In quest of the perfect long-term care system - Sweden.
What can we learn from the Europeans? Are they really that good?
One thing is certain: With the status of American long-term care these days - fragmented, overregulated, underfinanced - many in the United States are open to new ideas. If, that is, their implementation would fit comfortably within our culture. And that's a big if.
I was privileged recently to travel to Sweden and The Netherlands, bringing along my bag of questions and preconceived notions, as a guest of SCA Hygiene Products. Based in Gothenburg, Sweden, the company dominates the market for incontinence products throughout western Europe, particularly Germany, France and the United Kingdom. SCA Hygiene (formerly Molnlycke) has acquired a foothold in the United States in recent years, with about 12% of the incontinence product market. While wishing to share their own remarkable story (see Product Focus, August 1999), company officials gladly arranged for me to visit long-term care facilities in both countries, chauffeured me from place to place, helped with translations and even provided a formal presentation on the Dutch national healthcare system.
Spending a few days in each country hardly qualifies me as an expert. Still, I think I was able to pick up a sense of the situation in each and how it compared with "the American way."
So, are the Europeans that good?
In Sweden, almost.
My initial impressions in touring two facilities in the Gothenburg area were "sunny spaciousness" and "odor free." Even though the facilities varied markedly in size - a 189-resident multilevel "campus" vs a 28-resident "elderly care home" - both were laid out in neighborhood style and staffed to the hilt. Swedish caregiving authorities claim a 0.8 to 1.0 nursing staff-to-resident ratio in facilities throughout the country. Nursing assistants work a 37-hour week, plus one or two evenings a week and three of every seven weekends, and earn as much as $2,000 a month. Turnover is not a major problem.
At the A-Hemmet Elderly Living Complex - the large campus consisting of a nursing home, assisted living and group home - each nursing home/assisted living "neighborhood" of 40 residents had four RNs and 30-plus nursing assistants on duty. Each neighborhood had its own kitchen, living room and laundry. Just as striking was the size of the private rooms in these facilities - 35 square meters, each with the resident's own furniture, giving it a personalized look. What's more, the residents' larger pieces - fine, antique dressers, wardrobes, benches and tables - lined the corridors, adding to the homey appearance.
Common spaces included a large, colorful activities area; a lounge area where, while I was there, a visiting entertainer expertly sang show tunes (while in rooms off to the side, less musically inclined residents earnestly watched Ricki Lake, with Swedish subtitles); and physical therapy and swimming facilities so clean and spacious that they're open to the community at-large. The only flaw I saw in the overall scheme was the use of the double rooms in the nursing home, of which there were a few, each of which looked like a somewhat cramped hospital room.
The smaller elderly care home I visited, Eklandagarden, was a two-story facility that blended in well with the suburban tract community surrounding it. Residents with dementia - about half the total of 28 - occupied the second floor. Again, the atmosphere was one of sunny pleasantness and a complete absence of odor. Its spacious kitchen/living area, surrounded by resident rooms and fronted by a patio/picnic area, reminded me of the Evergreen facility in Oshkosh, Wisconsin, considered to be one of the more advanced facilities in the United States. True to Swedish form, professional staff at Eklandagarden consisted of two nurses and 25 nurse assistants for the 28 residents.
To the logical American question, how can the Swedes possibly afford all this, the answer is simple: common goals supported by local government and financing adequate to meet them. The Swedish long-term care system is community based. Each municipality owns the facilities and sets goals as to staffing ratios, room size, availability of support services and products, quality of care and quality of life. Contrary to common perceptions of European "socialized medicine," residents do private pay, to a point. Charges run at about $115 a day, but resident "spend-down" comes relatively soon, with residents allowed to keep about $200 a month of their pensions for personal use. Municipal government pays the balance for all levels of care, provides incontinence care and wound/ostomy products free of charge and medications for a small deductible.
Needless to say, taxes are stiff by American standards: a 30% minimum income tax, rising to 50% for the more well-off. (These taxes support a free educational system through college, as well.)
More detail on how this system works was provided by Kaj Andreasson, head of the Department of Eldercare in the city of Molndal, a youngish, mustachioed social worker with long experience in working with the elderly. Molndal, he explained, has a budget of about $30 million a year to care for some 1,690 elderly - 1,000 in home care and 690 in "special houses" resembling assisted living, in some cases providing Alzheimer's care. Social workers employed by his department decide which level of care to assign the elderly applicant. Families sometimes disagree with these decisions and can appeal them in court - but the case should be a strong one, said Andreasson, because one of the community's goals is to keep people at home for as long as possible. The community even provides free assistive devices toward that end. While there is no waiting list for home care, there is one of at least a month for the special homes. But Molndal's incentive to remedy that is a strong one: The national government requires it and other communities to pay hospitals more than $200 a day for patients who cannot be placed in long-term care facilities because of a lack of beds. "This is very effective in producing new facilities," said Andreasson.
Another community goal is to have residents move only once before they die, which means bringing as many services as possible to the initially assigned site.
In a move that Americans might find particularly intriguing, his department has been experimenting with provision of long-term care services by private providers under contract. A three-year contract was completed, and now the community is in the second year of a five-year contract, which was awarded by competitive bid. Private providers boast that they can cut costs compared to government managers and have, indeed, done so by as much as 10%, said Andreasson, "mostly by staff cuts." Those cuts haven't been too onerous as yet, though. The going staff/resident ratio in these facilities is 0.7 to 1.0, said Andreasson, "and quality is still good."
There is a community-run quality inspection program, but it is not quite in OBRA's ballpark. According to Andreasson, government inspections are conducted in response to individual complaints, are often done on 24-hour notice, and do require plans of correction but assess no fines. "We rely heavily on public opinion, and media stories and letters to the editor are generally encouraged, if necessary. Reputation is a very important factor in the community."
What does all of this mean to the American system of long-term care. As near as I can tell from my brief visits and helpful hosts' offerings, the two primary messages are: 1) You can provide decent, personalized, highly staffed services in pleasant surroundings at virtually all levels of care if you're willing to pay the taxes, and 2) A strong sense of community can make up for a great deal of regulatory red tape.
The extent to which this reflects, or does not reflect, the American environment tells us what would have to be achieved to get us to an "almost perfect" system, Swedish-style.
Next issue: A report on the Dutch system of long-term care.
Richard L. Peck is editor of Nursing Homes/Long Term Care Management.
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|Title Annotation:||Does Europe Have the Answers?, part 1|
|Author:||Peck, Richard L.|
|Date:||Sep 1, 1999|
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