Implementation of a close-care model, team-talk, and person-centred tailored time; keys to support the complex care of older adults with multiple needs at home

Abstract Background: This study aims to describe the pros and cons of the implementation of a close-care model for older adults with complex care needs living at home. The goal was to diminish hospitalization and still carry out high quality care at home. The close-care model was implemented by two organizations working in cooperation, the municipality, and the region. These handle social care and healthcare at the local level in Sweden to further develop safe and secure home care. Method: Six focus group interviews with personnel were carried out, half of them before the start of applying the new close-care model, and half after one year from close-care model implementation. The interviews were taped and analysed thematically.Results: Secured care satisfaction, Person tailored time, Shared professionalism, Care-chain cooperation, Caring for the next of kin were identified themes. Enrolled nurses emphasized the importance of securing professional and older person care satisfaction. The results further highlighted opportunities for being cared for at home even though the adults had multiple needs, by receiving person tailored time. Shared professionalism through close-care team-talks included nurses with different educational levels as well as rehabilitation professionals, and when needed a physician. Care-chain cooperation was another theme discussed and was experienced as delimiting repeated hospitalization. The close-care model also included person centred care as well as time to include the next of kin in the caring situation not least during palliative phases of the process. Conclusions: Trust and cooperation dilemmas are yet to be solved regarding shared professionalism and person tailored time which concerns enrolled nurses’ working conditions, and staffing stability. Another aspect is the existing digital communication boundaries between healthcare and social care organizations.