A preventive approach for community-dwelling older people, Rheinland-Pfalz, Germany
On the 15 June, we recognise Elder Abuse Awareness Day. Nurses, in partnership with families and other health professionals, have a key role to play in the care of older persons. Given the high incidence of the spread of the COVID-19 virus in care homes, nurses in those settings are key to leading and coordinating IPC measures and identifying infections early. WHO and CDC have published guidance documents on the older adults and the IPC in long-term care facilities, including mental health considerations for older adults in isolation and those with cognitive decline.
Today, we present a case study from Germany on a preventive approach for older people living independently in the community.
The object of the Gemeindeschwester-plus (community sister) project was to implement a community-based preventive approach for older people to enhance and support their self-care, independent living and social relations. The service was provided through local authorities by provided by qualified nurses. The project had two key aspects:
- Home-based information and counselling for people aged 80-plus who obtain no benefits from the compulsory long-term care insurance, with the aim to promote self-care, and detect and solve the need for help and support at a very early stage.
- Improving the infrastructure for older people by informing local authorities about their needs, and supporting the authorities by initiating the activities and services that are needed.
Germany, like many other western countries, is facing a dramatic demographic change, including a large increase of older people in the population. Even though older people are healthier and are able to live independently in their own homes for a longer period than 30 years ago, the need for care is rising. Most older people in Germany would like to stay at home as long as possible, and this is not only the best solution for them, their communities benefit from this as well. Living in a nursing home is quite expensive in Germany, and if someone cannot cover his or her costs, the communities have to pay. So, providing better conditions for independent living at home for older people is in their interests and those of their local communities.
The Gemeindeschwester-plus is service offered in nine communities in Rheinland-Pfalz, one of the 16 German federal states, a mostly rural area, with villages and small cities. One big issue that older people face is that many of the villages lack a community-based infrastructure that would enable them to be socially included and manage their everyday lives.
The aim of the home-based information and counselling is to inform people and give guidance about activities and support services, both private and public, and create a sense of security. In addition, the nurses support older people in using their individual resources and maintaining their social and functional activity as long as possible. The nurses also inform the local authorities about the needs of the older population and support the authorities or initiate the services that are required. The home visits are an offer that the individual older person may accept or refuse.
The nurses who provide the service undertook a 21-day training programme, which focused on empowering them in designing the role and function of the service. The main content included communication skills, knowledge about empowerment and supporting individual resources, early signs of disability, health problems in old age and community networking. In addition, the nurses were educated in using a multidimensional assessment process that included questions about social, health, functional and mental factors, which they could choose to use with patients, if appropriate.
Reaching the older people required ongoing public relations work. Most older people welcomed the service, but many were not acquainted with health promotion, preventive information and counselling. In the marketplace interviews, older people often said: ‘I will call you, when I need you,’ or ‘I don´t need you’. It was apparent that the service was always associated with help and nursing care on a larger scale, rather than with information and counselling to live longer independently at home.
The additional training given to the nurses was particularly important in defining clear roles and tasks for this new service, and nurses proved to be very adept in these new roles.
Telephone interviews with older people who had been visited revealed that they were better informed about local services, sensitive to healthcare issues and that they felt more secure. It seemed that knowing a local contact person created trust in their local authority’s ability to assist if help is needed. One surprising outcome was that more than 1,000 older people were connected to the information service for benefits from their compulsory long-term care insurance. The assumption is that older people are not generally well informed about the compulsory long-term care insurance: this programme created access to that service.
In addition, the nurses initiated more than 70 community-based activities, including local offers for exercise, shared meals, transport, security, participation in activities and services to support daily living.
The direct approach used enabled the communities to establish contact with their older citizens. The people who were visited by the nurses gained confidence in the public sector´s ability to assist, should the need arise, and thus created a sense of security in their daily lives. In addition, the local authorities received feedback from the service about the living conditions and needs of its older population. Beyond that, the nurses initiated local activities to enliven opportunities for older people in the communities.
After three and a half years, the service is well established in all nine communities. The results indicated that the service shows benefits for older people and the communities they live in, which led to the Ministry of Health in Rheinland-Pfalz continuing and extending the programme.