The Future of Elder Care is Already Here
As part of my studies of good practice in elder care, I decided to spend a couple of weeks in Holland. Many healthcare professionals in Sweden talk about Holland as a country that promotes innovation, so I wanted to go down and see for myself what is so good about Dutch elder care. I wanted to explore the innovative mindset that healthcare professionals in Sweden seem to associate with Holland, learn about the Dutch healthcare system, and visit a number of internationally recognized elder care groups.
I was amazed by what I saw in Holland. Through this blog post and through my other writings, I will try to communicate some of the strongest elements of the organizations that I visited, and of the Dutch elder care system at large. I think it is safe to say that we all are looking for inspiring examples that can help us shape the future of our elder care systems. In my view, some of the Dutch organizations that I visited already embody what I would like to see in all elder care organizations in the future, such as personal freedom, a focus on wellness and wellbeing, and an environment that feels just like home.
The Dutch healthcare and elder care systems provide universal coverage through healthcare insurance. All Dutch citizens are required by the Health Insurance Act to pay for private health insurance. The cost for private insurance ranges from 130 to 190 US dollars per month. The insurance companies must accept every applicant who applies for insurance. Companies also contribute toward healthcare insurance for their employees. There is a parallel insurance system for long term care, including nursing homes and exceptional medical expenses, such as extended hospital stays.
There have been a number of recent reforms to the payment system and the responsibility for elder care, which is now the responsibility of local municipalities instead of the central government. Holland spends about fifteen percent of gross national product on healthcare, including elder care. Elder care comprises around eighteen percent of total healthcare costs.[ref]Caroliena H. M. et al 2014, Aging in the Netherlands: State of the Art and the Science.[/ref]
There are almost seventeen million Dutch citizens, and sixteen percent of the population is sixty five or older. This number is slightly lower than the European average, with comparable figures for Germany and Italy at around twenty one percent.[ref]Eurostat.[/ref] The population over the age of eighty in the Netherlands is expected to increase to around ten percent in 2050.[ref]Caroliena H. M. et al 2014, Aging in the Netherlands: State of the Art and the Science.[/ref] As such, Holland, just like Sweden and many other countries, needs to think carefully about how to care for its aging population.
In Holland, life expectancy is eighty three years for women and seventy nine years for men, resulting in an overall life expectancy of eighty one years.[ref]Better Life Index.[/ref] The Dutch elder care system has traditionally been ranked as one of the best systems in the world by researchers and academics from different parts of the world. The system remains accessible and is based on the principle of solidarity and universal coverage. However, there are concerns about the increasing cost of long term and chronic care as the population ages. Holland is looking abroad for inspiration. Many of the healthcare professionals with whom I meet repeatedly say that they look to Sweden and Denmark for examples in healthcare.
Lifestyle and Wellbeing Matter
I visited a number of different care homes, homecare organizations, academic institutions, eHealth providers, and the University Medical Center in Groningen. Throughout my time in Holland, I noticed that innovative groups all shared a couple of fundamental ideas upon which they centered the delivery of care. The organizations I visited focused on wellbeing, wellness, and lifestyle choices. They focused less on the medical aspects of chronic and long term care. These groups did not consider themselves to be part of the curative strands of the healthcare system. The healthcare professionals I met with expressed that they wanted to focus on individual capabilities, freedom, autonomy, and wellness.
For example, the care homes wanted to provide a nice home environment, with homecooked meals, small groups, interior design choices, and a personalized care routine. The care homes focused on providing tasty meals, freedom to go to bed and wake up whenever, and an exterior environment that feels just like the environment in any city neighborhood. The homecare organizations strove to provide assistance at home, but only when individuals could not manage on their own. The nurses looked first at a person’s capability to care for him or herself. Next, the nurses looked to the neighborhood and what help neighbors could provide. Then the nurses reached out to relatives to see if they could be of assistance. As a final step, the nurses provide care.
The nurses and assistant nurses in the organizations I visited were able to help the individual not only with the medical aspects of homecare, but also with personal hygiene, with cleaning the house, and making sure that the person who receives the care is happy and satisfied. As we all know, satisfaction and wellness can come from many different sources, not only by following a medical care routine rigorously. Satisfaction and wellness may also be about how you feel in your home, whether the flowers are watered or your garbage is taken out.
What this boils down to, I believe, is a different view of the role of nursing. This is like going back to the basics. Many times today, the most experienced and most senior nurses are promoted to managerial positions. The most experienced nurses rarely see patients. The senior nurses assume more responsibility for administrative tasks. The senior nurses manage assistant nurses and younger nurses in the homecare organization. Some assistant nurses prefer to handle the more technical and medical aspects of homecare, such as treating wounds and distributing medication. Some nurses prefer to do this work instead of showering the individual, cleaning the house, and talking to relatives. In a way, the Dutch approach resembles what the district nurses did in the 1980s, when they assumed a holistic view of nursing.
The researchers and academics I met all considered autonomy and freedom to be critical elements of the future and present elder care system. Throughout my conversations, the researchers focused on vitality, a word that they associated with the state of remaining alert and active, despite the bodily weaknesses that comes later in life. The term vitality is not in opposition to aging, but accompanies aging when individuals alter their expectations and lead active lives based on their physical and mental capabilities. Overall, I think that we can all agree that many aspects of elder care can benefit from more freedom, personal autonomy, a focus on wellness, and vitality. Aging is a term that describes the physical deterioration of your body. Healthy anything is an expression that seems like an oxymoron if you look at it in this way. Vitality may be a better way of describing the process in which you get older but remain active.
Innovative Organizations: FocusCura and Dementia Village at Hogewey
I visited FocusCura, an eHealth provider currently headquartered in the city of Utrecht. I met with Dr. Daan Dohmen, the founder and chief operating officer of FocusCura. Dr. Dohmen is a trained elder care nurse, who completed his doctoral thesis on the adoption of technology among the elderly. He has built an eHealth technology company that currently provides two main software applications in elder care.
The first is a video conferencing application that works with a tablet. The application allows individuals to Skype with their homecare providers, the doctors in the hospital, the general practitioner, any other healthcare provider, and with relatives. The second application is a health monitoring device that helps patients manage illnesses such as chronic obstructive pulmonary disease, heart failure, and diabetes from their home. The application helps individuals collect their own health data and share it automatically with their providers. Both of these products have been rigorously evaluated and have received a European CE mark. The CE mark is a standardized product certification. The software applications are classified as medical products.
Throughout my discussion with Dr. Dohmen, I was surprised to learn about the many different facets of technology adoption and the way that FocusCura has chosen to introduce technology into elder care. The company focuses on providing services to the elderly, but at the core of this work is personal autonomy and freedom. Many other organizations provide standardized homecare, with little room to choose what kind of services and what kind of assistance you want. With the help of the applications, individuals can choose with whom they want to videoconference and what type of care they want. For example, individuals can choose whether they want an in person visit with the doctor or a digital visit. Individuals pay the same price through their insurance policy for videoconferencing as they would for an in person visit to the doctor. Many choose to receive blended care, a combination of digital and in person care.
This application provides freedom for individuals who receive homecare. This is also flexible model: If you want to see your nursing provider, you can do so. If, for some reason, you do not want to see a doctor one day, you can also choose not to. Individuals can also add neighbors or relatives as videoconferencing contacts so they can videoconference with other people who matter to them. The Dutch insurance system reimburses videoconferencing, which is far from common in every country.
I was also able to visit the famous Dementia Village at Hogewey, in the Weesp, about half an hour southeast of Amsterdam. This care home is constructed as a small, self contained village. Individuals who have been diagnosed with a later stage of dementia can live relatively normal lives here. The care home consists of smaller houses, with six individuals in each house, a street with a shop, an activity center, a theater, and a grocery store. The village also includes restaurants, a bar, and many different gardens that surround the smaller houses. Inside the village, individuals are free to walk around. Staff dress in normal clothing. At the front end, the village is just a normal village. At the back end, Hogewey is a nursing home with nurses and other healthcare professionals who deliver professionalized care.
I liked the atmosphere in the village. I sat down for a cup of coffee in the restaurant. I looked into the bar, and I saw the theater. The village attracts many volunteers from the city of Weesp. Many companies rent the theater for meetings and functions. Sometimes, the village is full of people, just like a normal village. Other times, the village is quiet. This variation instills some normalcy into the everyday lives of the individuals who live there.
Residents can stroll down the street and go into the grocery store to pick up whatever they like. There is no need to handle cash. At times, the lack of cash can be confusing, but it also simplifies matters for the residents. Each house has its own unique lifestyle. The lifestyle of the house can be city living, traditional living, or Indonesian living, for example. The small scale allows individualized care. Each nurse knows his or her residents quite well.
The nurse brings the residents to the grocery store to pick up ingredients for dinner. Later on, the nurse involves the residents in cooking. Such a simple activity also ensures that life in the dementia care home still contains strong elements of normalcy. Residents walk outside and engage in activity when they go to the grocery store. Families testify that individuals who live in the village need less medical care and consume fewer medications.
The focus on activities is strong in the village. Each resident can sign up for one free activity, such as joining the classical music group. Many residents pay for additional activities. This approach cuts to the core of what the Hogewey is all about: maintaining your physical and mental strength by engaging in the normal everyday activities that you have enjoyed throughout your life. The managers of Hogewey report that activities can reduce the need for rehabilitation services and prevent a range of medical illnesses, such as fall injuries for example. I was encouraged to see the amount of freedom, flexibility, and normalcy that the residents in the village could enjoy every day.
It is, of course, difficult in a blog post to describe all of the impressions that I gathered while I was traveling around Holland, exploring many of the innovative elder care services I have talked about in this blog post. I hope that I have been able to communicate some of the core principles of care and some of the approaches that these groups have taken. Many elder care providers around the world work hard to provide person centered, individualized services. Far too often, resources are scarce, the care needs are high, and staff turnover burdens care organizations. It is not easy to provide high quality elder care at an affordable price. Throughout the next few blog posts, I wish to communicate that achieving high quality and affordable elder care is possible, and that some of these organizations in Holland are doing just that. It will be my objective in the coming years to inspire others to look toward these innovative examples. I aim to help policymakers, practitioners, and community groups be inspired by these ideas and ultimately improve the quality of elder care. I hope that this blog post is the first step in that direction.