Definition
As in most European countries, the Dutch sector for care for elderly persons exhibits a shift from supply-driven to demand-driven approaches in care and service provision. According to these approaches, care and related services in welfare and housing should contribute to the fulfilment of care-related needs of individual elderly people and, therefore, to their perceived quality of life [
46]. In the Netherlands, this trend is known as being one towards demand-driven care (DDC) and demand-oriented care (DOC) [e.g.
44,
46]. Other concepts that can be found in international literature are ‘consumer driven health care’ [
21], ‘patient/client centred care’ [e.g.
38,
39], ‘patient/client oriented care’ [
59], etc. Although differences can be seen among the approaches, in terms of their specific emphasis and degree of client-centeredness [
5,
46], all developments represent a client perspective on care and service provision. We will define this general trend, which takes client demand as the basis for care and service provision, as one towards demand-based care, where ‘care’ encompasses services in housing and welfare as well. As such, we acknowledge the importance of the client’s central role. However, for the purpose of this paper, it is not relevant to go into a detailed discussion on the different emphases of all terms used.
The concept of demand-based care aims to give individual needs and wishes a more central role. As opposed to supply-driven approaches, where existing supply is the point of departure for care and service provision, the individual user’s wants and needs form the starting point in the demand-based approach [
46]. To accommodate individual demand, however, it should be clear what exactly clients’ needs are and what these needs imply [
64] for the organisation. Therefore, we now address the characteristics of our target population’s needs and subsequently translate these into implications for day-to-day care and service provision.
Needs: Diverse and Subject to Change
The concept of need generally refers to a condition characterised as ‘some disturbance in health and well-being’ [
64]. An individual elderly client perceives a disturbance, or gap, when the individual’s current state does not match the desired state in health and well-being. Intervention, then, is necessary to close or diminish this perceived gap. When the gap can be closed or diminished by services in housing, welfare and care, the individual elderly client is said to be in need of these services [
30].
Although all needs for HWC services exist because of some perceived gap or disturbance, the concept of need might vary considerably among elderly clients and can be transient and subject to change. First of all, variation is caused by differences in the current states of individual clients. An elderly client with diabetes has different needs from an elderly client who currently suffers from a broken hip. Even if two individuals have the same disability, they might perceive different needs [
64]. Elderly clients vary a good deal with regard to their health definitions, preferences, desires and priorities [
75]. These aspects will all influence the determination of the desired state or goal an individual elderly client wants to reach, and this makes the goal in health and well-being highly personal [
32]. For example, an elderly client who is recovering from a stroke has always been accustomed to clean her house herself. Therefore, she might feel it is very desirable to work towards a state of health in which she will be able to clean her house again. During rehabilitation she needs her care professionals to support this goal by means of physical therapy, for example. If she cannot recover fully, this elderly client will need help at home, where the domestic help will take over the heavy household work. Furthermore, the domestic help worker might assist the client herself to do some light household activities, such as dusting. Another elderly client who is also recovering from a stroke is used to contract out all cleaning activities: regardless of this lady’s state of health, the house is cleaned every week by a private cleaning lady. This client, therefore, perceives no need in this particular aspect of her life and might feel that it is much more important to focus on other aspects during rehabilitation. To reach the goals of these two individuals, and close the gaps between their similar current states but dissimilar desired states, different services in housing, welfare and care are needed. The need for care and related services, therefore, is highly personal [
31], since it depends on the perspective of the individual [
32,
47]. As such, great variety in needs for HWC services can be expected among elderly clients living independently.
Furthermore, the needs of an individual elderly client are changeable. Needs might alter over time both as a result of changing health conditions, which could either deteriorate or improve, and developments in knowledge [
64]. These developments might alter either the current state of health and well-being, or the desired state. When the perceived gap between the current and desired state diminishes, manifest needs might disappear; when it increases, latent needs might become manifest. In both cases, manifest needs might change in content, breadth or depth. For example, an elderly client who currently has problems with bending or stretching needs some assistance in the morning when taking a shower. Over time, his condition might deteriorate, and as a result, he will need support when getting out of bed and total assistance when taking a shower.
Both variety among elderly people and variation over the life course of an individual elderly person cause a high diversity on the demand side of HWC services. This will have implications for the supply side of HWC services, when organisations aim to provide their care and services in a demand-based manner.
Conversion to Daily Practice: Implications for Providers
The concept of demand-based care stimulates providers of care and related services to be sensitive to the diversity in needs. However, the provision of a care and service package that is exactly in line with each individual client’s preferences is not feasible for most care and service providers. Instead, organisations look for broader classes of clients, or segments, that can be reached more efficiently with options that match their unique needs [
24], also with respect to independently living elderly clients, segments have been identified [
35‐
37]. Within these segments, elderly clients have similar needs and requirements that differ substantially from the needs of elderly clients in another segment. At the same time, the needs of individual elderly clients within a particular segment might show a slight diversity [
12,
35]. Over time, the needs of an individual elderly client might change, which might even cause a shift from one segment to another.
An organisation that adapts its supply to segments recognises that clients differ in their needs and perceptions [
24]. For each segment of elderly people, a generic package of HWC services can be identified that matches the needs profile of this segment. However, due to the differences amongst individuals within a segment, this generic package requires further specification and its contents need fine-tuning [
35]. On the supply-side, services in housing, welfare and care can be better tuned to the diversity in needs when the available range of options in service supply increases [e.g.
16,
73,
75]. Only then will clients be able to fulfil their needs with care and services of their preference, given their personal background, taste and circumstances.
Choice options within a certain type of service are required to provide an optimal solution per individual. When alternatives are offered, elderly clients themselves, as much as possible and as far as they desire to avail themselves of the options, can select those that are best suited to their needs [
16].
In addition, the set-up of the care and service packages should be flexible. As well as choice options in the individual types of care and services needed, variation has to be enabled when combining different categories of services into a single package. Variation will allow for diversified care and service packages among elderly clients. Moreover, variation in HWC services is needed over the life course of an individual elderly client. Depending on the current state of health and well-being of the individual client, needs arise in order to enable him or her to stay in his or her own living environment as long as possible. However, this situation changes over time, mostly due to deteriorating health, and therefore adaptation and expansion in the nature, amount, and intensity of care and services will be required at different points in time.
Furthermore, to continuously provide the optimal answer to the needs of an individual, organisations have to
interact regularly with the elderly client. Clients value being involved in the care process, being taken seriously and being consulted in the determination of their needs for care and services [
48] with respect to their goals and preferences. As such, an organisation providing HWC services should arrange its care and service processes in such a way that they explicitly and adequately cater to the needs and requirements of elderly clients [
68].
Finally, when examining an elderly client’s needs for housing, welfare and (long term) care, organisations often tend to make strict distinctions between these main pillars of care and service provision [
10]. However, for an individual elderly client, these services are interrelated since they all enable an elderly person to continue to live independently as long as possible. Therefore, when taking client demand as the basis for care and service provision, HWC services need to be provided as an integral and coherent package. For providers, this implies they
jointly have to deliver an optimal package of HWC services as an integral answer to the multiple needs of their elderly clients.
To sum up, a variety of needs exist among elderly clients and over the life course of an individual. To both recognise and manage this diversity, segmentation of the elderly population can be of help. Furthermore, to fulfil an individual elderly client’s needs in a demand-based manner requires organisations to develop choice options and variety, and joint provision of HWC services. In addition, organisations should interact with elderly clients in order to determine their individual needs and wants, and be able to act upon them. Having determined several important implications of demand-based care on the operational level, it is time to look for principles and practices that will help HWC providers in dealing with these specifics. We turn therefore, to the field of OM; this field specifically addresses the organisational level where goods and services are actually delivered to the client. To get an idea of its contents, we will give a general introduction to OM in the next section.