Steve: Is This Any Way to Run a Country?

Senior Center at Hörnan

For Tuesday's class, one of the speakers was Steffan Osterstrom. Steffan works for Jönköping municipality and has spoken to previous classes I have brought here.  It's the 292 municipalities that have the responsibility for organizing and delivering services to older people.  This covers everything from occasional help in the home or snow removal services in the north of Sweden to nursing home care. 

Today Steffan talked about some of the trends in care, but what was really most astonishing were his descriptions of how the municipality decides what to do. Essentially, the national government sets guidelines for services for older people. A law called the Social Service Act states who has responsibility for carrying out the law and the values that should guide programs for older people, like assuring safety or supporting autonomy and quality of life. But the law does not tell municipalities what specifically they should do. Not how many nursing homes they should have.  Not how many staff they should hire. It's left to municipalities to organize care. The result is that there is considerable variability. For example, one municipality outside of Stockholm contracts all services for older people to private contractors, while other municipalities run 100% of the services themselves.  Some municipalities have proportionately more nursing home beds and others have fewer and instead emphasize home care. 

This allows modifying services to meet local needs. It also allows for innovations. Some communities, for example, are building something called security housing, which targets people over 75. In this housing, people have their own apartments and can live completely independently, but there are personnel available to help them if or when they need it. Meals are available as well as other onsite services. The idea is that community services can be provided more efficiently if people are grouped closer together, and the arrangement may help people stay at home because they feel secure that they will get help, if they need it. 

Contrast that with the U.S. Here everything gets specified in excruciating detail.  The laws specify what you can and cannot do in this type of housing, rather than allowing experimentation to determine what works best.  Spelling out exactly what a program must do leads to checking off tasks, rather than doing them well. It does not allow for local variability  or innovation. 

According to Steffan, local services reflect what elected officials choose after consultation with the staff who run the programs and in open discussions with people from the community.  Steffan told us, "It's beautiful to work in this system.  The democratic process works well."

When did you last hear a program manager say that their work is beautiful?

A Different Kind of Senior Center

In the afternoon, we visited Hörnan, a neighborhood center that provides some of the functions of a senior center.  The big difference is that the program is run largely by older volunteers, with only one part-time paid employee.  This creates a vibrancy in the. program. It belongs to the people who run it.  People can drop in when they want to have coffee, talk, play games, or listen to a speaker. We listened to a speaker who told us more than we ever thought we wanted to know about passenger ships, but we got the point. 

Steve: Geriatric care The Swedish way

These are shops where local artists display their work.

It's been cool and rainy for the past 4 days. I went out today with the maximum layers I could put on.  The students have remained focused and uncomplaining despite the weather. What we are learning is compelling.

Today the focus was health care. We traveled to Ryhov, which is the regional hospital, to meet with the geriatrics team.

There is much that can be admired in Swedish health care. It is affordable and there is universal coverage. For example, the maximum out of pocket payment for medications is SEK 1500, or less than $200. PER YEAR. Quality is high.

Sweden struggles, however, with the same problems as we do--a growing older population and rising costs. The geriatrics team told us about 2 innovative projects that they are conducting to help the most complex and challenging patients--people who have multiple health problems who tend to go in and out of the hospital and are likely to end up in nursing homes.

The first project is a mobile geriatric team. The goal is to stop the revolving door between hospital and home by bringing care into the home. Patients who are 75+ and have been hospitalized 3 times or more in the past year are eligible to receive care from the mobile team. The team does follow-up from the most recent hospitalization and makes sure all the follow-up care is being done. The team leader, Dr. Daniel Gustavson, called it "Sitting at the kitchen table."  It's where you have an honest, person to person conversation, find out the patient's goals and learn what's really going on so that the team can do what's needed to help the patient stay at home.

As an example, at the initial meeting, which can last 1 1/2 hours, the geriatrician and nurse  check the patient's medications. According to Dr. Gustavson, only 5 of 150 patients visited so far had the correct list of medications to take.

Home visits continue for up to 2 weeks, until the patient's situation stabilizes, and patients or their family can call the team if they have questions or run into difficulties. 

The project is still being evaluated, but so far it has shown a 62% reduction in hospital days among people receiving the mobile team compared to a control group. You can view a video of that describes more about the team at:

Http://YouTu.be/GCE4bsJgX08

The second project is called ESTHER and takes place in another town in the county. While the mobile team concentrates on follow up of medical care in the home, ESTHER works to bring together all the people and agencies needed to help an older person to stay at home. This includes health care, help in the home with activities of daily living, therapies and other things. The project chose the name, ESTHER, because it is a typical Swedish name among the oldest generations and the members of the project want everyone involved in providing care to ask themselves, "is this good for Esther?"  In other words, to personalize what they are doing.

As an example, after a hospitalization, members of the team provide "Welcome Back Care."  Before the older person gets home, they make sure the home is in good order, the bed is made, the right medical equipment has been available. They even put food in the refrigerator.

Like the mobile team, ESTHER lowers rates of rehospitalization

The program was chosen by CNN as one of the coolest innovations around the world. You can find an article about it by searching for Project ESTHER CNN.

Steve: Simple Practical Things Make a Difference

Råslätt 2016

On Friday, we visited a nursing home in an area called Råslätt. Marie Ernstt-Bravell, a faculty member in Gerontology, took us there. She said the nursing homes in Råslätt were the best in the area. Why?  It's the part of town where a lot of immigrants have settled. They are happy to get jobs in nursing homes and they are good caregivers. Marie brought the cabinet minister responsible for aging issues to Råslätt to see the nursing homes here, because the excel at what they do, even though it is perceived by the broader community as a slum. We had to point that out to the students, since it does not look like a slum at all, not by US standards.

We visited a program in one of the nursing homes run by an enthusiastic physical therapist. We had actually seen the program in its early stages 3 years ago with the last class we took to Sweden. It is an exercise program for persons with dementia, specifically using various exercise machines. As the PT explained, their cognition is impaired but not their bodies. We saw one class, minus the usual music that gets played while residents exercise. Like in any gym, residents worked out on a machine and then rotated to the next machine.

The PT explained that it is fairly easy to train people to use the machines, despite their cognitive problems.  And there is only one way to use the machines so residents can't get in trouble on them. When the music is blasting with 60s music, there are lots of smiles and laughs.

The program is using the equipment they obtained at the start. The PT said he wants to replace some of the machines. He now has a better idea about which machines work better for this population. In particular, machines should not be difficult to get on or off. The cross trainer they have now works best, but people are able to use all the machines.

When the minister visited, one of the residents was doing leg presses with over 200 pounds of weights.

There has been a small study of the program, which shows positive results. In addition, there are subjective impressions. The staff reports that residents sleep better after exercise, need less care and have lower anxiety. Almost everyone who tried the program has been able to do it.

A student asked the PT what was his favorite part of the program. He said, "The laughs; the smiles on their faces. Residents are always surprising us. Don't underestimate what an older person can do."

He hopes that the program will spread to other homes, but so far there has not been money to do so.

Steve in Sweden: Taking Care of the Kids

Torpa Preschool 2016

One of the highlights of this class for students, and for me, is learning about Swedish public policies concerning the family. We have seen our own kids struggle to balance the care of their children and work. Most of them got little time off after each child's birth.  They struggle to find good childcare and then the cost is as much as a second mortgage payment.  A child's sick days are always challenging, in fact, Judy is on-call to go to Pittsburgh for the grandchildren who are there.

The Swedes are practical people. When they see a problem, they get together to fix it, like how to help parents balance work and family. They have actually been working on it for a long time, since 1900 when Parliament passed a law providing a 4 week leave of absence after birth of a child. Since then, they have expanded benefits to create a comprehensive system of support that helps assure that infants and young children receive good care and helps prevent their parents from becoming overwhelmed.   What they do is really astonishing, especially when compared to the US.

In the US, mothers are guaranteed 4 weeks of leave after giving birth. Without pay. Swedish parents can take 13 months with full pay after the birth of a child and another 3 months at a flat rate, that is, not tied to their salary. They usually spread these days out, extending the leave to 2 years. Some of this time--at least 3 months is "Daddy time."  It must be taken by the father or the days are lost.  There are additional days that parents can take if a child is sick that extend through the school years. With pay.

At some point, usually around age 2, children start preschool.  There is an extensive network of high quality preschools, staffed mostly by teachers trained in early childhood education. Unlike here, the parents do not get socked by high costs. The maximum cost per child per month is $120. Less for a second child. That amount would cover a day's worth of care at some places in the US. The goal of the whole Swedish educational system, according to the lecturer in today's class, is to create opportunities for every child.

I can hear some of you saying, we can't do it here. It's too expensive.

It is expensive, but it's an investment in the quality of life of children and their parents.

We visited a pre-school in the afternoon.  It was a very nice program. The facility was old but serviceable. The teachers were engaged and creative, And the teachers had the freedom to be imaginative in creating activities for the children. There was music, art, running around, and a garden with fruit trees and vegetables planted by the kids.

While we might not be able to duplicate this kind of comprehensive program, maybe we could do some of it. And then, in time, we could expand it to meet more needs.  It's practical and solves a problem.