Initiatives for the most ill elderly people

The earlier Government is spending SEK 4.3 billion between 2011 and 2014 to improve health and social care for the most ill elderly people. The goal is for health and social care - in the form of home health care, care of the elderly, health centres and hospital care - to cooperate better with regard to elderly people.

Another aim is to streamline the use of resources so that health and social care focuses more closely on patient needs. For elderly people with many different symptoms and diagnoses, it can be confusing maintaining contact with various care providers, services and health care professionals. The aim, through strengthening incentives and conditions, is to encourage municipalities and county councils to develop coordinated health and social care for elderly people.

Joint effort

Eva Nilsson Bågenholm is the National Coordinator for Elderly Care and chair of a project team at the Ministry of Health and Social Affairs. The project is a joint effort with the Swedish Association of Local Authorities and Regions and the National Board of Health and Welfare. All the results of the initiative for the most ill elderly people are reported monthly, under an agreement with the Swedish Association of Local Authorities and Regions.

Continuity, overview and collaboration

For quite some time, an illness-oriented working procedure has been developed in Swedish health and medical care, that is to say care needs are assessed following diagnosis. This way of working suits a health care system in which many patients need help fast during occasional consultations, but it does not suit the needs of the most ill elderly people.

Ill elderly people often require a situation-oriented working procedure whereby health and social care is assessed by taking a holistic view of the patient's overall situation and people's differing needs, symptoms and ailments. There is a need for health and social care for elderly people that places higher demands on continuity, overview and collaboration across speciality areas, professions and organisational boundaries.

Definition of the group

The National Board of Health and Welfare defines the group as follows: "The most ill elderly people are those who are 65 years of age or older who have extensive impairment in their functional status due to ageing, injury or illness."

Inventory of problems

Through economic incentives and focusing on the needs of the most ill elderly people, the initiative aims to encourage, strengthen and intensify cooperation between municipalities and county councils.
In 2011, an inventory of problems was carried out by collecting input from meetings and interviews with decision-makers, stakeholders and care practitioners in the health and medical care sector. The inventory of problems and a summary of government-initiated projects and measures currently under way have served as the basis for providing an overall picture.