Background
Demographic change is a defining issue of our time. Some of the main features of demographic changes across the globe are an aging population, fewer births and smaller households, and gradual erosion of extended family supports – all with implications for the future of welfare and healthcare delivery [
1‐
4]. The European Commission (2020) [
1] outlines that the main challenge is, and will be, meeting a growing demand for sufficient, accessible, good quality, and affordable health care services. Strengthening long-term care services is part of the solution to this challenge, both for high- [
5], middle- and low-income countries [
2,
6,
7]. ‘Long-term care’ involves services specifically directed at people who cannot care for themselves due to, for example, chronic illness or disability. It involves a variety of services provided in the home, in assisted living facilities or in nursing homes to address medical and non-medical needs [
8]. One of the current challenges in long-term care is to identify optimal models of care [
9] responsive to demographic, economic, and social trends affecting care delivery across the globe [
10]. A ‘care model’ broadly describes the way healthcare services are delivered [
11] and offers guidance and direction on how to deliver services to the population served. Research on models of care that can provide high-quality, person-centered long-term care are relatively scarce [
12], and there is limited knowledge of different care models unfolding in the long-term care service landscape.
To fill this gap, the article aims to 1) identify and characterise models of care in Norwegian municipal long-term care services according to four modes of service delivery, and 2) analyse whether the identified care models vary with regard to municipal characteristics, more specifically ‘population size’ and ‘income’. Previous research has shown that for example population size and income were associated with the availability of specialised municipal services [
13,
14] and scope of assistive technologies [
15] and that municipalities with less financial leeway had a wider range of assistive technologies than those with a stronger economy [
15].
Discussion
The main objective of this study was to identify and characterise care models in Norwegian municipal long-term care services. Four care models were identified. The models differed in how much they seemed to prioritize the following four modes in their care delivery: Specialised municipal services, Assistive technology, Health Promotion and Activity and Planning and coordination of care. Moving forward, we want to note that we are not able to, nor is it our intention, to state that municipalities belonging to one care model provide better/worse services compared to municipalities in other models, or that some municipalities provide their services in a right or wrong way.
The different models appear to represent a continuum of care delivery and might represent different stages of development, where some municipalities are further along than others in implementing national healthcare policies in their long-term care services. Care model 4 was located at one end of the continuum. The municipalities in this model seem to give priority to all modes, providing a high number of services within all four modes. This reflects a broad effort to implement national health policy, like use of technology, active ageing and integrated care. Developing such services are supported by legislation and different type of national incentives. As a result, Municipalities in care model 4 will likely have more differentiated service delivery than municipalities belonging to the other models.
On the other end of the spectrum, we found the municipalities in care model 1. The municipalities in this model provided a small number of services within all four modes, having few specialised municipal services, assistive technologies, and services for health promotion and activity and for planning and coordination of care. In such, they may have a more generalist approach, meaning that their service delivery is organized as broader services intended to serve a wide range of people with varying needs (e.g., care coordinator, day services), rather than more specific services for given conditions or needs (e.g., dementia coordinator, day services for people with dementia). This is the traditional way of providing long-term care in Norway [
14], and the largest group of municipalities delivered services according to this model. Between Care model 1 and 4, we found Care model 2 and 3 which seemed to prioritise some modes of service delivery over others. Care model 2 gave high priority to planning and coordination of care as well as health promotion and activity. Planning and coordination of care is building a foundation for other priority areas later on, while a focus on health promotion and activity may be indicative of the fundamental shift form treatment to prevention, as seen in Norway and across the world. Care model 3 prioritised assistive technologies the highest and gave relatively high priority to services related to health promotion and activity. Together, they can be seen as synergetic modes of service delivery. This is because common assistive technologies are intended to contribute with early intervention, provide tailored patient education, medication and appointment reminders, and prevent adverse events and outcomes including falls, loneliness and cognitive decline [
54,
55], even though we know that that is not always the case – municipal practices have been dominated by piloting [
56‐
58], and welfare technologies are still not fully integrated into long-term care services and impacting patient care [
15].
Municipal characteristics were distributed differently among the care models. The most distinctive differences were between the Care model 1 and 4. The relatively few municipalities in Care model 4, were large in terms of population size. A large population entails larger volumes of patients, likely more social heterogeneity, and large variations in care needs, making it more feasible, sustainable, and necessary for these municipalities to organise and provide a wide range of services to serve varying needs and diagnoses. This is in accordance with previous research, which has shown more specialisation in larger municipalities [
13]. This organisation and specialisation may result in more delineated and clearly articulated service provision, compared to the smaller municipalities representing Care model 1, providing services with a generalist and flexible approach [
27]. Furthermore, municipalities in Care model 4 had the lowest municipal income compared to the other care models. Prioritising services within all the modes of service delivery may be due to a more strained economy which may drive innovation in service provision [
59], both in terms of what services are provided and how they are distributed, delivered and governed [
60]. Municipalities with less financial leeway may need new or different ways of providing long-term care services because they cannot afford to maintain the status quo and need novel solutions to sustain the required standards of care [
15].
With increasing demand for long-term care and a scarcity of resources affecting most health care systems around the globe, there is a need to meet and provide for the citizens in new and different ways, which drives the development of long-term care models forward. This study offers a snapshot of how Norwegian municipalities appear to have responded to a set of challenges facing long-term care. Increased emphasis on specialized training and certification of long-term care staff, introduction of care technology, shifting from treatment to prevention and the need for coordination and integration of care are some of the overarching challenges and external drivers of change shared by many countries [
4,
10,
29]. Our study contributes to show how care models are unfolding in the long-term care service landscape in Norway, where the methods used could be applied globally.
Identifying and characterising different care models can be seen as a first step to improve the quality, efficiency, and sustainability of long-term care [
28]. It is reasonable to assume that different priorities result in differences in service provision and different outcomes for patients and their families. As information about what types of models exist becomes available, it can be used in subsequent analyses of how various models may impact on outcomes on the micro, meso and macro levels.
Still, there are limitations of our study that are important to acknowledge.
The reality is that care models constantly develop, adjusting to national and international guidelines and priorities and inhabitants’ needs and expectations. As such, identifying and characterising care models is challenging, and a cross-sectional approach is likely not a strong study design. Our understanding is that care models are not descriptions of reality, but still, we believe they are useful tools to reflect on, discuss and develop care practices.
As we briefly touched upon, we are not able to produce generalisable results with this study – the care models we have identified and characterised are unique to the Norwegian long-term care setting. Around the globe, different models of long-term care provision have developed in diverse settings, and from very different starting points [
10]. Globally, healthcare systems differ in access, coordination, availability and comprehensiveness of care, and they have to meet the needs of very different populations [
33].
The included modes of service delivery, serving as a foundation for our hierarchical cluster analysis, are not exhaustive, there are other modes that are important for identifying and categorizing long-term care models that were not included, such as the scope of informal and volunteer effort in service delivery, composition, and structure of staff, and more. The operationalisation of the modes could also be more comprehensive, including more and other variables to measures e.g., Planning and coordination.
Furthermore, it was the authors – a team of researchers – who created and defined these modes and decided that they were important components of long-term care models. Not including relevant stakeholders in this work, such as policymakers, long-term care providers and users, is a limitation.
Regarding the study participants, every municipality in Norway was invited to participate, so no specific member of the population had a greater chance of making up the sample than any other. For unknown reasons, there were statistically significant differences between responding and non-responding municipalities regarding population size and municipal income. However, we do not believe that these differences have caused us to draw faulty conclusions, as our sample represented variation on all other variables central to their ability to plan and design their long-term care services.
Our data collection tool – the questionnaire – was carefully developed based on national healthcare policy documents, previous research, collaboration with a user panel and piloted by members of the target group. This facilitated a standardised data collection instrument with relevance across municipalities with varying characteristics, organisation, and prioritisation for their provision of long-term care. However, we only asked about what services the municipality provided and how the services were provided, we are lacking crucial information such as the volume and content of the services. Having or not having a service, is not an indication of whether the populations’ needs are being met or not, or the quality of care. For example, our care models cannot differentiate the level of coordination of care across long-term care services and professionals, nor if, or how, assistive technologies are used. Furthermore, the long-term services we asked about, are not necessarily clean-cut and understood in the same way across all municipalities. One example is our question concerning assisted living with 24-h staffing: some might interpret this as having staff on-site 24/7 while others may interpret it as having staff available/on-call 24/7. Consequently, an under- or overestimation of certain services was possible.
Our data is based on municipal managerial employees’ knowledge of the provision of long-term care services in their municipality, not observations or reports by the service providers themselves. The respondents may have lacked knowledge about the full extent of their municipality’s long-term care services since they were not engaged in hands-on work in the field. Moreover, information to answer the questionnaire may not have been available or could not be generated from the municipalities’ administrative systems.
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