This is the story on improving integrated care for sick elderly people in Sweden. A three year national initiative comprising five areas of improvement and management support. The results show that it is possible to improve on many levels over a short time. The report presents the results of this process and the paths to these results.
The vision ”I can age in comfort and autonomy with access to good health and social care” was formulated at the start of a national initiative to improve health and social care for sick elderly people. Then interviews, with nearly 300 older adults with complex health condition and a large consumption of care, were conducted.
They spoke about a system in which it was easier to call for an ambulance and go to the hospital than get an appointment at the medical center. Every fifth sick elderly person admitted to the hospital was re-admitted within 30 days. The use of inappropriate medication was high, as was the number of drugs that were prescribed
For quite some time, inadequate cooperation on many levels has been a problem. Municipal, county and primary care institutions have not had any natural common arenas. The first time executive managers from both municipal and county institutions met in the same room to discuss common challenges was in the spring of 2011. This can be said to be the start of the quiet revolution that has characterized health and social care in recent years.
Today, five years later, health and social care staff are working with new standardized, common and evidence-based approaches. Systematic appraisals and risk assessments have led to the implementation of preventative measures and it is now possible to follow key results in real time. Improvement initiatives implemented in regular operations lead to results. The desire to learn and improve emerges when team together reflects on their results.
A Better Life for Elderly Sick People has been made possible through a frame- work agreement between SKL and the Swedish government on Coordinated health and social care for the most severely ill elderly people, in which annual agreements about the details were made from 2010 to 2014. Five areas have been identified for improvement:
The focus of the agreement was to support municipalities and counties in developing a common, long-term and systematic change management pro- cess. The municipalities and counties that achieved the set objectives were awarded performance bonuses. Funds were allocated for development leaders, management support, quality registries and analysis work. SKL was responsible for national coordination.
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