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Update From Modern Aging Singapore: Kickoff Workshop

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Modern Aging Singapore kicked off in the middle of August. So far, the program has seen active participation and support from aspiring entrepreneurs. About three hundred students, health practitioners, researchers, and members of the public attended the Kickoff Workshop held at the NUS I Cube Building Auditorium on the morning of August 15.

Attendees were treated to four presentations from experts in aging and business: Overview of Aging by Prof. Angelique Chan of Duke-NUS Graduate Medical School, Healthcare and Business by Dr. Jeremy Lim of Oliver Wyman, Home and Center Based Care by Dr. Ng Wai Chong of the Tsao Foundation, and Product Design for Seniors by Hunn Wai of design firm Lanzavecchia + Wai.

MA2Prof. Chan highlighted some key trends and statistics on aging in Singapore. One surprising point was the high prevalence of social isolation among seniors here. This finding spurred aspiring entrepreneurs to think of novel solutions to address this trend.

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Dr. Lim went on to outline the aging sector in terms of business potential. One suprising finding, according to theNational Center for Policy Analysis, is the average net worth in 2010 was 848,000 USD for sixty five to seventy four year olds and nearly seven hundred thousand dollars for those above seventy five. These figures encouraged aspiring entrepreneurs to enter the aging sector.

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Dr. Ng discussed the current status of home and center based care in Singapore. He highlighted specific needs in these care settings frequently used by seniors. This discussion allowed aspiring entrepreneurs to hone in on key areas of need and address these pain points. For example, some challenges in these settings include the quick and painless transferring of patients from bed to chair and vice versa, and increasing the time health practitioners can spend with seniors.

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Mr. Wai rounded off the presentations with insights from product and design perspectives. He introduced examples of good design for seniors, such as mixed use canes and walkers, or stylish back braces. This presentation especially inspired aspiring entrepreneurs to consider seniors’ lifestyles and tastes when introducing new product ideas.

In addition to expert presentations, attendees also heard two senior role models share their life experiences and lessons. Younger members of the audience seemed glad to hear the wise advice dispensed by the seniors. The kickoff event concluded with a networking lunch. Participants became so engrossed in conversations around aging that they lingered past the scheduled end time.

Currently, Modern Aging Singapore has progressed to the business curriculum and selection phase. The top twenty teams have been selected and paired with industry mentors to hone their business ideas. The twenty teams will soon be pitching at the semifinals judging event for the top six spots. Meanwhile, all participants of Modern Aging Singapore are able to access the same business and aging curriculum on the Modern Aging Online Learning Portal to continue learning and improving their business ideas. If you would like to access the Portal, please write an email request to info@modernaging.org.

Find out more about Modern Aging, at www.modernaging.org.

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TioHundra: How One Company Is Driving Innovation in Integrated Care

Mikael Thorberg, Sweden, has authored this blog post with Sofia Widén.

TioHundra main entrance

TioHundra main entrance

Our team at ACCESS Health International studies how countries deliver high quality and affordable elder care in Europe, Asia, and the United States. When we find promising and successful models, we analyze these models to understand their success. This blog post shares the results of one such study.

The healthcare sectors in many countries are innovating rapidly to meet the needs of aging populations. One of the most important opportunities in elder care is the development of new care models designed specifically to respond to the needs of an aging population. The elderly require care that is long term, integrated across multiple levels, and coordinated among different care providers. This care must be high quality, but it must also be affordable to the payers, be they individuals, insurance companies, or governments.

The ability to deliver on the promise of high quality, affordable elder care is no easy task, but many examples of promising models exist. In this blog post, we profile one such example: Care Company TioHundra, a public healthcare company in Sweden.

A Unique Model

TioHundra provides healthcare, homecare, and social care in Norrtälje, a city in Stockholm County. Throughout most of Sweden, counties oversee healthcare, and municipalities are responsible for providing homecare and social care. The two levels of government fund care separately and often do not communicate with one another, despite responsibility for the care of shared patients. At its formation, TioHundra took a unique approach to providing integrated care. Rather than attempting to coordinate care across multiple organizations and payers, TioHundra merged care providers and created its own payer. TioHundra now operates as one large healthcare and social care system, owned and managed jointly by the municipality and the county. This unusual merger represents one of the biggest regional reforms in Swedish healthcare in over twenty years. TioHundra is the largest employer in Norrtälje Municipality.

Information and Integration

TioHundra aims to integrate the entire care system in new and innovative ways. The objective of the company is to increase efficiency, quality, and safety while reducing the costs of care. As many as sixty people may be responsible for the care of a single elderly patient. Integration between hospitals and social care organizations enables TioHundra to overcome some of the friction and inefficiency that would inevitably result from large and uncoordinated care teams. One of the key benefits of integrated care is the relative ease with which information can flow between different care providers.

Healthcare providers use digital information systems to manage information about patients. Many counties and municipalities in Sweden use different digital information systems that are incompatible with each other. Likewise, a wide digital divide often exists between technologically advanced hospitals and traditional homecare organizations. The integrated structure of TioHundra enables different providers to access timely and accurate information about patients and their care plans. At this time, that information is in read only format. As a single, integrated provider, TioHundra is well positioned to introduce a single electronic health record system that allows different levels of access to different healthcare professionals. The company is exploring options to introduce such a unified system.

Technology alone will not improve the flow of information. Organizational integration is also vital to the seamless transfer of information. The leadership team at TioHundra works across organizational boundaries. A manager can pick up the phone, without hesitation, call another department manager, and immediately solve an issue. The focus at TioHundra is on patient care, not organizational boundaries. This focus on patient care is a crucial element of the integrated care model.

 

Norrtälje Hospital

Norrtälje Hospital

Payment and Incentives

A unified payment system is another key to the success of TioHundra and its integrated care model. Both Norrtälje Municipality and Stockholm County finance TioHundra, but the funds are channeled through a single entity. Elsewhere in Sweden, counties pay for healthcare through one avenue, while municipalities pay for homecare and social care through another. Payment through a single funder supports collaboration between healthcare providers and homecare and social care providers.

An integrated care system can also offer counties and municipalities the opportunity to explore payment models that reward positive health outcomes. The payment system should incentivize care providers to keep patients healthy. Dr. Peter Graf, Chief Operating Officer of TioHundra, recognizes this as an opportunity for improvement to the TioHundra integrated care model.

Many provider payment models encourage extensive care rather than positive patient outcomes. Currently, Stockholm County provides only sixty percent of reimbursements to providers based on capitation. Payments to providers based on capitation can encourage a focus on keeping patients healthy rather than delivering (and charging for) more care. The capitation rate of Stockholm County is the second lowest in Sweden.

It is relevant to question this model since, as Dr. Peter Graf puts it, “more care does not always result in better health outcomes”. An integrated care system is able to take a larger responsibility for patients, since it is a full service provider. An integrated care system along with the current technological development creates new opportunities to reward care organization based on health outcomes rather than on the number of services provided.

Challenges and Opportunities

The population of Norrtälje is aging even more rapidly than the population of Sweden overall. The lessons that Norrtälje Municipality and Stockholm County are learning through the innovations of TioHundra will provide valuable knowledge for anyone interested in the future of the Swedish healthcare system, elder care, and healthcare systems facing similar challenges.

Stockholm County and Norrtälje Municipality established TioHundra in 2006 as an experiment. The merger of healthcare, homecare, and social care at TioHundra is a complex process. The work of full integration is ongoing. Cultural differences across its component organizations add to the challenges of achieving full integration of care. TioHundra has had many successes, but the company is not without critics. Some areas of care have shown only limited progress toward full integration, and hospital readmission rates remain higher than desired. Until 2014, the company had been operating at a loss. Despite these challenges, TioHundra offers a living laboratory in which we can study the ongoing experiment in Norrtälje. The management team of TioHundra has shown a strong commitment to integrated care and sound financial management. The company broke even for the first time in 2014. We will keep an eye on TioHundra as the company continues to grow, continues to learn, and continues to improve how it provides integrated elder care.
Click here to download TioHundra Case Study: Part One.

Informal Child and Elder Care in Singapore: South Central Community Family Service Center

At ACCESS Health International, we like to feature good examples of community and elder care. A recent visit to the South Central Community Family Service Center in Singapore reveals a thriving space where different generations of neighbors visit, work, and play with one another.

The South Central Community Family Service Center is located in the southern part of Singapore. The Center is shown as a red dot on the map.

The South Central Community Family Service Center is located in the southern part of Singapore. The Center is shown as a red dot on the map.

The South Central Community Family Service Center is just one of many other Family Service Centers in Singapore. Family Service Centers are an important part of the “Many Helping Hands” approach of the Singapore government toward social services. The Many Helping Hands approach emphasizes the involvement of multiple sectors in providing for the social welfare needs of people. Family Service Centers are run by Voluntary Welfare Organizations and are supported by the Ministry of Social and Family Development, the National Council of Social Services, Community Chest, or the Singapore Totalisator Board [1]. This is one way the government supports and encourages care provision by nongovernmental entities.

The South Central Community Family Service Center is unique in one respect. In January 2013, the Center became an independent entity with its own board of directors. The mission of South Central Community Family Service Center remains the same: to promote the wellbeing and self reliance of families. The main focus is supporting lower income individuals and families in the Bukit Ho Swee, Henderson, Redhill, and Indus Road neighborhoods. Between 2013 and 2014, the Center managed an average of four hundred cases. Casework involves counseling or referral to specialized services. For example, children from families lacking in basic necessities may face challenges in schoolwork or dealing with classmates. Center staff can counsel children or their parents on managing these problems. Where necessary, families are referred to other services, such as specialized psychiatric help or financial aid.

The entrance was decorated with cheerful cartoon sheep to welcome the year of the sheep.

The entrance was decorated with cheerful cartoon sheep to welcome the year of the sheep.

Besides casework, another focus of the Center is community engagement. To this end, Center staff organize events to involve nearby residents and create community spirit. As the Center is located on the ground floor of a block of residential flats, it is accessible and open to residents in the neighborhood. Our visit took place during the Lunar New Year period. As seen in the photo, festive decorations lining the entrance created a welcoming and friendly atmosphere.

Outreach worker Erwin showed us around the Center. Erwin explained to us that a guiding principle for the Center and staff is community cooperation and participation. This principle is informed by the Asset Based Community Development approach to community work. This approach ensures sustainability because initiatives are driven by the residents themselves. Residents volunteer to help care for their neighbors’ elderly relatives or children. Residents worked together to plant a community garden full of useful medicinal herbs.

Residents take ownership of the community garden and bond while caring for the plants. (Photo: South Central Community Family Service Center)

Residents take ownership of the community garden and bond while caring for the plants. (Photo: South Central Community Family Service Center)

The Center is a collaborative environment. The community garden is a visible fruit of this collaborative environment. The garden had been an empty space in front of the Center. Center staff wanted to galvanize residents to work on a common project. Residents contributed ideas and voted for the winning project: a medicinal herb and vegetable garden. Because the idea came from residents, the garden has been adopted and cared for by residents.

Residents contribute ideas to keep the garden fresh and growing. Residents can vote for the next plant type by placing a marble in the respective bottle.

Residents contribute ideas to keep the garden fresh and growing. Residents can vote for the next plant type by placing a marble in the respective bottle.

In the picture above, one can see a board where residents can vote on the next plant type. At the time of visit, sweet potato leaf was the leading candidate. The board itself was constructed by hand by a resident who is a carpenter by trade.

The Request and Offer board matches community resources to areas of need.

The Request and Offer board matches community resources to areas of need.

Inside the Center hangs another board, where residents can request items or services they need, or post offers of items or services they can give. The platform helps match community resources to people who need them most.

Residents streamed in and out of the Center throughout our visit. Erwin pointed out a pair of young siblings playing games on the couch. Erwin told me the siblings come to the Center after school ends to wait for their parents to get off work. I also saw groups of elderly chatting with one another at tables and chairs. The open space created by the South Central Community Family Service Center helps with informal child and elder care as residents look out for and engage with one another.

Outreach worker Erwin, in gray, briefs volunteers on a house visit activity.

Outreach worker Erwin, in gray, briefs volunteers on a house visit activity.

Near the end of our visit, there was a briefing for a large group of about twenty five volunteers, both young and old. They were preparing to give out yusheng packs to shop owners and residents at the Lengkok Bahru neighborhood. This showcased lower income families and children as goodwill ambassadors as part of this “Lo Hei Outreach”. The yusheng salad is traditionally eaten during the Lunar New Year, and Lo Hei is the dialect term for tossing the salad. Family and friends gather to Lo Hei together, signifying prosperity and togetherness. The briefing was punchy and positive with the staff recognizing the contributions of volunteers.

The South Central Community Family Service Center is an example of successful informal community and elder care. The staff and volunteers have created an open venue where residents are encouraged to join community activities and contribute their talents. Can their model of community involvement and ownership be replicated elsewhere? For example, could elder care as a larger industry move toward being more community based and operated? Share your thoughts with us by leaving a comment.


1. The Singapore Totalisator Board, also known as Tote Board, manages the surplus funds generated by Singapore Turf Club and Singapore Pools. They channel funds in support of various causes in Singapore such as arts and culture, social services, community development, education, health, and sports.

A New Perspective: Design Thinking for the Elderly

This post is the first in a series of articles focused on design thinking and aging. In future posts, we will explore the use of personas in designing solutions for seniors. We will also address problems identified by seniors themselves.

Imagining the ecosystem surrounding seniors in Singapore. Examples given are not exhaustive.

Imagining the ecosystem surrounding seniors in Singapore. Examples given are not exhaustive.

Last week, the ACCESS Health Singapore team attended a DesignSingapore forum titled Rethinking Health and Wellness for the Elderly. Among the fresh perspectives and opinions shared at the forum, one point really stood out to us: Often, designers who design products for seniors view seniors as isolated individuals. In reality, the elderly live and interact with others in their families and communities, such as family members and health professionals. They engage others in their external environment multiple times throughout the day: when getting coffee, seeing their neighborhood doctor, seeing specialists at hospitals, visiting community centers, going to the supermarket, and even through online sites and discussion boards. Behind these interactions, or touchpoints, lie many higher level entities that share an active interest in the wellbeing of the elderly, such as ministries or charities.

This learning point came from applying design thinking and ethnography to aging. One principle of design thinking is that all design activity is social in nature. Ethnography aims to explore social phenomena from the point of view of the subject, in this case seniors. At the forum, videos were shown of interviews with various seniors and their caregivers. These seniors and caregivers were asked what challenges they faced in daily living. Beyond these answers, researchers also followed the seniors on their daily activities, like cooking and exercising, in true ethnographic fashion.

In one clip, a frail senior was shown cooking for himself. His legs are weak so he sits on his wheelchair at the stove. But this position is often low and awkward. Upgrading to an adjustable height chair could make cooking easier for him.

A video still showing a senior cooking. An adjustable height chair could make cooking easier. (Photo: DesignSingapore)

A video still showing a senior cooking. An adjustable height chair could make cooking easier. (Photo: DesignSingapore)

One woman interviewed in the video had left her job to care for her father full time. Even while providing fulltime care, she said, there are moments when she cannot be there, physically, to catch her father if he falls. Such personal examples peppered the forum, turning abstract issues into real and moving stories.

When we think of the people, places, and organizations seniors interact with, many opportunities come to light. One senior featured in the video had lost his leg to amputation due to diabetes. After being fitted with a prosthetic, he still found it tiring to navigate his neighborhood. He told the interviewers that he was truly glad to receive a motorized personal vehicle from a welfare organization. Some limitations remain. Narrow corridors and places without ramps are inaccessible to him. However, he is now able to take public trains and go shopping, everyday tasks that would have been nearly impossible before. The motorized vehicle has improved his quality of life. In this case, an organization found a solution that has allowed this senior to engage more with the people and places around him.

A motorized personal transport like the one pictured can help seniors unlock and explore more of their community and environment. (Photo: Free Images)

A motorized personal transport like the one pictured can help seniors unlock and explore more of their community and environment. (Photo: Free Images)

Engaging ethnography and design thinking for the elderly may seem unconventional. But some researchers acknowledge the benefit of taking into account social and environmental aspects of aging. A recent BMJ article reviewed existing ideas and concepts of Successful aging refers here to physical, mental, and social wellbeing in older age. The authors found that traditional conceptions of successful aging focused largely on individual bodily health. For example, the Activities of Daily Living scale tests a senior’s ability to complete a basket of self care tasks. These tasks include feeding, toileting, and grooming.

The authors found in their review that psychosocial and external factors are important to successful aging too. Yet, the authors found that these factors are underrepresented in traditional models of successful aging. For example, the Activities of Daily Living scale does not measure social activities such as holding a conversation or enjoying a sport outdoors. The authors wrote, “[Successful aging] is clearly not simply a physiological construct, so it seems intuitive that psychosocial components should be included in otherwise biomedical models of [successful aging].” The authors concluded that conventional models for aging can benefit from including social and external components of seniors’ lives.

Design thinking and ethnography can be applied at all levels of the ecosystem surrounding seniors. Consider seniors, the people they interact with, the people and places they engage with, and the organizations that help support them. Imagine a senior living out a typical day in this environment. What gaps and opportunities do you see? Are there any potential collaborations between organizations? We feel these added perspectives will help craft more targeted, efficient products and solutions to help seniors.

Technology and Aging: Read the Interview and Learn what the Elderly Want!

ACCESS Health studies good examples of elder care in Sweden. In a series of group interviews, the Swedish team of ACCESS Health meets with a group of senior citizens to understand their needs. In this interview, the participants discuss technology, share their views on Swedish healthcare, and tell us about their experiences as informal caregivers. When they learned about the work of ACCESS Health, the participants volunteered for the focus group. The focus group participants live in the city of Eskilstuna, one hour southwest of Stockholm.

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The city of Eskilstuna is shown as a red dot on the map.

The blog post of this week is an extract from a group interview conducted on December 31, 2014 with Gudrun Bergström, eighty six, Gujje Byström, eighty nine, Inga Brehmer, eighty eight, and Ingrid Svahn, eighty five.

This is an insightful and fun read! Enjoy!

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Participants of the ACCESS Health technology focus group. From the left: Inga Brehmer, Gudrun Bergström, Ingrid Svahn, and Gujje Byström.

Interview

Inga Bremer (IB): My name is Inga Bremer. I am eighty eight years old. I am interested in technology. I own an iPad. I own a Doro telephone. [Doro is a company that developed a simplified mobile telephone for older users.] My Doro is easy to use. My Doro telephone is not a smartphone. Dora does develop smartphones for older consumers right now. I also own a laptop. I own other technical devices at home, such as a dishwasher and a washing machine. I also have a small automatic vacuum cleaner so that I do not need to vacuum constantly. I have three large flat screen televisions with over fifty channels. I would call myself mildly interested in technology.

Inga med devices

Inga Brehmer shows her Doro telephone and her tablet, which she uses to listen to the radio, to view emails, and to take pictures.

Gudrun Bergström (GB): My name is Gudrun Bergström. I am eighty six years old. I love technology. I am handicapped. I have poor eyesight. Technical solutions help me live with my sight impairment. I do not own a smartphone. I own a Doro telephone.

I have one of the newest stationary computers that you can buy. I use a magnifying software program that helps me increase the size of the text of the documents on my computer. I own an external hardware product. This hardware product helps me to magnify texts and images so that I can read and see the images better. This program is called Zoom Text.

I wear a watch that reads the time for me out loud. That is a great device. I have hearing aids. I also have three televisions. I use my three televisions. I have connected my television in the kitchen with an external hard drive so that I can record programs and store them.

Gudrun

Gudrun Bergström shows her enlargement hardware, her computer, and her tablet.

Text förstorare

The enlargement hardware allows Gudrun Bergström to read small print.

Sofia Widen (SW): Do you record a lot of television programs?

GB: Yes. It allows me to watch them when I want to watch the programs. It took some time to figure out how to record programs. Learning is a gradual process.

I buy technology products. The booklet with instructions is written in a small text. This is problematic. It is difficult for older consumers to read small text. I can read instructions with my magnifying program. My dream is that doctors will find a way to operate a new sight nerve into my eyes so that I regain my sight. We are not there yet.

SW: Do you use your computer to browse websites?

GB: I browse a lot of different websites. I disapprove of some things that people write on Facebook.

SW: Do you have a Facebook account?

GB: Of course. I am on Facebook.

SW: Are you active on other social media sites?

GB: No. I am not interested in blogging or in tweeting. I use Skype. I Skype with my family. I have a wireless internet connection in my apartment.

IB: We should have spoken before you, Gudrun. You have so many devices.

GB: I love technology. My husband was not interested in technology. I installed devices at home. I learn about new products. I want to buy them. More people my age ought to take an interest in technology. Technology can help the elderly.

Ingrid Svahn (IS): Technology is in your nature. Either, you understand technology or you do not.

GB: I disagree. Look at the young who adopt technology. Are they born with an ability to absorb technology quickly? I do not think so. The young set aside time to learn how to use the technology.

IS: My name is Ingrid Svahn. I just turned eighty five. My husband knew everything about technology. I never needed to learn. My husband passed away a few years ago. I use modern technology. I am not interested in technology. I had a computer. I threw it out when it crashed.

SW: What did you use your computer for?

IS: I served on the board of an organization. I used my computer to type out the minutes from our board meetings. I have a smartphone. I use my smartphone sometimes.

SW: How do use your smartphone?

IS: I play games. I like Alphabet and Scrabble. I will say, though, that like other retirees, I do not have time to play all these games. Many retired people I know say they are busy. I also feel that I am busy all the time. I also own televisions. I use a dishwasher and a vacuum cleaner.

I use a pen for my touchscreen smartphone. I do not have Wi-Fi. I access the internet through the mobile network. Other family members discuss what kind of technology I need. They discuss whether I should install Wi-Fi or not. I do not know how the discussion will end. I might buy a tablet.

Fokus grupp bild

From the left, Inga Brehmer with her Doro telephone and her tablet. In the middle, Gudrun Bergström, with her Doro telephone and her tablet. To the right, Ingrid Svahn with her smartphone.

GB: I recommend a tablet. Tablets are great. You can carry it around. You can carry a mobile phone of course. I would not compare the two products. A tablet is helpful for my reduced sight. I prefer a larger tablet.

Gujje Byström (GBO): I am eighty nine years old. I am not interested in technology. I own one television. I watch eleven channels. I dislike watching television during the day. I record my programs. I watch them in the evening.

From the left, Inga Brehmer with her Doro telephone and her tablet. In the middle, Gudrun Bergström, with her Doro telephone and her tablet. To the right, Ingrid Svahn with her smartphone.

GBO: I use hearing aids. I use a walker. The walker helps me when I shop. I can carry a lot of bags. I hang them on my walker. People pestered me to get a walker. I think it is wise to wait until you really need a walker before getting one. You become dependent on your walker. I could not manage to carry my groceries without my walker.

Rulator

This is the type of walker that the participants use.

I prefer to use a cane. I have a beautiful cane. I like my cane. I have had hip and knee surgery. After my surgery I decided to get a cane. There are flowers on my cane.

IB: I have a cane. My doctor prescribed the cane, so I obtained it for free. We buy technology such as canes and walkers. We buy them because we want nicer versions. In Sweden, you obtain technical aids from your doctor or from your municipal care organization. The devices are almost free or charge. You pay up to a fixed sum every year. This is a low sum. If you pay the fixed sum, you can obtain all devices that you need.

GB: We can discuss if you always obtain all the devices and all the aids that you need. I have a friend who requested two walkers. She was refused those two walkers. She wanted one robust walker for outside use in the snow. She wanted a smaller walker for use inside her apartment.

I returned the walker I was given for free. I bought my own walker. Look at my walker. I can lift it. It is light. [Gudrun demonstrates. She brings out her walker to the focus group.]

GBO: Those walkers are expensive. You made an investment.

GB: I can carry up to seven bottles of wine with this walker!

SW: Can you use the walker with thin wheels outside in the snow?

GB: If it is that snowy I do not go outside. There is no reason for me to leave the house when I cannot walk on the streets. Most Swedish cities are not accessible to the elderly in the winter. Too much snow and ice on the pavement prevents the elderly from leaving their houses.

Södermanland County Council hands out two types of walkers: one with large wheels and one with smaller wheels. Rules vary from county to county because regional governments are autonomous. The number of aids that you can obtain from each county varies.

GBO: The design of certain walkers can hurt your shoulders. I experience pain in my shoulders because of the way I walk and what I carry. I never experienced pain in my shoulders before. I have experienced pain in all other parts of my body before. I never suffered pain in my shoulders before.

You will soon be able to read the entire interview, posted on the ACCESS Health website here.

TioHundra – A New Integrated Care Model for Sweden?

This blog post introduces Care Company TioHundra in Norrtälje, Sweden. This is a unique model of integrated care in Europe. I have had the opportunity to interview Peter Graf, Chief Operating Officer of TioHundra. Peter Graf talks openly about the challenges and the many opportunities that TioHundra faces. I have also had the opportunity to interview members of the staff and managers throughout the organization. Through these interviews, I have gained an understanding of the different parts of the company. I will tell you about my impressions of TioHundra in a series of blog posts. You can access the full interviews and all relevant background information from this case study on the ACCESS Health website.

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Entry to Care Company TioHundra

Background

An older person with multiple diseases often requires care from several healthcare and care providers. This elderly patient may travel to a local hospital for treatment. It is not uncommon that up to sixty people from various care organizations are involved in the care of an older individual with complex care needs. Patients with complex care needs require the services of both the county healthcare providers and the local municipal care organizations. As individuals in Sweden age, and as more people live with multiple diseases and have complex care needs, counties and municipalities realize the need for greater care coordination. Care coordination to meet the needs of the elderly is one of the greatest challenges in Swedish healthcare, witnessed by the large effort of the previous center right coalition government to improve care coordination in the program “The Most Ill Elderly” from 2010 to 2014.[1] The previous government allocated over four billion Swedish kronor to improve the coordination of care for the most ill elderly. TioHundra shows that their model of integrated care already works well. During the program The Most Ill Elderly, TioHundra received funding based on the results they displayed in their work for the most elderly ill. These results included a reduction in unsuitable medication for the elderly and shorter wait times in the emergency room, among other areas.

Elsewhere in Sweden, regional governments manage the healthcare provision while local governments provide homecare and social care. Well defined areas of responsibility ensure that each provider in healthcare and in social care can focus on a range of services. In theory, the specialization of each level of government ensures that citizens obtain the healthcare and homecare they need. In practice, the division of responsibilities causes delays in service delivery, and at times, it compromises the quality of care. Regional and local governments use different communications systems, have distinctive work cultures, and use individual terminologies. Older frail patients, among other groups, suffer when healthcare providers fail to communicate effectively across organizations. TioHundra overcomes many problems of care coordination. Instead of coordinating care across organizations, TioHundra merged multiple care providers, now operating as one large healthcare and care system. This merger entails one of the largest regional reforms of Swedish healthcare since the Nobel Reform in 1992.

Care Company TioHundra is a public healthcare company that provides integrated care in Norrtälje, a city one hour north of Stockholm in Sweden. TioHundra operates an emergency hospital, six primary healthcare clinics, and a home healthcare organization for patients who are unable to travel to obtain care. It also manages social care and homecare organizations. The company runs nine nursing homes and it has 3,500 employees, including healthcare professionals and administrative staff.

To improve the quality of healthcare and to overcome the care coordination problems of regional and local administrations, Norrtälje and the Stockholm County Council established TioHundra in 2006.

250px-Norrtälje_Municipality_in_Stockholm_County

Norrtälje municipality is shown in light pink. This is the area of Care Company TioHundra.

Philosophy

The guiding philosophy of TioHundra is to construct an integrated healthcare system. The objective is to be the leader in integrated care in Sweden, and to be the number one choice of care provider in Norrtälje. The management approach centers on constant improvements. Managers and employees at all levels of the company identify areas for improvement, suggest new routines, and implement changes. The idea is to constantly improve service delivery and employee satisfaction.

Improved Care, Lower Cost

The ability to turn around negative operating results of previous years into a positive net result helped to convince politicians in the region that TioHundra improves the quality of care while lowering the delivery costs. Results from the employee survey show that the company employs a more satisfied workforce in 2014 than in 2013.

TioHundra manages to overcome certain problems of care coordination that persist in other regions and in other municipalities. Formal and informal channels of communication improve the transfer of information between different departments. Patient data is shared throughout the organization with the help of read only functions in patient journals. Weekly meetings of the management team foster an atmosphere of cooperation. Where disagreement occurs, the meetings serve as an arena for constructive debate.

Financing

TioHundra obtains one pool of financial resources from municipal and county taxes. Elsewhere, counties raise taxes for healthcare while municipalities raise separate taxes for social care. Budget silos prevent counties and municipalities to coordinate care in other parts of Sweden. One level of government is sometimes reluctant to deliver a service it considers to be the responsibility of the other level of government. The organizational structure of TioHundra allows this problem to be overcome through a lateral integration of caregivers from the county and the municipality.

Conclusion

In summary, TioHundra is a unique healthcare company. There are no other companies like TioHundra in Sweden. Few similar care organizations exist elsewhere in the Nordic countries. TioHundra reported a balanced budge for the first time in 2014. It also marked a year where management recorded improvements in employee satisfaction. TioHundra delivers healthcare of high quality at relatively low costs. The company has reduced the number of medications per older patient, reduced the prescription of unsuitable medications for the elderly, and it has shortened emergency room wait times for this patient group.

It remains to be seen how the integrated care model of TioHundra evolves. A transition in 2015 away from a focus on balancing the budget, towards operational and organizational changes is already noticeable. This is a young company with an eager management team. If the quality of care improves dramatically, and if the costs of healthcare can be contained in Norrtälje, other counties and municipalities may look into adopting the model of TioHundra.

[1] De mest sjuka äldre

Too Good to Be True?

In my previous blog post, I described the work of the Mobile Team for the Elderly in Uppsala, Sweden, a municipality of two hundred thousand. In this blog post, I will discuss some of the tangible benefits of the Mobile Team to the municipality, to patients, and to patients’ families.

Mobile Team Photo

Before I get started, I want to explain how healthcare and government is managed and financed in Sweden. Sweden is organized into municipalities. Several municipalities comprise each county. Uppsala County includes eight municipalities, including a municipality called Uppsala municipality (see the maps below). Uppsala County manages healthcare provision for all citizens in the county. The County Council in Uppsala is the payer of healthcare in the county. An autonomous government governs each Swedish municipality. Municipalities are responsible for social care for the elderly. The Mobile Service offers healthcare to the elderly, thus touching on the responsibility of both Uppsala municipality and Uppsala County. The Mobile Emergency Team serves the elderly only in Uppsala municipality, not the entire county.

Uppsala County is located to the northwest of Stockholm County and to the east of Västmanland County

Skärmavbild 2015-01-07 kl. 10.20.06

Uppsala Municipality borders the Municipalities of Östhammar, Tierp, Heby, Enköping, Håbo, and Knivsta in Uppsala County, north of Stockholm County.

Since the establishment of the Mobile Team in September 2011, fewer older patients visit the emergency room at Uppsala University Hospital. The Mobile Team started as a pilot project, which became a permanent unit in Uppsala, in January 2014.

Uppsala University Hospital is the only hospital with an emergency room in Uppsala County. Uppsala University Hospital is a public hospital financed by county taxes. Fewer visits to the emergency room thus save costs for the county. One visit to the emergency room is assumed to cost the county hospital 2,500 Swedish kronor (350 US dollars)[1]. In a conversation with the Mobile Team, one of the team’s two physicians, Magnus Gyllenspetz, explained to me that Uppsala County saves costs if the team makes three home visits per day. The savings come from reductions in the number of ambulance trips and the number of treatments provided in the hospital.

The total yearly cost of the Mobile Team is 3.5 million Swedish kronor (five hundred thousand US dollars). Uppsala County saves 2.5 million Swedish kronor (350,000 US dollars) on reduced outpatient treatments of the elderly alone. The largest savings are in the area of reduced hospitalizations for this group. Estimates for 2012 indicate that the Mobile Team saves Uppsala County over nine million Swedish kronor (1.2 million US dollars) annually on inpatient treatments for the elderly, excluding the costs of the Mobile Team.

Without the Mobile Team, an estimated 460 patients would have traveled to Uppsala University Hospital for treatment during the pilot phase, from September 2011 to January 2014. These 460 patients are “avoidable inpatients,” patients who can avoid a stay in hospital with treatment or social care assistance at home.

Apart from the economic benefits, patients like the Mobile Team. Fewer patients need to travel to the hospital. Fewer patients need to wait in emergency rooms. Fewer relatives worry about the health of their elderly loved ones. Fewer relatives must take time from work to help their relatives get to the emergency room. The Mobile Team cares for the ill residents in nursing homes. Because ill nursing home patients are the responsibility of the Mobile Team, the nurses in the nursing home are able to continue to care for all of their patients. If the nurse from the nursing home had to travel with the resident to the emergency room, then that nurse could not care for other patients.

Considering all the benefits, why is there only one Mobile Team with this setup in Sweden? Why do some older patients who need urgent care still travel to the emergency room? Is the Mobile Team too good to be true? How can we explain the fact that there is only one Mobile Team financed by a municipality and a county in Sweden?

There are many answers to these questions. Some older patients feel safer in emergency rooms. Most patients want the freedom to choose where to obtain treatment, at home or in emergency rooms, and some older patients feel safer in emergency rooms. People do not like to be told what kind of healthcare is best for them. Some simply do not know about the Mobile Team. Healthcare personnel follow routines. Some employees of the county do not work with the Mobile Team simply because it is not part of their routine. In my conversation with the five members of the Mobile Team, they expressed a desire to develop a new promotional strategy that would help the team reach out to more patients and partner organizations in the county.

The Mobile Team in Uppsala became a permanent unit one year ago, on January 1, 2014. I hope that other municipalities will establish Mobile Teams in the future, as more people become aware of the many benefits a Mobile Team can bring.

This is a happy thought for the New Year.

Happy New Year to all readers!

[1] “Final Report on the Mobile Emergency Team for the Elderly, 2013”. Author of the report: Swedish Association of Local Authorities and Regions (Slutrapport för projekt kring de mest sjuka äldre Mobila hembesöksteamet i Uppsala, SKL)