Why It Matters
On a recent trip to Norway, IHI Senior Fellow Maureen Bisognano learned about innovative models of elder care — and why she shouldn't hold the door for a 71-year-old stroke survivor.
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New Models for Elder Care: 3 Ways Norway Inspired Me

By Maureen Bisognano | Tuesday, April 12, 2016

Maureen Bisognano patient-centered elder care Norway

Maureen Bisognano, Senior Fellow at IHI, met 71-year-old Jarle in an independent living facility in Norway. Last May, he suffered a massive stroke.

On the plane flight from Boston, I thought about what I would teach and what I would learn in Norway. Each time I travel with IHI, I think about how my curiosity quotient (CQ) will be filled. Learning by seeing is one of the best parts of my role as a Senior Fellow.

Health care innovators in Norway had invited me to speak at several leadership and safety meetings. I also had the great joy to spend time visiting care sites. Anders Vege, Head of Section for Quality Improvement at the Norwegian Knowledge Centre for the Health Services, served as my guide. We visited with patients, carers, and health care professionals in long-term care settings.

In Norway, as in many countries, the population is aging and the burden of disease is increasing. Elder care will need new designs and new models. Here are three things that most inspired me on my trip to Norway.

1. Raising expectations for how much patients can do for their own health

Before I went to Norway, I’d never heard a common term throughout Europe: re-ablement. Re-ablement is what it sounds like — helping people return to their ability to take care of themselves and their health. It goes beyond rehab to provide comprehensive support for patients who are recovering from acute care and returning home.

An interprofessional team of occupational therapists, social workers, physical therapists, and nurses work with patients in their homes. They offer intense rehab and support for daily household tasks, with the understanding that this support will drop off as the patient takes over more and more of this care on their own. The entire approach is based not only on their clinical care needs, but what matters most to them — what health goals they most want to achieve. They look to build on patients’ assets, and not to be limited by today’s constraints.

Thomas Lystad, a leader of the re-ablement team, led me on the learning journey. The idea, imported from a municipality in Denmark, was adopted in 2012 to respond to increases in need and constraints on resources. The team has now grown to 25 full time employees, and in addition to the amazing outcomes for patients, the team saved the municipality US $3.5 million last year by using less cost-intensive care.

I visited a patient who was living in an independent, supported living community after suffering a massive stroke last May. Jarle, now 71, would surely have ended up in a nursing home in many systems in the US, where dependency is almost encouraged. Instead, he went through re-ablement care. It was so beautiful to see this man living independently.

At one point, I was walking down the hallway with him and offered to get the door. The re-ablement staff basically told me to back off and let him do it himself. My inclination was to help, to do for Jarle, but Thomas and his team have a different outlook. They encourage and enable patients to do for themselves. And they find that they are able to achieve the IHI Triple Aim of better health, better care, and lower costs when they care with people rather than for them.

2. Safety and patient-centeredness in long-term care

We also visited Oppsalhjemmet-Stovner, a long-term care facility, and met an innovative and committed leadership team with a forward-thinking approach to safety and patient-centeredness. Dr. Stefan Ore and his team showed us what safety in long-term care can do to protect the residents. Everywhere I looked I saw run charts on every possible defect. And they live every day asking “what matters to you?” They see the residents in the broadest way, not only tracking clinical goals and outcomes but also focusing on social supports and joy in living.

Each resident had a bulletin board displaying the question, “What Matters to You?” and their answer. One man said he wants to drink a scotch every night at 5:00 PM. Another patient said she never wanted to be taken out of her room without her make-up on.

It reminded me of how far we need to go to provide not only safe care but also social connections and vibrancy in long-term care.

3. The importance of leadership to create a vision and signal culture

I spoke at a conference of 800 health care professionals organized by the Norwegian Directorate of Health. I was fortunate to give my plenary just after the Minister of Health and Care Services, Bent Høie, who shared a powerful message about culture and modeled what a transparent, open system looks like. Bent was courageous enough to say that the system performed less well in safety this year than it did the year before, and encouraged both staff and patients to speak up when they see something that’s not right.

In a great example of the beauty of “and” rather than “or”, Bent also shared a vision that went far beyond health care alone. He envisions a role for health care in promoting health in the community. His vision reminded me of the Triple Aim — keeping people healthy while also getting better at caring for them when they’re sick.

People from all over the world invite me to teach them, but when I travel, I learn just as much. I’m grateful for all I learned from Norway’s excellence in elder care. How might you take up these ideas? Leave your thoughts in the comments.

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