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Learning about Finland: Pathways into residential care

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In Finland, when you enter residential care you are renting an apartment. It’s your home – there just happen to be services, such as food and nursing care, attached. Staff don’t enter your home without knocking. The fee for services depends on how much you need and your income. The rent depends on the size of the apartment. In both cases, help is available to pay for these services depending on your income. If you can’t pay at all, the municipality pays for you.

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Koukkoniemi home for older adults. A larger facility in Tampere.

Residential care facilities include those run by the municipality as well as private facilities that have apartments that residents pay for out-of-pocket and apartments purchased by the municipality. The size and quality of facilities can vary. Some of them can be quite large and feel more like a hospital with a nurses’ station and long, sterile hallways. Others are smaller and feel more homelike. These tend to have a cozy common area and staff are less separated from the residents. Some large facilities are divided into smaller units that mimic this more homelike atmosphere. There are very few facilities left analogous to what we think of us nursing homes in the United States. Even places where the residents need a substantial amount of care are more likely to be structured into smaller units and the underlying philosophy is that this is the residents’ home and should be treated as such. Many places have courtyards or other outdoor areas and some of these include small gardens where residents can pick berries or dig up potatoes. All have saunas available for residents to use. These are important for quality of life as regular saunas and outdoor activities are important parts of Finnish culture.

There is a formal process for entering residential care. It begins with a referral from the municipal social worker or perhaps the family. Typically there is a waiting list. By legislation the wait for residential care should be less than three months, however, there is currently a longer wait in many places. Once you are on the waiting list, you are given a place in the next facility that has an opening as long as it is suitable for your needs. You can decline it if it is not where you want to be, but then you go back onto the waiting list. The municipal social worker manages the waiting list and can move you up in line if your situation changes. Of course, if you can afford it, you can pay out-of-pocket for an apartment in the facility of your choice and the wait may be shorter.

The criteria are high just to get into the queue. The social worker visits the home and does a complete biopsychosocial assessment. This assessment is then reviewed by an interdisciplinary group made up of a doctor, physiotherapist, nurse, hospital social worker, and a social worker from community care. They decide whether or not you are accepted into the queue. This group meets once a week. Sometimes they require additional evaluation before they will make a decision. It is a very time consuming and bureaucratic process that can be difficult for the older adults and their relatives.

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Viola Home in Tampere won an award in 2009 from the International Academy for Design and Health.

How does this compare to your experience or knowledge of residential care for older adults in the United States?

 

Learning about elder care in Finland

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When I first got here I envisioned frequent posts about my experiences here. And then suddenly it is June!

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This week Masters of Social Work students from Michigan State University were in Tampere with my colleague Karen Newman as part of our MSU – Tampere of University of Applied Sciences exchange. They visited a variety of agencies, had class with Finnish MSW students, and had fun learning about social services here, the Finnish culture, and the ways we are the same and different.

I’ve learned a lot in my time here as well. Thanks to my collaborator Ulla-Maija Koivula for putting together a great program for the students and making my time here so pleasant and productive.  (Here are are some blog posts by Ulla-Maija and her students who visited the United States in Fall 2013. Sorry – it’s in Finnish, but there are some pictures and headlines that will give you a sense of where they went).

Here are a few tidbits from what I’ve learned so far related to elder care:

  • As in the United States and elsewhere, elder care is in flux. Finland is struggling with a lagging economy and a growing population of older adults. They are making changes to the structure of all health and social services and anticipate more changes on the horizon
  • The focus for elder care and the issues Finland is facing are also similar to those in the United States. In particular, there are more resources being put into caring for older adults at home for as long as possible so that residential care is a final resort. Consequently, older adults are in need of more care by the time they enter residential care, although staffing has not always changed to accommodate this greater need.
  • The City of Tampere has been quite thoughtful about how to manage this shift. For example, they closed geriatric residential units in a local hospital and used that money to fund a start up project for an in-home rehabilitation program. After a year of getting the program off the ground, it has become integrated into overall home health services as a means of improving customers’ quality of life and helping them stay at home longer.  This service isn’t free, but older adults pay on a sliding scale based on their income.  The balance is covered by the municipality and for those who can’t pay anything the full cost is covered.
  • As in the United States, the people who do this work do it because they love it and they love the people. It’s hard work that can be both physically and emotionally draining, but the people I have spoken to have a passion for it.
  • Unlike the United States, there is very little turnover in residential care staff in Finland. I need to delve into the details and reasons behind this a bit more. Two initial thoughts that come to mind include better financial supports (including salaries as well as the overall health and social services available to workers and customers) and the country’s investment in education (which is free at all levels) which means that workers in all roles tend to be better educated.
  • The decision to enter residential care is not entirely up to the older adult and his/her family. More on this later, but in a nutshell, an interdisciplinary municipal board made up of health care professionals evaluate the situation of the older adult and if he/she meets the criteria they will be placed on the waiting list. When they reach the top of the list, the next available place will be offered to them which may or may not be in the facility of their choice.

More thoughts about differences and similarities in future posts. And if anyone has suggestions for slowing down time, please let me know.

Hei Suomesta! (Hello from Finland!): Crowd sourcing my interview questions

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Okay, I’m not physically in Finland yet, but mentally . . . ? tampere

I’m looking forward to my time in Tampere. In particular, I’m excited to:

  • Participate in the Tampere University of Applied Sciences Social Science International Week;
  • Practice my Finnish (friend, colleagues, family – please speak to me in Finnish as much as you can stand it);
  • Learn about elder care in Finland.

As a reminder, I am comparing elder care in Finland, Estonia, Romania (a new addition!), and the United States.  My questions and focus have evolved over the semester. (Reading and thinking and talking to people does that). I’m still interested in workforce issues and how each country is preparing for the impending shortage in health care and social service professionals prepared to work with older adults. But, much of that information I can gather from existing sources.

The added value of talking to actual people is that I can learn about their experiences on the ground. So in each country I want to talk to service providers, older adults, and informal caregivers about their experiences with elder care. Why? There is evidence that different health care and social service systems lead to different population-level results.  But what about the lived experience of those receiving those services? Do older adults, caregivers, and service providers have a different experience in Finland than they do in the United States? And, if yes, what are those differences and where do they come from?

I don’t expect to answer these questions over the next seven weeks, but I hope to talk to as many people as possible to get the ball rolling.

Here’s where the crowd sourcing part comes in.

First, if you know someone in Finland I should talk to – who works in elder care, an older adult receiving care, a family member or friend helping an older adult – let me know (in other countries too, but I may not get to them this time around). I will ask an hour of their time tops, with the actual interview lasting 30-40 minutes.

Second, if you could ask them anything you wanted, what would you ask about their experience? Here are my initial questions. All you thoughtful, curious readers, feel free to edit, delete, add, or otherwise share your thoughts.

For Service Providers:

  1. Please describe the structure and services of this office.
  2. Please describe your role as a [position title] within this office.
  3. What is your background? [education, pathway to this position]
  4. Please describe a typical day (or yesterday or one day last week). Who did you see? How many did you see? What did you do with them?
  5. Please describe the structure of elder care in Finland/Tampere, particularly as it relates to what you do. (How are clients referred? How are services paid for? What happens when someone can’t pay?)
  6. What is the hardest thing about your job?
  7. What is the best thing about your job?
  8. Anything else you would like to share?

For clients/caregivers:

  1. What types of services are you receiving currently?
  2. What led you to seek help?
  3. When was the last time you received services?
  4. Please describe the experience for me? (Interaction with service providers. Ease of making appointments, wait times, paying for services, getting there.)
  5. What do you like about the services you receive?
  6. What has been most challenging?
  7. Anything else you would like to share?

Post your suggestions below.

Thank you to the American Scandinavian Foundation for supporting this research.

 

 

How expensive is the welfare state anyway? And does it really matter?

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The expense of the welfare state comes up in all sorts of political and public conversations even if it’s not worded quite that way.  What to do about Social Security, Medicare, health care?  Make welfare recipients take drug tests?  Dock welfare payments from families who kids miss school?  They all have to do with money in some way, but are also code for ideologies and beliefs about who deserves help and how much the government should provide.  In the United States, the argument against a more universal approach to social welfare often comes down to money (at least on the surface).  Big welfare states are too expensive, we’re told.  I suggest that the money argument is a distraction from ideological differences that really underlie this ongoing debate.

Social spending includes things like old-age, survivor, and disability pensions; health care; family support; active labor market policies; unemployment; and housing. A number of studies that compare the cost of social expenditures across Organization for Economic Co-operation and Development (OECD) countries find that the expenditures in some countries (like Finland) are overestimated and in others (such as the U.S.) are underestimated because they don’t take into account taxation on benefits and private spending.

For example, one 2009 OECD report found that while gross public social expenditures for the U.S. (17.1% of GDP) were less than Finland’s (29.8% of GDP), the net total social expenditures were much closer (27.2% of GDP for the U.S. and 24.4% for Finland).  They account for this difference in three main ways:

  1. Finland directly taxes public social benefits at a higher rate – about 18% for public and 22% for private transfers compared to 6% and 12% in the U.S.  They also tax different types of benefits differently.  In Finland, pension transfers and unemployment benefits are taxed and social security is deducted, but at a reduced rate.  In the U.S., pensions are taxed at a reduced rate and unemployment benefits are taxed as earning, but social security isn’t deducted from either.
  2. Indirect taxes – the taxes we all pay on groceries, clothes, and other things – are different.  In Finland, the average indirect tax rate in 2009 was 20.8% compared to 4.3% in the U.S.  That means that the same amount of benefit doesn’t go as far in Finland as it does in the U.S.  OECD countries, like the U.S., that have low indirect tax rates also tend to have lower social expenditures.
  3. The U.S. has more tax breaks designated as being for “social purposes” than any other OECD country (at about 1.5% of GDP in 2009).  These include lower taxes on some sources of income or for some types of households.  They also include things like tax credits for dependent children that reduce taxes or exempt some from paying a tax and are intended to do the same thing as a cash transfer.  And they include tax breaks that are intended to stimulate some sort of non-governmental provision of benefits like tax exempt non-profits or better tax deals for private pension and health care contributions.  These last two play a much bigger role in the U.S. than in Finland where they are virtually nonexistent.

So, monetarily there are fewer differences in the amount of social spending across OECD countries than we tend to think. The differences are in the ways in which that spending is funded (indirect and direct taxes versus tax breaks).

But are these two means to an end equivalent? And are they really intended to reach the same end anyway?

It turns out that the mix of public vs. private spending can end up with very different results, especially when it comes to income inequality.  Countries like Finland, where the amount of public social spending is above average and where public spending is a greater proportion of the total, also have below-average income inequality. Countries like the U.S., with low levels of public social spending and where private spending is a greater proportion of the total, have higher levels of income inequality.  This makes sense.  Private spending like tax advantages toward pensions and health care are more likely to benefit those who start out with more money.  Private employment-related benefits (like tax exclusions for employer contributions to health care) only shift income among those who are or have been employed.  When social expenditures rely more on private pending than public, the benefits are stacked in favor of those who have more from the start and there are bigger holes in the safety net for the most vulnerable to go tumbling through.

The U.S. stands out as having the least efficient net after-tax social spending with both spending and inequality higher than all other advanced economies except for France which has higher spending and Israel, Turkey, and Mexico which have higher inequality.

Of course, there is all sorts of political freight attached to notions of income inequality and public vs. private social spending.  But there is also growing evidence that inequality has real consequences.  This is true internationally as well.  The U.S. has greater private spending on health care and education, but notably poorer outcomes in mortality and graduation rates.  For those who don’t see inequality as an ethical issue, maybe money will talk since these consequences come with costs.

 

Health care workers – how do we love thee

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In the Sunday, Feb 8 issue of the New York Times there was an article about the impact of the economic crisis and extreme austerity measures in Greece on health care.  This NYT article looks in particular at the shortage of nurses forcing hospital patients to hire private nursing care. Enter the entrepreneurs and a burgeoning business of selling illegal nursing care. Not surprisingly, the “nurses” (mostly or entirely women I assume) who provide this care are untrained which is leading to a variety of noticeable consequences. Besides substandard care for individuals (an important issue in and of itself), there has been an increased spread of illnesses in hospitals because the illegal nurses are not following basic hygiene protocols like wearing gloves.

Given that I’m thinking about health care workforce issues a lot right now, this article caught my attention and made me wonder what data is available related to health resources (particularly workforce) and health outcomes. No one is expecting such extreme problems in the countries I’m looking at (the U.S., Finland, and Estonia), but they are anticipating a shortage of health and social services workers adequately trained to work with our aging populations. Beyond the substitution of unqualified and untrained workers, what impact might a worker shortage have? It’s easy to imagine the impact on an individual’s health through delays in care, not getting care at all, or getting inadequate care. But what about a population’s health? Does a shortage of health care workers, make us, as a country, less healthy?

The short answer seems to be yes. A variety of studies both between and within countries have found that the density of health care workers (i.e., the number of workers divided by the number of people in the population), particularly doctors and nurses, is associated with health outcomes ranging from maternal and infant health and mortality to mortality, hospitalization, and spending among Medicare beneficiaries in the U.S.  Of course, it’s probably more complicated than density alone. Geography, race, and FTEs (i.e., the amount of care provided vs. the number of workers) are important too.

There’s not as much data on other types of health workers such as community health workers, social workers, and complementary and alternative medicine practitioners. Nor is there as much focused specifically on outcomes among the older population as there is about mothers and children. (At least I haven’t found it yet – if you know of some, please share!). Given that geriatricians, geriatric nurses, and geriatric social workers are where health care worker shortages are predicted to grow over the coming years, some understanding of what counts as a shortage and what impact that may have is worth thinking about.

A teeny, tiny peek at health expenditures in three countries

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I’ve been trolling through World Health Organization data for the United States, Finland, and Estonia. (Yes, more fun with data!) For anyone interested in global comparisons in all things health-related, WHO is the place for you. It is a treasure trove. I’m only at the beginning of this part of my project (or any part of my project, to be completely honest) and there is lots to look at, but here are a few things that have caught my attention so far.

In 2011, Finland had more mental health outpatient facilities, beds for mental health in general hospitals, community residential facilities, and more beds in those facilities than the United States. The latter is most striking with Finland having 134 beds per 100,000 people compared to only 22 in the U.S. On the other hand, the United States has slightly more mental hospitals compared to Finland and more beds in those hospitals. (According to the only data available on these variables, Estonia has more mental hospitals than either Finland or the U.S.). This dramatic difference in community-based facilities highlights a significant gap in U.S. services for the mentally ill. If you need to put a face on why this matters, read this story in The Washington Post.  People cannot get into hospitals when they need it because of lack of beds and others can be held in the hospital against their will because there is no place to discharge them to. Not surprisingly, it costs much less to support someone in the community than to keep them in a hospital. Why then is the U.S. not investing more in community-based resources? (A topic for another day).

I also find it interesting that, even with universal coverage, Finland and Estonia have lower per capita government expenditures on health than the U.S. and, in fact, since 2008 government expenditures in Finland have fallen. (See figure, based on World Health Organization Global Health Observatory data).

govt expenditure on health

So even though most of us pay something for our health care coverage, for many of us our employers pay something as well, and there is great variation in terms of the levels and type of coverage we each can afford, the U.S. government is still spending more per person than two countries where the state provides equal coverage for everyone.

Yes, I hear some of you saying, that the citizens pay for it through much higher taxes in Finland and Estonia. That is true. It’s the equal coverage part I’m interested in here. Yet another topic for yet another day – what citizens in each country get for the taxes they pay and how this relates to quality of health care and overall health outcomes.

So, what are you doing on your sabbatical anyway?

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I want to write a book. Period. I love the ups and downs of the writing process. The reading and then thinking on the page. Making messes with words then slowly tidying them up like tapping a stack of papers on a desk to line up the edges. I love those times when I get so absorbed in my work that the timer goes off and I never hear it. I even love the days when 15 minutes seems like forever and my brain is all a tangle. It’s a puzzle and I know I’ll find the right thread to pull eventually as long as I keep showing up.

So when someone asks me what I’m doing on my sabbatical, my current answer is, I’m working on a book. They look at me expectantly. I look back at them. They look at me. Etc., etc., etc. Faculty advise doctoral students to have the “elevator pitch” – that 20 to 30 second blurb about your dissertation that you can spout off at the drop of a hat. Oh, Professor Woodward – take thy own advice.

Consider this my pitch – for now. Subject to change, feedback welcome. (I’m hoping for slow elevators).

If you haven’t been living in a hole somewhere, you know that the population is getting older across most of the world. Most of us need some help as we age and, while informal caregivers are important, we will probably need some professional help, too. But, while the number of older adults increases, the workforce available to meet their needs is shrinking. Not only that, but economic changes are straining health and social welfare systems and everyone is looking for politically acceptable and cost effective solutions.

I am comparing how the United States, Finland, and Estonia are addressing these issues within the context of their different welfare systems. All three countries are relatively similar in economic organization, mortality and morbidity, and their exposure to the forces of globalization. And yet they vary in important ways in their historical development, culture, and structure of services. The U.S. is a largely market driven system that relies heavily on private non-profit and faith-based organizations to provide many services to those in need. Historically and culturally there is resistance toward state intervention (e.g., ongoing challenges to the Affordable Care Act), and there is significant cultural heterogeneity.

Finland and Estonia are similar geographically, sharing a border and a history with Russia, and have similar languages, belonging to the Uralic family of languages along with Hungarian. They also have similar political structures and social welfare systems with universal health and social services administered largely through municipalities. At the same time, Finland is culturally Nordic while Estonia is culturally Slavic.

Each of these countries does some things better than the others.  Some of one country’s strengths might be portable to other countries, but which ones?  And how much are those strengths embedded in cultural norms that can be easily translated to another country?  Ultimately, I hope a combination of population-level data and qualitative interviews with care providers, care recipients, and policymakers can help pull some of this apart. And then I can browbeat policymakers with it.

But really, I just want to write a book.