HOW IT WORKS
Skaraborg’s objective is to bring providers and services to the homes of frail elderly people and their caregivers. The program features planned visits and access to services through a 24/7 hotline. Patient counseling, self-management, and involvement are central to the program, and care is provided mainly at home. The operation model consists of three mobile functions: 1) a multidisciplinary care team; 2) a specialized palliative care team; and 3) home care physicians teamed with home health nurses. These mobile functions involve hospitals and primary care agencies, which have regional responsibility, as well as home health services and social care services, which have responsibility in municipalities. Patients are admitted to the program through referrals from hospitals, primary physicians, and social care agencies. Admission is based on assessments of multimorbidity and functional decline. A key feature is assessment of social factors and living conditions. Within the teams, health care professionals work together with patients and their caregivers to develop an individualized care plan covering a wide range of health and social care services.
Since launching in 2008 at one site, the model has spread to two other regions, where an assessment is ongoing. Data on program activities are collected routinely. The program is currently undergoing an external evaluation.
For providers. Providers from across health and social care sectors can refer patients to the program. Members of the teams meet regularly to discuss each patient’s progress and to determine appropriate care stage based on his or her current needs. A key program feature is bringing physicians and other providers to the patient’s home.
For patients/caregivers. The program reaches out to frail elderly patients who are at risk, evaluating their needs through a comprehensive assessment conducted at home with an engaged caregiver and subsequent regular home visits. Patients and caregivers are actively involved in setting goals and creating the care plan. They receive consultation and support in self-managing their conditions.
The governance structure brings together municipal and county councils, which together form the steering committee. This organizational structure allows better coordination of health and social care delivery. Data on program operations are collected and regularly reviewed. Efforts are ongoing to build a data infrastructure to support the program.
SUPPORTIVE POLICIES: A set of policies and procedures support staff in their efforts to provide team-based, patient-centered, integrated health and social care:
- Multiprofessional mobile teams and functions working together with municipal personnel at patients’ homes
- Responsibility for target patient population shared among hospital, primary care, and municipality of residence
- Individualized and person-centered methods of operation
- Improvement through learning networks in which staff co-create and -develop health and social care that is responsive to the needs of patients and caregivers
- Common management and leadership at strategic and operational levels