The Norwegian strategy for developing better integrated and less expensive long term care services Terje P. Hagen Department of Health Management and Health Economics, Institute of Health and Society

1) Background Two main elements An action plan – The care plan 2015 (Omsorgsplan 2015) The coordination reform Main aims of both: Expand primary care and longterm care

2) The Care Plan 2015 (2009-2015) The targets Subsidy given for 12 000 new places in nursing homes and/or sheltered housing between 2008 and 2015 12 000 new care workers (FTEs) between 2009 and 2015

Places with subsidies from the state

User groups (planned) in nursing homes

User groups (planned) in sheltered houses

Care workers (FTEs)

Conclusions If current trends continue: The targets for the investment subsidy will be missed The targets for the supply of labour to the LTC sector will be met (most likely already this year) This reflects a general trend of deinstitutionalization

3) The coordination reform (2012- ) The Coordination Reform (White paper from 2009) pointed to three primary challenges in the Norwegian health services: Patients’ needs for coordinated services are not being sufficiently met. In the services there is too little initiative aimed at limiting and preventing disease. Population development and the changing range of illnesses among the population.

Main reform elements: Municipal co-financing of treatment in the state owned hospitals’ internal medicine departments and out-patients clinics was implemented from January 2012. Municipal payment for patients ready for discharge was also implemented from January 2012. Implementation of municipal acute bed units (MAUs). MAUs are intermediate units or community hospitals set up to reduce hospital admissions, in particular for elderly patients. 12th August 2014 NOPSA 2014

Municipal acute bed units (MAUs) The MAUs is one of the measures of the coordination reform and the government’s aim is that all municipalities shall have a MAU running from 2016 either organized as a municipal or an inter-municipal service. The MAUs are funded partly by a matching grant from the central state to the municipalities and partly by transfers of resources from the regional health authorities to the municipalities. 12th August 2014 NOPSA 2014

Initially the MAUs were regarded as a service for patient with the following characteristics: Stable patient with known diagnosis where the main problem was an acute disease that could be evaluated and treated by primary care methods or patients with a worsening condition with need of adjustment of the treatment. Stable patients with unknown diagnoses in need of observation and medical evaluations. Typical patients expected to be admitted to the MAUs were elderly patients with pneumonia, urinary tract infections, other infections, gastroenteritis, chronic obstructive pulmonary disease (COPD), diabetes, heart failure and dehydration.

Results 12th August 2014 NOPSA 2014

Dependent variable: Admittances age group 80-89/population Variable name Est. (sig) Intercept -0.31 -0.22 Nursinghomes -0.01*** -0.02*** GPs 0.00 SHPOP80+ 0.22*** Deathrate 0.23*** Disabled -0.01 Traveltime -0.01* MAU -0.06*** MAU Host - 0.03 MAU Alone 0.05** *, **, *** = p<0.1, 0.05, 0.01

Effect of MAU on admittances for the higher age groups (4-6%) Smaller (<1%) for the population as a whole 12th August 2014 NOPSA 2014

4) Conclusions Care for elderly: Main political topic The central state intervenes more often than in Sweden/Denmark However, the municipalities are reluctant to state interventions and adapts to local demands and within their budgets restrictions 12th August 2014 NOPSA 2014