Ehtookoto provides housing and support services to older adults and adults suffering from mental health problems in the municipality of Lempäälä, Finland. It was founded in 1965 and embodies the principles of empowerment and client-centered services that we often talk about, but sometimes struggle to put into practice. It is also situated in a lovely, wooded setting with gardens, chickens, and a fire pit for summer (or winter) sausage grilling.

Ehtookoto is a nonprofit association that receives most of its funding from the municipality which purchases its services. Residents pay rent and a service fee that is based on the amount of care they need. Depending on their income, the municipality may pay for some of all of this care. In that way, Ehtookoto is similar to other senior housing agencies I learned about during my time in Finland. I think, however, the level of client participation sets it apart.

• There is a resident and client council that meets once a month.
• Residents are involved in the recruitment and interviewing of new employees. Even when they were hiring for the dementia care unit, a resident of that unit was involved and asked good questions. According to the executive director, you can learn a lot about a potential employee by how they respond to the resident member of the interview team. A word to the wise future applicant: if you don’t speak to or acknowledge the resident interviewer in the same way you do with everyone else, you won’t be working at Ehtookoto.
• Residents are involved in various organizational development activities such as identifying and defining the values of the organization and the elements of a good home visit.
• Residents plan and organize a variety of recreational activities
• Residents and their relatives regularly provide feedback

The director’s office door is always open and residents are not shy about voicing their concerns and sharing their ideas. At least, not eventually. Older adults are increasingly moving to places like Ehtookoto with more physical, mental, and cognitive problems than in previous years. This is because Finland’s 2013 Elder Care Law dictates that older adults should be cared for at home for as long as possible and institutional care as we have known it is being phased out. Older adults are moving to Ehtookoto, therefore, from elderly care institutions or psychiatric hospitals that are being shut down or after years of having received home care. It can be a difficult transition from a setting where you are a passive care recipient to one where you have choices and can decide how you want to live your life, with the support you need to make that happen.

Ehtookoto provides more services on the campus and in the community than I have space to describe here. The atmosphere and smiles among staff and residents alike attest to the culture of the place.

And, they have a resident circus.

 

 

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.

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.

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

 

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

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.

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

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.