The healthcare professionals were asked about their perceptions of quality of homecare and how that could be recognised in practice. This encouraged them to expand their discussions around what the pros and cons of the close-care model might include. The participants described the hopes and expectations regarding the need for tailored time in relation to caring for older adults at home and to be able to share professionality within the close-care team as well as having a functioning care chain cooperation. When working close to the older adult at home, next of kin are often close, and with complex care needs in old age, end of life care might also be present. The following themes emerged: Secured care satisfaction, Person tailored time, Shared professionalism, Care-chain cooperation, Caring for the next of kin.
The healthcare professionals talked about the opportunity to deliver care-satisfaction at home. The primary aim is to make it possible for older people to stay at home with high quality care. According to the participants, quality homecare also needs to have a physician to contact and cooperate with. In the close-care model, the physician is present one day a week and can be reached on other weekdays, which is a significant difference compared to traditional homecare service. Delivering homecare through cooperation between physician, nurse, enrolled nurses, and rehabilitation professionals is explained as being a prerequisite for care satisfaction from the personnel perspective of care but also something that in their view could secure patient satisfaction. Nurses have the possibility of finding direct medical guidance from the physician which makes homecare more satisfying for those delivering it. Moreover, experiencing more cooperation between care professionals leads to further care satisfaction. In FG 1–3 the superlatives stand out as they are about to start working in close-care. They explain that it feels unbelievably luxurious to have such a small group to work with and that nurses and physicians are there. The experienced care satisfaction is also discussed within the group of professionals after having worked in the project for a year (FG 4–6) but fewer superlatives are used. Care-satisfaction is expressed regarding the different professionals in place and that the physician is easy to get in touch with apart from being there in person one day each week. Knowing one´s caregivers also add to the experienced care-satisfaction in terms of feeling safe and secure for the older adults. The fact that the care is adjusted to the person is also mentioned and described. "The patient also knows the staff […] the same people come home to them […] I think it leads to an increased feeling of being safe and secure” (FG4).
Healthcare professionals being able to create relations and continuity to promote wellbeing for the older person with multiple care needs is an important part of secured care-satisfaction according to the professionals’ perspectives. “...that we create relations […] also support their mental health.” (FG5) This is related to the fact that the patients feel safe with those who come to work in their home. Continuity in care and feeling safe and secure are discussed in all focus-groups.” …that we create relations […] also promote their mental health through the assurance of those who come they feel better” (FG 6)
Securing care satisfaction is also related to holding on to person-centred care, which is mostly discussed indirectly in the focus-groups before the start of the project. However, person-centred care is only mentioned explicitly once as a concept (by FG 2) even though there is a lot of discussion about putting the person in centre and adjusting the care to the person. The enrolled nurses discuss the person’s influence in care and there are some differences in how much that is possible in every situation. Being there for the person caring with heart and feelings forming alliances and mediating trust in the person is described as also giving the person the possibility to decide about their own life.” To work with heart and feelings and mind and really let the person herself […] decide about their life. That we have an alliance” (FG1). The nurses discuss this in terms of trust (FG 2). Participants in FG 1 talk about their own feelings of care satisfaction: “It should feel good in your heart when you go home at the end of the day”.
Person tailored time
The focus group discussions present the close-care model in terms of caring with having enough time. There is agreement that person tailored time is important when developing a close-care model (FG 1). With more time to form individually there is time to see and care for the whole person. An example is told by an experienced homecare worker, an enrolled nurse who argues that to be able to support a person to walk, you simply support the person walking around a few times in the person's home, with a walker- each visit. When cleaning, you can include the person to do some dusting or in personal care to comb their own hair (FG 3). Unscheduled time is needed to enable caring for the whole person. Being flexible in one’s care, actions steered by the needs and feelings of the persons are preferred by the participants. Having person tailored time is often repeated. But there are also voices of doubt about whether everyone is going to be equal in this new close-care model.” That there will be time, this is most important for good care […] I don´t think there will be time […] no, but I hope there will be” (FG 3). The participants’ comments show the ambivalence, the need for person tailored time, time not allocated to a particular task and doubts that it would really happen. “I think it is that (time) which is what we all worry about, because we have our backgrounds from a stressful environment, both from care homes home help/care, hospital” (FG 3).
A different voice among them comes from an enrolled nurse who has experience of having plenty of time, thanks to structured tasks, the worry was now if it was enough time when doing her duties. In FG 3 the discussions centre around time and how the close-care model works. Since the patients have varied needs and their conditions can vary, flexibility in work is needed according to them. “How the hell can we put a time frame on ill persons”? (FG 3) It is worth noticing that this is said before the implementation of the close-care model and after a lively talk on this theme the conclusion is that they will take the problems when they come. In FG 4–6 time is also mentioned a bit more concretely as a necessary requirement for quality of care. For example, having person tailored time is related to the person/patient feelings of trust in experiencing a safe and secure situation.
I think it is important that one makes them feel safe and secure with oneself (the care personnel) when one comes. That one not only comes in and is super stressed; that one comes in and has tranquillity after all. […] yes, that we have the time […] I am in a patient´s home and something happens that makes me need to stay longer. I will then simply call some of my colleagues and they will take my next visit, because we have the possibility to do so (FG 6).
Time to listen and to help, not being in a hurry, is emphasized in FG 5. This is related to new work challenges, such as feeding with a tube. Discussions also question whether there will be time to learn new skills, or whether they will be allowed to work side by side. However, it is also possible to save time as the following quote from FG 5 shows: “To not have to go to the primary care centre […] here once again time is very, very important. It often depends on it.” The participants underlined that caring and safe medical conditions really depend on having enough time. After a year of the project confidence is expressed from experience that the close-care model works in relation to the person tailored-time goal, and this really pleases the healthcare professionals. In relation to distance and travel time between patients’ homes there are still some difficulties with the planning.
Another situation that often occurs and which needs person tailored time and continuity in care is at the end of life. “I myself come from a care home, then we of course we are with the person at the end of life, palliative care” (FG 6). She tells how she and another carer wash and clothe the dead person, and that next of kin then say farewell. “We need that time because they will soon die. But if we have too many users, we don’t have the time... It is in this way that we should work, I think. We should follow then until they say “goodbye” (FG 6). Having worked at care homes means that the chance of being experienced in end-of-life care is greater than for an enrolled nurse /nurse aid working in home help/home care.
According to enrolled nurses, caring is related to shared professionalism in the team. Home care enrolled nurses work closer with nurses and rehabilitation professionals. This lifts the status of home care personnel, creating opportunities to use everyone’s competences. The mix of professionals in the new project may add further quality to the close-care model.” That one knows one's job- in a team” Some have experience from homecare, others from hospital care” (FG 3). This group discusses shared professionalism prior to the start of the close-care model. Communication with home care/home personnel between, for example, the physiotherapist means rehab personnel and nurses have the same line of thought. “To share work experiences and together develop professional knowledge” (FG 3). That smaller interprofessional work groups would enable shared professionalism is often mentioned to benefit the older adult receiving care at home. The other professionals depend on and trust the enrolled nurses and even know them by name “… they know who is coming” (FG 3). Shared professionalism with respect and trust in different competencies is seen as a prerequisite to close-care. “That visiting staff are competent, not only to carry out things practically but in the encounters...that one is professional and competent” (FG 1).
Most focus group participants are enrolled nurses. Shared professionalism is an issue which evokes strong feelings among some of them. Those who identify healthcare competence as their main competence feel underestimated.” […] I am terrified that the prerequisites we are told to have won´t be there” […] then we would become an ordinary home help/home healthcare” (FG 3, several voices). Later in the same interview someone adds that” we are after all more multi-professional […]” They end by saying” […]no one will send home patients with us. So, we won´t be able to show our competence.” In FG 5, even after having implemented close-care the worry is still “[…] Not only wipe” number two” […] that we will have more challenging cases […] more responsibilities”. Others seem to be satisfied with their professionalism being part of holistic care, where the `dirty bodywork´ is included. “I experience that care is all this […] that is around, thus shower and hygiene and eating breakfast, this that makes the flow of everyday life.” (FG 3).
The enrolled nurses express in the early stages of the close-care project that fine goals may not be met or may be removed. However, focus groups after a year of implementation are more positive about how the close-care model develops. In FG 5 there are voices of hope that the intention of the close-care model will survive, and this spirit will continue. Their discussion relates to identified obstacles connected to shared professionalism, since not all have the necessary medical competencies.
Professionalism is also discussed in terms of how the team structures work. The division of time with separate responsibilities is developed after a year of practicing the close-care model. The separate responsibilities, however, are more restricted than were discussed beforehand. At the beginning the assessment decision on care interventions made prior to close-care was not so strictly followed, care staff helped with everything. But now it is more structured you must follow the assessment plan, “we follow the decision and do it.” And we talk about it in the group so that all are aware of” what do we have a decision on”? So, that is something that has changed as well.” (FG5).
There is also talk about the improvements they have experienced in comparison with ordinary home help:” It takes several days less for the patient to receive help”. Discussion continues” Don´t take in too many patients because it then becomes like normal home help and we would have to run the heck out of us, that is not how it should be, it won´t be good” (FG 5). So, with experience of the new way of working this quote shows that there is a risk of going back to the old way, with too many older people to care for and limited visiting time.
The latter focus groups mention both specific and interrelated aspects of professionality, the closeness so conducive to effective communication is exemplified by the fact that registered nurses (RNs) and enrolled nurses sit in the same room (FG 5) and the wish “that it will continue in this spirit” (F6). “The most important thing, is what we say all the time, it should be close-care.” They mention that their knowledge creates safety and that the way they encounter each other is so important.” […] they kind of thank God every day for us” (FG 6). The same group concludes that now they have succeeded with everything, yet they also bring up problems they must deal with such as language – in a positive way. A detail worth mentioning is that in FG 6 the physician is referred to by their first name, which suggests that after a year of working as a team in close-care, a sense of closeness is created.
When the roles of the occupational therapist (OT) and physiotherapist (PT) in the team are brought up, FG 1 say “we hope they (the OT and PT) want to come into the team and have time and engagement.” Their expertise is important for managing daily life at home, for example the OT has the important role of checking the home environment to prevent falls (FG 3). The double system of PTs in both municipal and regional employment is seen as an obstacle to shared professionalism.
Before starting to work in close-care FG 1 express views on how care may improve by sharing professional knowledge. They emphasize the importance of having a physician who can make assessments in the homes of older adults with complex needs and that the enrolled nurses can do more health and medical care. Traditional phone calls and digital solutions are used to enhance communication “nurse, enrolled nurse, physician, occupational therapist…the cooperation and communication in the group and the competency, to learn from each other” (FG 2). FG 2 add how important it is to work in the same way, to write in the carry out plan and to share one´s experiences.
Before starting close-care FG 1are not sure exactly how the cooperation is going to be formed, beyond understanding that the primary care physician will be able to contact the hospital in case a person needs to be moved to the hospital without going through the emergency department. The close-care team can serve as a care chain, a bridge between the medical organization of the region and the medical care administered at home. FG 3 add “To escape going to the hospital it is necessary to have a doctor nearby who can come home and make an assessment, and that we can do a bit more a bit more health and medical care… the whole chain as we say, where home care staff can do delegated tasks.”
Related to care-chain cooperation is attaining the goal of fewer hospitalizations: “There are those who have not been to the hospital at all since we came into the picture” (FG 5).
System wise communication between the two different organizational systems of region and municipality is a recurring theme from several perspectives. This is the case in relation to the two categories of professionals of OT and PT. With one OT and one PT it is in a way easier to introduce them into the team and to the older adult/patient. However here an organizational problem is mentioned and there is a wish that the PT from the region and the PT from the municipality are synchronized, “that the rehab staff are on the same loop of thinking as we are now” (FG1). Close-care team meetings are mentioned by FG 2 as a safe way of finding solutions to such problems. There is some doubt that there will be enough time or interest to attend from OTs or PTs for team meetings. However, in the focus group containing an OT and PT one participant says they will invite them “we will also think of you “(FG 4). Dietitian, counsellor and “elder-nurse” are also mentioned. FG 4 also pinpoints, a special nurse to liaise between the region and the municipality.
The latter groups (FG 4–6) bring up some problems, such as in the evenings when there is less flexibility, and wish they were “a bit more engaged”. They also ask for more timely technical assistance “it is a bit of slow motion: one wants more drive... (FG 6). However, there are positive comments “that we as enrolled nurses go out, that we then have OTs and PTs and physicians and registered nurses backing us up. So that we can feel safe and ask and... It becomes good work with a team” (FG 4). If cooperation fails such as when not being able to communicate on how to work with the same line of thought, then there is a problem, and the hope is that team meetings help them solve such problems. This is discussed specifically in FG 1 who also say explicitly: “It is kind of a whole chain”. A concrete suggestion by FG 5 setting the starting point in the care chain is that the so-called contact person in the team welcomes and has the first meeting with the new person receiving close-care.
There is discussion about the different documentation systems between the region and the municipality and the barrier these places on effective communication, "It would have been clear as a bell if we used the same journal (documentation) system” (FG3). There is optimism that they will we be able to enter each other's digital patient documentation systems. However, having a shared documentation system is a wish outside the care personnel’s control, where some seemed less optimistic than others.” The only thing we can see is our regional nurse who can go into […] the regional journals and then she can see when anyone else is there” (FG 6). The implementation of a shared documentation system is ambitious although several groups talk positively about VIVA as the main system and other possible ways of bridging gaps between parallel documentation systems. Communication and team meetings are emphasized as being vital for handling these gaps. FG1 talked about this problem of separate documentation systems in an easy-going way “...it is so exciting to see how it will turn out”. FG 2 describe VIVA as supporting communication within the team, through its `message function´, but they find it is also important that there are thorough care plans. The need to build up a system, a routine, for documentation is specifically called for by the same group (FG 2). This is also a general theme in other groups. One focus group (FG 4) specifically talk about the two different laws regulating their care work: social services law and healthcare law, which create a division in planning and carrying out care.
Night personnel are specifically mentioned by FG 2 and FG 4, where communication barriers are a problem. These need to be solved to make the care chain complete, since they do not belong to the close-care team and are not able to communicate directly with them in the team. Likewise, a suggestion to solve the communication barriers is to have a registered nurse working in the evenings and at weekends, who can transfer messages between different care personnel. The close-care model does not work around the clock, and takes place in the last part of life for the older adults with multiple needs in focus here. End of life care is not specifically asked about by the interviewer. However, palliative care is mentioned by several of the focus group participants. While no explicit comments on the care chain, in terms of the palliative care team, commonly linked to the hospital, are voiced, FG 4 state that:
[…] being able to decide from the beginning that I want to die at home…and if we would not be there with nurses and physicians and occupational therapists and everything behind us…then it would not have gone so well at home”. FG 5 says that” the good thing with our group is that we have some from home help/ home healthcare, some from care homes where it is a matter of course to be with them at the end of life, palliative care…this is how we should work
To be close to the next of kin
One gets to know the family well working in a small group- but that is also the case in ordinary home help (FG3). Several groups mention the importance of meeting the couple living together at home. Various perspectives come up related to next of kin to the older adult with multiple needs having care at home. It is noteworthy that next of kin are part of the care context and an important resource, providing the older patient in focus allows it (FG 1, FG 2). However, the risk of next of kin taking control from the older adult in focus needs to be considered. For example, one participant in FG 3 says that it should not be the opinion of the next of kin that decides on pain relief. FG 1 also mention that safety is created by having the next of kin participate in the care. The importance of listening to next of kin with sensitivity is emphasized by many.” Next of kin, it can be a great grief for them, that their husband or wife…they also need care”. But awareness that the relationship is not always good is also expressed.
Some next of kin you must really push… that they can take help from us, we must remind them that it is their right to relief care” (FG 4).
“We help each other, so we are as dependent on next of kin as they are on us” (FG 5). This acknowledges that it is due to the input of next of kin that many older adults can continue to live at home, and that care personnel sometimes must remind them to ask for help and use the available relief services (there are municipal relief services for next of kin) “...we somehow work in a team also with the next of kin”. In FG 6, quite detailed reports on how the care personnel communicate with next of kin are given, regarding house cleaning, laundry, walks, medicine and inviting them to next of kin meetings (which is another service offered to support them). One voices that the cooperation with next of kin works so well; “I am so meticulous to call next of kin if something happens and they can call us even if it is only to ask ´Does anything need to be bought this week? Well then, we check what needs to be bought” (FG 6).
There is a dilemma when the person with complex care needs dies, and the other spouse becomes alone and must change care staff (not being eligible to close-care) (FG4).
FG 3 also brings up the feeling of being in safe hands since anxiety can be strong for the spouse at home. The added competence from all in the close-care team can form a care-chain that lasts until death arrives.