Age-appropriate elder care recipients? Care manager's categorisation practices in intraprofessional case conferences.

Age categories are related to perceptions and norms concerning appropriate behaviour, appearances, expectations, and so forth. In Sweden, municipal home care and residential care are commonly referred to as "elder care", primarily catering to individuals in their 80s or 90s. However, there is no set age limit reserving these services for an older age group. In intra-professional case conferences, care managers convene with colleagues to discuss care needs and eligibility for elder care services. Despite their significance, these conferences have received limited scholarly attention. The aim of this study was to analyse how care managers categorise persons based on age in intra-professional case conferences when discussing care needs and appropriate support to meet these needs. The study utilised data from 39 audio-recorded case conferences involving the discussion of 137 different cases, which were analysed using discourse analysis. Our findings showed that chronological age was frequently made relevant and applied in discussions about the appropriateness of usual elder care services. Four themes emerged, representing how the care managers implicitly and explicitly categorised clients of different chronological ages as typical/normal or atypical/deviant in these discussions: the "too young", the "not-so-old", the "old", and the "extraordinarily old". The findings contribute to research on ageing by demonstrating that, in an elder care context, being categorised as atypical/deviant (in terms of being younger) may be more beneficial than being seen as a normal or older elder care recipient. This underscores the importance of further research on the impact of informal age categorisations of clients on actual decisions about welfare services.

Ethical challenges causing moral distress: nursing home staff's experiences of working during the COVID-19 pandemic.

OBJECTIVE: To investigate the experiences of healthcare staff in nursing homes during the COVID-19 pandemic. DESIGN: Individual interviews. Latent qualitative content analysis. SETTING: Ten nursing homes in Sweden. SUBJECTS: Physicians, nurses and nurse assistants working in Swedish nursing homes. MAIN OUTCOME MEASURES: Participants' experiences of working in nursing homes during the COVID-19 pandemic. RESULTS: Four manifest categories were found, namely: Balancing restrictions and allocation of scarce resources with care needs; Prioritizing and acting against moral values in advance care planning; Distrust in cooperation and Leadership and staff turnover - a factor for moral distress. The latent theme Experiences of handling ethical challenges caused by the COVID-19 pandemic gave a deeper meaning to the categories. CONCLUSION: During the pandemic, nursing home staff encountered ethical challenges that caused moral distress. Moral distress stemmed from not being given adequate conditions to perform their work properly, and thus not being able to give the residents adequate care. Another aspect of moral distress originated from feeling forced to act against their moral values when a course of action was considered to cause discomfort or harm to a resident. Alerting employers and policymakers to the harm and inequality experienced by staff and the difficulty in delivering appropriate care is essential. Making proposals for improvements and developing guidelines together with staff to recognize their role and to develop better guidance for good care is vital in order to support and sustain the nursing home workforce.

The COVID-19 pandemic has affected both patients and staff in nursing homes, in Sweden and worldwide.Our study highlights that during the COVID-19 pandemic, nursing home staff encountered several ethical challenges which caused moral distress.Moral distress stemmed from not being given adequate conditions to perform their work, thus not giving the residents appropriate care.Moral distress could also originate from nursing home staff's feeling of being forced to act against their moral values.

Trustful conversations: a qualitative interview study on older patients' experiences of the intervention Proactive healthcare in a Swedish primary care setting.

AIM: To explore older patients' experiences of the intervention Proactive healthcare for frail elderly persons. BACKGROUND: Previous research has indicated that continuity and good access to primary care can improve satisfaction in older people seeking care. However, little is known about the older patients' experiences in taking part of interventions aiming to enhance the care. METHODS: Individual interviews were conducted with 24 older patients who participated in the intervention Proactive healthcare for frail elderly persons, selected from nine Swedish primary care centres. Interviews were analysed using qualitative content analysis. FINDINGS: Older patients' experiences of the intervention involved five manifest categories: Ways of naming the elder care team, covering the older patients' lack of understanding regarding their connection to the team, and the need for clarity on this and on how the specialised care provided differed from conventional care; Availability, indicating how older patients associated easy access and a direct telephone number with a team nurse available at certain times with a sense of security; The importance of relations, covering how patients appreciated continuity in their personal and professional conversations with staff; A feeling of safety and trust, stressing the value of older persons attach to being given enough time, to be listened to and being recognised as people; and Finiteness of life, which refers to the difficulty of having end-of-life conversations and the need for experienced staff with personal knowledge of the patients. The latent theme Trustful conversations was created to give a deeper meaning to the content of the categories.Trustful conversations, created through good personal knowledge of patients and continuity of contact, engender a feeling of safety in older patients. Using elder care teams could result in a better quality of care, with increased satisfaction and feelings of security among patients, and a reduction in healthcare needs.

"I See What You Mean"-A Case Study of the Interactional Foundation of Building a Working Alliance in Care Decisions Involving an Older Couple Living with Cognitive Decline.

BACKGROUND: Social workers have a key role in needs assessment meetings with families dealing with dementia, providing information, support, and advocacy, while also assessing needs and making decisions about care services for several parties. These contacts are especially important during the introduction of home care services, where often the person has previously relied on informal support from relatives. The needs assessment process entails the involvement of all present parties, with the aim to reach a mutual agreement, a working alliance, regarding which services to apply for. PURPOSE: The aim of this case study is to explore how the participants, by means of different conversational practices, jointly create a working alliance between the different parties in one family. The study provides insights into the process of co-constructing a working alliance in the needs assessment process for elder care services. METHODS: This article addresses the process by which social workers build a working alliance in a multi-party conversation with a family living with cognitive decline; a meeting that lasted 50 min. In this case study, we benefit from an inductive and detailed conversation analytic methodology. The theoretical framework of working alliances in institutional interaction has informed the analysis. RESULTS: The findings illustrate how the social worker in this case study involves all parties in the decision regarding care services and explores the use of the conversational practices of mitigations, positive framing, adding information, and positioning, as a "we" achieve mutual agreement toward the end of several sequences. CONCLUSIONS: Drawing on the results of this case study, we argue that multi-party interaction involving relatives enables diversity in role-taking, where the professional, for instance, can pursue a more empathic role. Also, our results indicate that minimal agreement to a proposal is sufficient in a multi-party interaction involving clients with cognitive decline.

'Do you have a future when you are 93?' Frail older person's perceptions about the future and end of life - a qualitative interview study in primary care.

OBJECTIVE: To explore frail older persons' perceptions of the future and the end of life. DESIGN: Qualitative content analysis of individual semi-structured interviews. SETTING: Nine primary health care centres in both small and middle-sized municipalities in Sweden that participated in the intervention project Proactive healthcare for frail elderly persons. SUBJECTS/PATIENTS: The study includes 20 older persons (eight women and 12 men, aged 76-93 years). MAIN OUTCOME MEASURES: Frail older persons' perceptions of the future and end of life. RESULTS: The analysis uncovered two main categories: Dealing with the future and Approaching the end of life. Dealing with the future includes two subcategories: Plans and reflections and Distrust and delay. Approaching the end of life includes three subcategories: Practical issues, Worries and realism, and Keeping it away. CONCLUSION: This study highlights the diverse ways older people perceive future and the end of life. The results make it possible to further understand the complex phenomenon of frail older persons' perceptions on the future and the end of life.KEY POINTSThe study found that older persons described their future as contradictory- with a broad spectrum of approaches, where some wanted to deal with these subjects and others wanted to ignore them.•Older persons that consciously planned for the future had tactics that often were related to goals that functioned as motivators to live longer.•Those who adopted a more passive approach did not think about what the future might hold in terms of losing autonomy and deteriorating health.•Older persons that approached end of life in a more proactive way wanted to plan practical arrangements around death but often found it hard to address this issue with relatives.•Those older persons that had a more passive approach to end of life preferred not to think about those issues, and some explicitly stated that they did not want to address the final period of life.

Maneuvering the care puzzle: Experiences of participation in care by frail older persons with significant care needs living at home.

PURPOSE: Despite evidence that older persons want to be involved in care, little is known about how frail older people with significant care needs living at home experience participation in care provided by different stakeholders. This study investigates the experiences of participation in care by older people following their involvement in an intervention of a health care model called Focused Primary care (FPC). METHODS: Individual semi-structured interviews were conducted with 20 older persons in five municipalities in Sweden. RESULTS: The results show that older persons highlighted opportunities and limitations for participation on a personal level i.e., conditions for being involved in direct care and in relation to independence. Experiences of participation on organizational levels were reported to a lesser degree. This included being able to understand the organizational system underpinning care. The relational dimensions of caregiving were emphasized by the older persons as the most central aspects of caregiving in relation to participation. CONCLUSIONS: Primary care should involve older persons more directly in planning and execution of care on all levels. An ongoing connection with one specialized elderly team and a coordinating person in Primary care who safeguards relationships is important for providing participation in care for frail older persons with significant care needs living at home.

Proactive healthcare for frail elderly persons: study protocol for a prospective controlled primary care intervention in Sweden.

INTRODUCTION: The provision of healthcare services is not dedicated to promoting maintenance of function and does not target frail older persons at high risk of the main causes of morbidity and mortality. The aim of this study is to evaluate the effects of a proactive medical and social intervention in comparison with conventional care on a group of persons aged 75 and older selected by statistical prediction. METHODS AND ANALYSIS: In a pragmatic multicentre primary care setting (n=1600), a prediction model to find elderly (75+) persons at high risk of complex medical care or hospitalisation is used, followed by proactive medical and social care, in comparison with usual care. The study started in April 2017 with a run-in period until December 2017, followed by a 2-year continued intervention phase that will continue until the end of December 2019. The intervention includes several tools (multiprofessional team for rehabilitation, social support, medical care home visits and telephone support). Primary outcome measures are healthcare cost, number of hospital care episodes, hospital care days and mortality. Secondary outcome measures are number of outpatient visits, cost of social care and informal care, number of prescribed drugs, health-related quality of life, cost-effectiveness, sense of security, functional status and ability. We also study the care of elderly persons in a broader sense, by covering the perspectives of the patients, the professional staff and the management, and on a political level, by using semistructured interviews, qualitative methods and a questionnaire. ETHICS AND DISSEMINATION: Approved by the regional ethical review board in Linköping (Dnr 2016/347-31). The results will be presented in scientific journals and scientific meetings during 2019-2022 and are planned to be used for the development of future care models. TRIAL REGISTRATION NUMBER: NCT03180606.

Processing older persons as clients in elderly care: A study of the micro-processes of care management practice.

Elder care has undergone a marketization in recent years in which various models for care management have been introduced with the aim of making assessments efficient. This article investigates the effects the care management model has on resource allocation for home care when handling the requests of older persons in the needs assessment process. Sixteen tape-recorded assessment conversations with associated case-file texts were analyzed through discourse analysis. The results show that a managerialist thinking has had a partial impact on the assessment process where the documentation requirements have entailed bureaucratization in terms of the transfer that occurs from talk to text. The findings from the study nevertheless indicate that the assessment conversations have clear elements of an individual-centred perspective in which there is room for a care rational dialogue. This constitutes a welfare policy dilemma today. Providing for older people's requests should be on the basis of quality and an individual-centred perspective and care management has had a contrary effect in which focus is directed instead towards needs assessment and bureaucratic processes.

Handling the Dilemma of Self-Determination and Dementia: A Study of Case Managers' Discursive Strategies in Assessment Meetings.

In assessment meetings concerning care services for people with dementia, Swedish case managers face a dilemma. On the one hand, according to the law, the right to self-determination of every adult citizen must be respected, but on the other hand cognitive disabilities make it difficult to fulfill obligations of being a full-fledged citizen. In this article, we examine 15 assessment meetings to identify discursive strategies used by case managers to handle this dilemma. We also examine how these affect the participation of persons with dementia, and indicate implications of our study for social work practice and research.

Home care as a family matter? Discursive positioning, storylines and decision-making in assessment talk.

Home care arrangements for older people are coordinated via a client-centred assessment process. This article describes how storylines and discursive positioning are used among older people and their relatives when divergent opinions of care needs are expressed. Eleven assessment interviews were studied using discourse analysis. The results show that relatives and older people advanced three major storylines, and positioned themselves within them with respect to the need for help. These storylines were based on whether the persons viewed home care as an intrusion into daily routines and relationships, or as a complement and support in everyday life, or as a right. The content of the storylines and the ways in which positions were shaped within them illustrate how positioning is incorporated as part of the ongoing reflexive process in interaction in which participants form an image of the older person's needs. Assessments clarify the views of the participants on home care, but they also reflect the discourses that are prevalent in the aged care community and in society in general. The article raises questions about strengthening older people's participation in the decision making process and also whether a new communicative practice is needed for assessments, i.e., one that proceeds on the basis of a broader family perspective.