitants) had, on average, better informational continuity compared to larger municipalities (ß = -0.47). CONCLUSIONS: Documentation systems have a limited focus on long-term care needs of older care recipients beyond clinical and medical information. There is a potential for enhanced communication- and care-pathways between GPs, the allotment office and nurses in homecare services. This can support the coordinating role of homecare nurses in ensuring informational continuity for older adults with prolonged and complex care needs and help develop the facilitating role of (electronic) documentation systems.

Sharing responsibility: municipal health professionals' approaches to goal setting with older patients with multi-morbidity - a grounded theory study.

BACKGROUND: Recent health policy promoting integrated care emphasizes to increase patients' health, experience of quality of care and reduce care utilization. Thus, health service delivery should be co-produced by health professionals and individual patients with multiple diseases and complex needs. Collaborative goal setting is a new procedure for older patients with multi-morbidity. The aim is to explore municipal health professionals' experiences of collaborative goal setting with patients with multi-morbidity aged 80 and above. METHODS: A qualitative study with a constructivist grounded theory approach. In total twenty-four health professionals from several health care services in four municipalities, participated in four focus group discussions. RESULTS: Health professionals took four approaches to goal setting with older patients with multi-morbidity: motivating for goals, vicariously setting goals, negotiating goals, and specifying goals. When 'motivating for goals', they educated reluctant patients to set goals. Patients' capacity or willingness to set goals could be reduced, due to old age, illness or less knowledge about the health system. Health professionals were 'vicariously setting goals' when patients did not express or take responsibility for goals due to adaptation processes to disease, or symptoms as cognitive impairment or exhaustion. By 'Negotiating goals', health professionals handled disagreements with patients, and often relatives, who expected to receive more services than usual care. They perceived some patients as passive or having unrealistic goals to improve health. 'Specifying goals' was a collaboration. Patients currently treated for one condition, set sub-goals to increase health. Patients with complex diseases prioritized one goal to maintain health. These approaches constitute a conceptual model of how health professionals, to varying extents, share responsibility for goal setting with patients. CONCLUSIONS: Goal setting for patients with multi-morbidity were carried out in an interplay between patients' varying levels of engagement and health professionals' attitudes regarding to what extents patients should be responsible for pursuing the integrated health services' objectives. Even though goal setting seeks to involve patients in co-production of their health service delivery, the health services´ aims and context could restrict this co-production.

Structured Observation and Early Warning Scores in Long-Term Care.

With increased responsibility for follow-up of patients in long-term care, the importance of accurate observations are reinforced. Here, health care professionals experience with the use of structured observations guides are studied. The results are based on five focus group interviews. The health care professionals states that the tools gives them confidence in their care delivery, it's structures their actions and enhance communication. However, the implementing require competence, training and focus over time.

Hospital nurses' and physicians' use of information sources during their production of discharge summaries: a cross-sectional study.

Hospital nurses' and physicians' production and exchange of accurate information between levels of care are crucial for ensuring safe and seamless care for patients in transition. We report on a study in which we explored hospital providers' use of information sources when they prepared discharge information for colleges in the community health-care sector. In this cross-sectional study, 510 nurses and 236 physicians responded through a questionnaire. Our findings show that nurses and physicians use different information sources in patient records when they produce their discharge summaries.

Rapid spread in Norway of an erythromycin-resistant pneumococcal clone, despite low usage of macrolides.

During the last 4 years, Norway has experienced an increase in macrolide resistance among systemic isolates of Streptococcus pneumoniae. The Norwegian reference laboratory for pneumococci received the isolates from over 85% of the Norwegian cases of systemic pneumococcal disease in the period studied. To study the details of the increased macrolide resistance, all macrolide-resistant systemic pneumococcal isolates (410 isolates) collected in the period from 1995 to 2005 were characterized phenotypically, and a representative selection of 68 strains was also studied genotypically. The serogroups most frequently associated with macrolide resistance in the studied period were 14, 6, 23, 19, and 9. The resistance M-type was expressed in 85% of the resistant isolates. Of the 68 isolates analyzed by multilocus sequence typing, 19 different sequence types (STs) were represented, including several of the international resistant clones. All but one of the clones appeared at a low frequency; mainly as isolated cases. The increase in macrolide resistance seen from 2001 to 2005 proved to be caused by ST-9, defined as the England(14)-9 clone by the Pneumococcal Molecular Epidemiology Network. All ST-9 isolates tested, carried the mef(A) gene and expressed the resistance M-type. This clone first appeared in the Oslo region in 1993, but was by 2005 isolated from all over the country. Children were overrepresented among the cases caused by this clone; however, people aged 20-29, possibly involving the parent generation, were also represented at an increased frequency. The England(14)-9 clone has been able to spread successfully in the Norwegian population despite a relatively low consumption of macrolides.

Molecular characterization of non-penicillin-susceptible Streptococcus pneumoniae in Norway.

A total of 125 non-penicillin-susceptible Streptococcus pneumoniae isolates were received at the Norwegian Institute of Public Health in the period from 1995 to 2001. The strains were tested for antimicrobial susceptibility, serotyped, and genotyped by multilocus sequence typing (MLST); and their penicillin-binding proteins (PBPs) were typed by restriction fragment length polymorphism analysis of their pbp genes. Of the 125 strains, 48 (38%) were fully resistant to penicillin and 77 (62%) were intermediately resistant to penicillin. Most of the strains resistant to penicillin were also resistant to one or several additional antibiotics. The most frequent serotypes among the non-penicillin-susceptible strains were 14, 9V, 19F, 23F, and 6B. MLST analysis showed a high degree of genetic diversity among the 119 strains tested, with a total of 74 different sequence types. Six of the 26 internationally known resistant clones were present; the Spain(9V)-3 clone was the most frequent, with 19 isolates. A total of 74 (62%) of the isolates were related to 1 of the 26 international clones. Restriction enzyme analyses of the pbp1a, pbp2b, and pbp2x genes revealed 12, 12, and 19 different patterns, respectively; and a total of 43 different PBPs types were demonstrated. Our data indicate that the non-penicillin-susceptible strains in Norway are highly diverse genetically and that limited spread of the internationally known resistant strains occurred in the country in the period examined.