The current steering by the state cannot simultaneously make operations more effective and ensure high-quality and safe services for people living in private homes. The main question of the audit was to ascertain whether technology supports the provision of high-quality and safe services. This document contains a summary of the main results of the audit. The entire audit report is available only in Finnish.
Opinions of the National Audit Office
The object of the audit was the use of technical assistive devices as a part of the services supporting older persons in living at home. The most important operators in the use of technical assistive devices are the Ministry of Social Affairs and Health, hospital districts’ assistive device centres and units and municipal welfare and health care services. The Ministry of Social Affairs and Health uses steering to create a framework for the use of assistive devices. For their part, assistive devices centres and units as well as municipalities are responsible for introducing assistive devices. The aim was to find out whether the operating practices for the introduction and use of technical assistive devices are such that they make operations more effective and improve productivity as well as support the provision of high-quality and safe services.
The main question of the audit was to ascertain whether technology supports the provision of high-quality and safe services. The main question was divided into four parts that concerned the use of technical assistive devices, the acquisition (selection) and allocation of technical assistive devices as well as monitoring the suitability of technical assistive devices to the customer.
The main finding of the audit was that the current steering by the state cannot simultaneously make operations more effective and ensure high-quality and safe services for people living in private homes. In order to reach these goals simultaneously, the state must, by means of steering, create preconditions for using technology in service provision and support technology use. At the moment, steering by the state does not fulfil these goals.
Municipalities poorly prepared for ensuring that home care is the first choice
Municipalities have various technical assistive devices in use. However, some of them fulfil the same need. This diversity is an indication of the fact that a single technical assistive device does not suit everyone. Although there are major differences between municipalities in the total amount of assistive devices in use, these differences tell us nothing about how many users a single assistive device has once it has been introduced. An assistive device may only have two or three users. In municipalities, technical assistive devices are more widely used in assisted housing units with 24-hour assistance than in private homes.
When approving the Act on Supporting the Functional Capacity of the Older Population and on Social and Health Services for Older Persons, the Parliament required that if the recommendations concerning the allocation of personnel in 24-hour care are not met during 2014, the Government should submit a proposal on making the allocation of personnel a statutory requirement. The allocation of personnel is not in accordance with the recommendations in all assisted living units, and the Ministry of Social Affairs and Health is now considering whether to submit a proposal on making the allocation of personnel a statutory requirement. The view of the National Audit Office is that the technical and basic assistive devices used in the units as well as the use of information technology should also be taken into account when calculations regarding the allocation of personnel are made.
The amendments to the Act on Supporting the Functional Capacity of the Older Population and on Social and Health Services for Older Persons impose more stringent requirements on placing patients in long-term institutional care and obligate municipalities to determine whether it is possible to meet the service needs of the older person with the help of welfare and intelligent technological solutions. The amendments will mean that in the future older persons in poorer health will be cared for at home. However, the safety phone service with accessories remains the most common assistive device for people living at home. Technical assistive devices should be introduced more quickly so that technology can be used for ensuring that patients in poorer health suffering from memory disorders are provided with care equivalent to assisted living. Expanding the use of technology is, however, complicated by the fact that the steering exercised by the state has not been adequate to make the telecommunications network infrastructure equally accessible in all parts of Finland. As a result, not all municipalities are equally well-placed to use technology.
Technical assistive devices have helped to improve access to support services, but partly at the expense of customer safety
The use of technical assistive devices has helped to make support services that are part of home services more widely available. This is because with technical assistive devices, services can be provided without home visits (safety phone) or the frequency of home visits can be substantially reduced (meal vending machine). Moreover, under the Act on the Status and Rights of Social Welfare Customers, it is not necessary to prepare a service and care plan for all support service customers.
However, the use of technical assistive devices is usually based on electricity or network connections. Where there are problems with the power supply or network connections, there are also problems with the use of assistive devices. If the customer only has a safety phone without a door alarm, there is no guarantee that anyone will check the functioning of the device after an operational failure. This means that customer safety depends on the functioning of the technical assistive device, which is, however, not particularly reliable.
Introduction of technical assistive devices in home care has changed the nature of customer work
In home care, a mobile device with mobile entries, electrical locks and/or optimisation programs has helped to increase the employees’ actual working hours. Employees no longer need to travel from one place to another as much as before and administrative work such as recording patient information can now be performed at the customer’s home instead of at the office. The introduction of technical assistive devices has helped to reduce the amount of time spent on non-client work and the customer visits may only last as long as laid out in the service and treatment plan.
However, it seems that efficiency improvements in home care have not increased the availability of regular home care services. Technical tools introduced in home care would seem to be one way of influencing personnel needs in social and health care services. However, from the customers’ point of view, making home care more efficient seems to have changed the quality of personal presence.
No overall estimate of the costs of technical assistive devices
The estimates of the cost of the technology depend on the angle from which the matter is examined. The costs of the technical assistive devices consist of acquiring the device, any alterations to the customer’s home, training of the personnel, software updates, and repairing, maintaining and transporting the devices. Moreover, technical assistive devices will only properly function as a service if they are used in combination with other services: alarm reception and assistance services, content producers and meal deliverers. Malfunctions in technical assistive devices also cause additional costs.
No studies have been made in Finland on the cost impact of the use of technical assistive devices on services for older persons. When the focus is on one sector only and on specific costs within that sector, the understanding of the costs remains inadequate. Based on the audit, the costs of technology supporting independent living should be examined as comprehensively as possible by taking into account its introduction, use and maintenance.
Shortcomings in the decree on assistive devices
The text of the decree on assistive devices is open to interpretation. The explanative memorandum fails to define the central concepts such as an assistive device used in medical rehabilitation. The memorandum also fails to justify its claim that the decree on assistive devices has no independent effects on the finances of the state or municipalities.
In practice, each assistive device centre and unit spends time on considering how to interpret the decree, and by drawing up and updating criteria on which devices are allocated. This may slow down the spread of new technical assistive devices. The interpretations and availability criteria drawn up may be seen to have a wider economic significance since more advanced technologies could be used to support older persons in living at home and thus control the increase in treatment and care costs. The deficiencies in the decree also increase the risk of customers being given the same technical devices on different grounds. Likewise, it is possible that assistive device centres only examine the costs of introducing technologies from their own point of view, and their usefulness is thus not considered from a multiprofessional perspective. This is why the principles of access to devices used for medical rehabilitation should be subject to national level coordination.
Memory-related assistive devices not defined as assistive devices for medical rehabilitation
The incidence of memory disorders increases with age, but there is no national policy on arranging memory-related assistive devices. While the decree on assistive devices states that a condition for assigning an assistive device is that the person in question has an illness diagnosed on medical grounds that adverse affects their functional capacity and makes it more difficult for them to cope independently, assistive device centres do not provide memory-related assistive devices to people with memory disorders. Assistive device centres see this as the municipalities’ responsibility. However, municipalities do not have adequate expertise for evaluating what kind of equipment could be used to support the independent coping of people with memory disorders. On the other hand, whereas assistive device centres would have technical assistive devices that could possibly be used in the care of older persons with memory disorders, they do not have enough knowledge about ageing, old age and memory disorders. Expertise in memory disorders and expertise in technical assistive devices thus do not meet. The Ministry of Social Affairs and Health should prepare a national policy ensuring that the requisite assistive devices for medical rehabilitation are provided for people with memory disorders by the municipalities’ welfare and health care services.
Personnel training on technical assistive devices is inadequate
The audit found that social welfare services need more expertise and training related to technical assistive devices. The use of technical assistive devices adds new elements to basic work that the current training does not fully cover. The audit indicates that education and training in the social welfare and health care sector should include content on technology, its correct use and its potential. This would save time and money spent in municipalities on the training and induction of employees. Additionally, it would increase the ability of social welfare services to assess which technologies might benefit the customers. This in turn would improve access to welfare and health care services.
The decree on assistive devices and the decree on services for the disabled overlap
In principle, the acts that inform the division of work between the assistive device centres and services for the disabled are clear. Assistive device centres are in charge of mobile assistive devices, while the services for the disabled are in charge of equipment with fixed installation. However, the audit found that in practice some of the technical assistive devices require alterations in the customers’ homes. This results in division of the costs, overlaps in assessments, and in the worst case scenario, external costs to a third party, i.e. the services for the elderly.
For example, environmental control systems could support older persons in living at home. Based on the decree on services for the disabled, the arrangement and funding of a single environmental control system is the responsibility of services for the disabled. Even though older persons with illnesses fulfil the definition of a disabled person, their needs are considered to be the responsibility of the elderly care services. This issue is about the internal allocation of funds of social services within municipalities.
Based on the audit observations, it would be reasonable to centralise all functions related to the assistive device process (assessment, procurement, transfer, alterations in the home, maintenance and monitoring) to the assistive device centre when it comes to technical equipment intended for the use of the customers of health care, care for the disabled and care for the elderly services.
The chosen assistive device may not be optimal
Assistive device centres and municipalities mainly purchase technical assistive equipment through a tendering process. A great deal of information must be accumulated in order to define the content-related criteria for an assistive device in a tendering process. Municipalities do not yet have sufficient expertise to define the criteria for technical assistive devices, or to assess their usability and suitability in relation to the other activities of the organisation and the differences in the customers’ functional capacity during the procurement process.
While there are a number of companies offering similar technical assistive devices in Finland, no information is available on the effectiveness of the technical assistive devices on the market in meeting the customers’ service needs. Municipalities and assistive device centres are obliged to rely on experience, either their own or that of other actors, and the assurances of the manufacturers when procuring devices. Added to the fact that the price is an important factor in the choice of technical assistive devices, the option that optimally meets the needs of the customer or the municipality is not always chosen among the available alternatives. This does not promote the market access of the latest and technologically more advanced technical assistive devices, as meagre financial resources do not allow risk-taking.
To support their choices, the decision-makers need information on new technologies on the market, their cost efficiency and their applications. They would also need recommendations on which new technical assistive devices would be useful in providing services for customers with a certain level of functional capacity. The National Audit Office finds that the Ministry on Social Affairs and Health needs to promote not only best practices but also good technological choices. However, no unambiguous evaluative information of a high standard is available on technical assistive devices. The management team for the Structural Policy Programme also highlighted the importance of impact assessments in supporting decision-making in their final report.
Correct use of technical assistive devices important for customer safety
It seems that technical devices themselves do not pose a danger to the customer. Most hazardous situations are caused by incorrect use. However, the maintenance of assistive devices mainly focuses on checking that the device is being used and that it is in working order. On the other hand, whether or not the customer is able to use the device correctly is, in a manner of speaking, only assessed after an incident affecting the customer or the device. However, the responsibility for making sure that the customer knows how to use the assistive device after it has been handed over rests with the customer or the employees of services for the elderly working with the customer.
The problem is that the customer may not be able to assess their own use of the device, and even if they were, they might be disinclined to give up using it. Some of the customers to whom technical assistive devices have been handed over are merely support service customers who receive no visits from social services employees. Additionally, even though the assistive device centre has the duty to guide the employees working with the customer, social services personnel have no obligation to be present when the device is delivered to the customer’s home. Another problem is the high turnover of personnel working with a customer. Information on the correct use of the assistive device may not be communicated from one employee to another. The audit found that the instructions for monitoring assistive device services in their current form are ineffective as they only concern health care services.
The audit observations indicated that an assistive device tab in the information system that would improve the sharing of information between the assistive device centres and social services would be useful. Information on all assistive devices used by the customer would be collected under this tab, and all parties working with the customer or processing his or her affairs would have access to it. This would decrease the workload of collecting information when assessing service needs, prevent overlaps in lending assistive devices to costumers, promote the circulation of assistive devices and, when considering the allocation of an assistive device to a customer, make it easier to decide if it could be combined with devices already in use. Moreover, an assistive device tab would fulfil the goals of Jyrki Katainen’s government programme of continuing the construction of the electronic social welfare and health care data management system so that customer data is easily accessible when required.
A more accurate definition of equipment a precondition for guaranteeing safe care
A precondition for safely caring for older persons in increasingly poor health is using tools that are appropriate from the perspective of providing safe care. Despite this, the new Social Welfare Act and Act on the services for older person no longer contain provisions on the equipment that operating units must have to carry out their work. The statutes concerning private service providers continue to regulate the standard of equipment, but none of them specify in detail the meaning of appropriate equipment. This has led to differences in the standard of equipment between various assisted living units, the customers may not always have access to the assistive equipment they need, and some municipalities that belongs to regional assistive device centres fund the standard of equipment in their own units at the expense of other municipalities.
The social welfare and health care sector legislation emphasises the customers’ right to self-determination. Based on this right, the customers may decide what kind of technical assistive devices used by the employees they are willing to have in their homes. Refusals remain rare, but customers often wish to discuss the issue, and this is likely to become more common in the future. At worst, the customer only agrees to accept the technical assistive device after several visits to the doctor. These delays in accepting a device result in additional costs to the municipalities, for example if two employees are required to care for a customer where one would otherwise be enough. Municipalities are also responsible for ensuring that their employees have the tools required by their working conditions.
The audit indicates that as a criterion for granting services, a policy of the customers accepting tools that are installed in their homes to facilitate the work of the employees would be needed to ensure customer safety and to safeguard the employees’ occupational safety. The customer would then be aware of the terms and conditions of service provision before a customer relationship is formed. This would meet the requirement for the customer’s right of self-determination and ensure a safe working environment for employees. Additionally, a nation-wide policy would solve the ambiguous section in the rationale on the decree on employees’ work ergonomics that the information package provided by the Ministry of Social Affairs and Health to the municipalities failed to do.
Recommendations of the National Audit Office The National Audit Office recommends that the Ministry of Social Affairs and Health:
Investigate the total costs of technology supporting living at home.
Set up a project tasked to define national criteria for the availability of assistive devices for medical rehabilitation.
Working together with hospital districts and municipalities, examine if it would be more appropriate to centralise the technical assistive devices used in health care and care for the disabled and the elderly to assistive device centres, and what the ensuing advantages, disadvantages and costs would be.
Develop the monitoring process of assistive device services with the aim of ensuring seamless cooperation between assistive device centres and units and social welfare services.
Make sure that unambiguous evaluative information of a high quality on technical assistive devices is available for assistive device centres and units and municipalities.
Specify the appropriate minimum standard of equipment in assisted living units.