Healthcare professionals' perception of barriers and facilitators for care coordination of older adults with complex care needs being discharged from hospital: A qualitative comparative study of two Nordic capitals.

BACKGROUND: The handover of older adults with complex health and social care from hospital admissions to homebased healthcare requires coordination between multiple care providers. Providing insight to the care coordination from healthcare professionals' views is crucial to show what efforts are needed to manage patient handovers from hospitals to home care, and to identify strengths and weaknesses of the care systems in which they operate. OBJECTIVE: This is a comparative study aiming to examine healthcare professionals' perceptions on barriers and facilitators for care coordination for older patients with complex health and social care needs being discharged from hospital in two capital cities Copenhagen (DK) and Stockholm (SE). METHOD: Semi-structured interviews were conducted with 25 nurses and 2 assistant nurses involved in the coordination of the discharge process at hospitals or in the home healthcare services (Copenhagen n = 11, Stockholm n = 16). The interview guide included questions on the participants' contributions, responsibilities, and influence on decisions during the discharge process. They were also asked about collaboration and interaction with other professionals involved in the process. The data was analysed using thematic analysis. RESULTS: Main themes were communication ways, organisational structures, and supplementary work by staff. We found that there were differences in the organisational structure of the two care systems in relation to integration between different actors and differences in accessibility to patient information, which influenced the coordination. Municipal discharge coordinators visiting patients at the hospital before discharge and the follow-home nurse were seen as facilitators in Copenhagen. In Stockholm the shared information system with access to patient records were lifted as a facilitator for coordination. Difficulties accessing collaborators were experienced in both settings. We also found that participants in both settings to a high degree engage in work tasks outside of their responsibilities to ensure patient safety. CONCLUSIONS: There are lessons to be learned from both care systems. The written e-communication between hospitals and home health care runs more smoothly in Stockholm, whereas it is perceived as a one-way communication in Copenhagen. In Copenhagen there are more sector-overlapping work which might secure a safer transition from hospital to home. Participants in both settings initiated own actions to weigh out imperfections of the system.

Disability pension among persons with chronic disease: Differential impact of a Danish policy reform.

BACKGROUND: In 2013, Denmark implemented a reform that tightened the criteria for disability pension, expanded a subsidized job scheme ('flexi-job') and introduced a new vocational rehabilitation scheme. The overall aim of the reform was to keep more persons attached to the labour market. This study investigates the impact of the reform among persons with chronic disease and whether this impact differed across groups defined by labour market affiliation and chronic disease type. METHODS: The study was conducted as a register-based, nationwide cohort study. The study population included 480 809 persons between 40 and 64 years of age, who suffered from at least one of six chronic diseases. Hazard ratios (HR) and 95% confidence intervals (CI) of being awarded disability pension or flexi-job in the 5 years after vs. the 5 years prior to the reform were estimated. RESULTS: Overall, the probability of being awarded disability pension was halved after the reform (HR = 0.49, CI: 0.47-0.50). The impact was largest for persons receiving sickness absence benefits (HR = 0.31, CI: 0.24-0.39) and for persons with functional disorders (HR = 0.38, CI: 0.32-0.44). Also, the impact was larger for persons working in manual jobs than for persons working in non-manual jobs. The probability of being awarded a flexi-job was decreased by one-fourth (HR = 0.76, CI: 0.74-0.79) with the largest impact for high-skilled persons working in non-manual jobs. CONCLUSION: Access to disability pension and flexi-job decreased after the reform. This impact varied according to labour market affiliation and chronic disease type.

Inequalities in employment rates among older men and women in Canada, Denmark, Sweden and the UK.

BACKGROUND: In most developed countries, governments are implementing policies encouraging older persons to work past 65 years to reduce the burden on societies related to disability benefits and pension payments. Despite this push to extend working lives, we know little about who already works past this age and any inequalities that may exist. Our study investigates the employment rates of those aged 65-75 years of age by educational level, health status and sex in Canada (CAN), Denmark (DK), Sweden (SE) and the United Kingdom (UK). Secondly, we aim to relate findings on employment rates to prevailing policies in the different countries, to increase the understanding on how to further extend working lives. METHODS: We used nationally representative cross-sectional survey data from the 2012-2013 Canadian Community Health Survey, 2013/14 Survey of Health, Ageing and Retirement in Europe for Denmark and Sweden and the 2013 English Longitudinal Study of Ageing to examine employment rates for those aged 65-75 years by sex, educational level and health status (having limiting longstanding illness (LLI) or not). RESULTS: Employment rates decline by age, but we see a linear decline in CAN and the UK compared to an initial decline then a plateau of employment rates from 66 to 68 years in DK and SE. Employment rates among persons aged 65-75 years were lower in the UK than in CAN, DK and SE. Among women, employment rates were highest in SE. Women with low education and a LLI had considerably lower employment rates than men with low education and a LLI (employment rates for men ranged from 27% to 12% compared with employment rates for women which ranged from 12% to 0%). CONCLUSIONS: Our results suggest that educational level, sex and health all play a role in extending working lives. The variation in employment rates between the four countries implies that policies do matter, but that social differentials show that policies cannot be 'one size fits all'. Policy-makers must consider different groups (i.e. low-educated women with a LLI) when designing policies to extend working lives.

Utilisation of psychiatrists and psychologists in private practice among non-Western labour immigrants, immigrants from refugee-generating countries and ethnic Danes: the role of mental health status.

PURPOSE: The stressful migration process has been associated with higher vulnerability for mental health problems, implying a greater need for mental healthcare among immigrants compared with native-born. Our objective was to investigate whether potential differences in the use of psychiatrists and psychologists in labour immigrants, immigrants from refugee-generating countries (RGC), and ethnic Danes could be fully explained by mental health status. METHODS: We conducted a nationwide survey in 2007 with 3,573 individuals aged 18-66 comprising ethnic Danes, labour immigrants (Pakistan and Turkey), and immigrants from RGC (Iran, Iraq, Lebanon, and Somalia). Survey data was linked to healthcare utilisation registries. Using Poisson regression, contacts with private practising psychiatrists and psychologists were estimated. Analyses were adjusted for socioeconomic factors and mental health status. RESULTS: Overall, 2.2 % among ethnic Danes, 1.4 % among labour immigrants and 6.5 % among immigrants from RGC consulted a psychiatrist or psychologist. In adjusted analyses, for psychiatrists, compared with ethnic Danes, labour-immigrant women (multiplicative effect = 1.78), and immigrant women from RGC (multiplicative effect = 2.49) had increased use, while labour-immigrant men had decreased use (multiplicative effect = 0.03). For psychologists, immigrant men from RGC had increased use (multiplicative effect = 2.96), while labour-immigrant women had decreased use (multiplicative effect = 0.27) compared with ethnic Danes. CONCLUSIONS: Mental health status had a somewhat explanatory effect on the use of psychiatrists and psychologists. These selected parts of the Danish mental healthcare system seem responsive to health needs across different population groups, particularly for immigrants from RGC. Yet more attention should be given to non-Western labour immigrants to meet their mental health needs.

Conceptual equivalence of WHOQOL-HIV among people living with HIV in Ethiopia.

PURPOSE: The WHOQOL instruments are intended for cross-cultural studies of quality of life (QoL) but African countries have been poorly represented in its development. This study aimed to explore the conceptual equivalence of WHOQOL-HIV in Ethiopia. METHODS: The fieldwork included home visits, interviews, and focus group discussions with HIV patients and caregivers. RESULTS: We found that although WHOQOL-HIV includes many relevant facets, its applicability has several limitations in the Ethiopian setting. The most salient shortcomings of the instrument relate to the Social, Environmental and Religion/Spirituality/Personal Beliefs domains of the instrument. Themes not captured by the instrument include family responsibilities, disease disclosure, exclusion from common resources, basic needs, adequate food, and job opportunities. In addition, several of the tool's facets such as dependence on medicine seem less relevant. Also, the role of religion is more complex than captured in WHOQOL-HIV. We found that the tool is based on an individualist focus, which tends to overlook the social context of the patient. CONCLUSION: We conclude that the conceptual equivalence of WHOQOL-HIV is only partially attained for use in Ethiopia. The findings from this qualitative study are used in the further process of developing and validating a QoL instrument for use in Ethiopia.

How do general practitioners experience providing care to refugees with mental health problems? A qualitative study from Denmark.

BACKGROUND: Refugees are a particularly vulnerable group in relation to the development of mental illness and many may have been subjected to torture or other traumatic experiences. General practitioners are gatekeepers for access to several parts of the psychiatric system and knowledge of their patients' refugee background is crucial to secure adequate care. The aim of this study is to investigate how general practitioners experience providing care to refugees with mental health problems. METHODS: The study was conducted as part of an EU project on European Best Practices in Access, Quality and Appropriateness of Health Services for Immigrants in Europe (EUGATE). Semi-structured interviews were carried out with nine general practitioners in the vicinity of Copenhagen purposively selected from areas with a high proportion of immigrants. The analysis of the interviews is inspired by qualitative content analysis. RESULTS: One of the main themes identified in the analysis is communication. This includes the use of professional interpreters and that communication entails more than sharing a common language. Quality of care is another theme that emerges and includes awareness of possible trauma history, limited possibilities for refugees to participate in certain treatments due to language barriers and feelings of hopelessness in the general practitioners. The general practitioners may also choose different referral pathways for refugees and they report that their patients lack understanding regarding the differences between psychological problems and physical symptoms. CONCLUSION: General practitioners experience that providing care to refugees differs from providing care for patients from the majority population. The different strategies employed by the general practitioners in the health care treatment of refugees may be the result of the great diversity in the organisation of general practice in Denmark and the lack of a national strategy in the health care management of refugees. The findings from this study suggest that the development of conversational models for general practitioners including points to be aware of in the treatment of refugee patients may serve as a support in the management of refugee patients in primary care.

The association of neighborhood socioeconomic characteristics with cardiovascular health: A quasi-experimental study of refugees to Denmark.

Neighborhood socioeconomic disadvantage is associated with cardiovascular health, although it is unclear which specific aspects of neighborhoods matter most. We leveraged a natural experiment in which refugees to Denmark were quasi-randomly assigned to neighborhoods across the country during 1986-1998, creating variation in exposure to various aspects of neighborhood disadvantage. The cohort was followed through December 2018. Exposures included neighborhood-level family income, educational attainment, unemployment, and welfare transfers measured in the first neighborhood after arrival to Denmark. Outcomes included cardiovascular risk factors (hyperlipidemia, hypertension, diabetes and anxiety/depression) and cardiovascular disease (acute myocardial infarction and ischemic heart disease). Neighborhood-level income and education were most consistently associated with cardiovascular risk factors, whereas welfare transfers were most consistently associated with cardiovascular disease. Addressing these specific aspects of neighborhood disadvantage could therefore lower the risk of poor cardiovascular health among refugees. Future research is warranted to examine if results are generalizable to other immigrant groups, countries or time periods.

Health care for immigrants in Europe: is there still consensus among country experts about principles of good practice? A Delphi study.

BACKGROUND: European Member States are facing a challenge to provide accessible and effective health care services for immigrants. It remains unclear how best to achieve this and what characterises good practice in increasingly multicultural societies across Europe. This study assessed the views and values of professionals working in different health care contexts and in different European countries as to what constitutes good practice in health care for immigrants. METHODS: A total of 134 experts in 16 EU Member States participated in a three-round Delphi process. The experts represented four different fields: academia, Non-Governmental Organisations, policy-making and health care practice. For each country, the process aimed to produce a national consensus list of the most important factors characterising good practice in health care for migrants. RESULTS: The scoring procedures resulted in 10 to 16 factors being identified as the most important for each participating country. All 186 factors were aggregated into 9 themes: (1) easy and equal access to health care, (2) empowerment of migrants, (3) culturally sensitive health care services, (4) quality of care, (5) patient/health care provider communication, (6) respect towards migrants, (7) networking in and outside health services, (8) targeted outreach activities, and (9) availability of data about specificities in migrant health care and prevention. Although local political debate, level of immigration and the nature of local health care systems influenced the selection and rating of factors within each country, there was a broad European consensus on most factors. Yet, discordance remained both within countries, e.g. on the need for prioritising cultural differences, and between countries, e.g. on the need for more consistent governance of health care services for immigrants. CONCLUSIONS: Experts across Europe asserted the right to culturally sensitive health care for all immigrants. There is a broad consensus among experts about the major principles of good practice that need to be implemented across Europe. However, there also is some disagreement both within and between countries on specific issues that require further research and debate.

Expert opinion on "best practices" in the delivery of health care services to immigrants in Denmark.

INTRODUCTION: Delivery of health care to immigrants is an emerging field of interest. Immigrants are frequently characterised by health outcomes that are inferior to those of other groups with regard to morbidity and mortality. In addition, health professionals report difficulties associated with the encounter with immigrant patients. MATERIAL AND METHODS: A Delphi process with eight Danish experts from the field of immigrant health was performed as part of an EU project. The objective of the Delphi process was to investigate expert opinion on "best practice in the delivery of healthcare to immigrants". Initially, 60 factors were suggested by the experts. Next, these factors were summarised into 32 factors that the experts were invited to rate and, if possible, agree on. RESULTS: The top 11 factors identified in the Delphi process were access to interpreters, quality of interpretation, ensuring medication compliance, having sufficient consultation time, coherence of offers, interdisciplinary collaboration, allocation of resources, the role of the practitioner, acknowledgement of the individual patient, education of health professionals and students and access to telephone interpretation to supplement other services. CONCLUSION: The Delphi process can be a valuable tool in the investigation of expert opinion and may thereby help to guide future policy directives. In the light of the importance experts placed on access to interpreters and on the quality of the interpretation services offered, it seems as an untenable strategy to introduce as from June 2011 self-payment for interpretation services provided to immigrants who have stayed in the country for more than seven years.

What is the effect of changing eligibility criteria for disability benefits on employment? A systematic review and meta-analysis of evidence from OECD countries.

BACKGROUND: Restrictions in the eligibility requirements for disability benefits have been introduced in many countries, on the assumption that this will increase work incentives for people with chronic illness and disabilities. Evidence to support this assumption is unclear, but there is a danger that removal of social protection without increased employment would increase the risk of poverty among disabled people. This paper presents a systematic review of the evidence on the employment effects of changes to eligibility criteria across OECD countries. METHODS: Systematic review of all empirical studies from OECD countries from 1990 to June 2018 investigating the effect of changes in eligibility requirements and income replacement level of disability benefits on the employment of disabled people. Studies were narratively synthesised, and meta-analysis was performed using meta-regression on all separate results. The systematic review protocol was registered with the Prospective Register for Systematic Reviews (Registration code: PROSPERO 2018 CRD42018103930). RESULTS: Seventeen studies met inclusion criteria from seven countries. Eight investigated an expansion of eligibility criteria and nine a restriction. There were 36 separate results included from the 17 studies. Fourteen examined an expansion of eligibility; six found significantly reduced employment, eight no significant effect and one increased employment. Twenty-two results examined a restriction in eligibility for benefits; three found significantly increased employment, 18 no significant effect and one reduced employment. Meta-regression of all studies produced a relative risk of employment of 1.06 (95% CI 0.999 to 1.014; I2 77%). CONCLUSIONS: There was no firm evidence that changes in eligibility affected employment of disabled people. Restricting eligibility therefore has the potential to lead to a growing number of people out of employment with health problems who are not eligible for adequate social protection, increasing their risk of poverty. Policymakers and researchers need to address the lack of robust evidence for assessing the employment impact of these types of welfare reforms as well as the potential wider poverty impacts.

Too sick to work, too healthy to qualify: a cross-country analysis of the effect of changes to disability benefits.

BACKGROUND: Denmark and Sweden have implemented reforms that narrowed disability benefit eligibility criteria. Such reforms in combination with increasing work demands create a pincer movement where in particular those with moderate health problems might be unable to comply with work demands, but still not qualify for permanent disability benefits, ending up with temporary means-tested or no benefits. This paper examines whether this actually happened before and after the reforms. METHODS: The Survey of Health, Ageing and Retirement in Europe (SHARE) study waves 1-2 and 4-6 in Denmark and Sweden for the age group 50-59 years (N=5384) was used to analyse changes in employment rates and benefits among people with different levels of health before, during and after disability benefit reforms. Interaction between time and health in relation to employment versus permanent or temporary benefits was used as a criterion for whether our hypotheses was confirmed. RESULTS: Overall, employment rates have increased in the age group, but only among the healthy. The OR for receiving temporary or no benefits increased from 1.25 (95% CI: 0.81 to 1.90) before to 1.73 (95% CI: 1.14 to 2.61) after policy reforms for the 29% with moderate health problems and from 2.89 (95% CI: 1.66 to 5.03) to 6.71 (95% CI: 3.94 to 11.42) among the 11% with severe health problems. The interaction between time and health was statistically significant (p<0.001). CONCLUSION: People with impaired health and workability are forced into a life with temporary means-tested or no benefits when pressed by rising work demands and stricter disability benefit eligibility criteria.

Patient experienced continuity of care in the psychiatric healthcare system-a study including immigrants, refugees and ethnic danes.

AIM: The purpose of this study was to investigate continuity of care in the psychiatric healthcare system from the perspective of patients, including vulnerable groups such as immigrants and refugees. METHOD: The study is based on 19 narrative interviews conducted with 15 patients with diverse migration backgrounds (immigrants, descendents, refugees, and ethnic Danes). Patients were recruited from a community psychiatric centre situated in an area with a high proportion of immigrants and refugees. Data were analysed through the lens of a theoretical framework of continuity of care in psychiatry, developed in 2004 by Joyce et al., which encompasses four domains: accessibility, individualised care, relationship base and service delivery. RESULTS: Investigating continuity of care, we found issues of specific concern to immigrants and refugees, but also commonalities across the groups. For accessibility, areas pertinent to immigrants and refugees include lack of knowledge concerning mental illness and obligations towards children. In terms of individualised care, trauma, additional vulnerability, and taboo concerning mental illness were of specific concern. In the domain of service delivery, social services included assistance with immigration papers for immigrants and refugees. In the relationship base domain, no differences were identified. Implications for priority area: The treatment courses of patients in the psychiatric field are complex and diverse and the patient perspective of continuity of care provides important insight into the delivery of care. The study highlights the importance of person-centred care irrespective of migration background though it may be beneficial to have an awareness of areas that may be of more specific concern to immigrants and refugees. CONCLUSIONS: The study sheds light on concerns specific to immigrants and refugees in a framework of continuity of care, but also commonalities across the patient groups.

[Migrant status and access to health-care services in Denmark]. / Migrantstatus og adgang til sundhedsydelser i Danmark.

Access to health-care services in Denmark is dependent on migrant status. Emergency care is available to all migrant groups though people not officially residing in the country may be subjected to payment. For regular immigrants and persons with refugee status access to health-care is regulated by The Health Act, whereas access to non-acute health-care for other migrant groups such as asylum seekers, undocumented migrants and persons subjected to human being trafficking is mainly regulated by The Alien Act. The most vulnerable migrant groups are the ones with the most restricted access to care.