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Experiences in providing access to integrated medico-social and community based home care services

Care at home for frail and sick elderly – commitment to action

Von Christine Rutschmann & Alexandra Papis

In all countries, and in developing countries in particular, measures to help older people remain healthy and active are a necessity, not a luxury (WHO 1995). But many Governments do not have the financial resources or the knowledge to develop adapted services for the growing needs of their ageing population. Thus, there is a need to promote “active ageing” (WHO Active ageing) and age friendly policies including home care and to build up the cooperation between the public and the private sector.

Care at home for frail and sick elderly – commitment to action

(Photo: © SRC Belarus)

Population ageing is one of the most significant demographic and social trends of the 21st century, affecting all countries in the world. In Europe and the Countries of Independent States (CIS), the proportion of people aged 65 or above was projected to almost double between 2010 and 2060, from 16% to 29% of the total population (Council of European Development Bank 2014). Helping older people to remain integrated in the society and to support elderly people to receive care and support to remain in their communities for as long as possible is important. As a consequence of demographic and social changes European countries health and social care systems are facing growing demand on long-term care (OECD, 2011), including home care. The provision of services for care and support need to be carefully examined, aligned to national policies and demand-driven. The majority of the elderly prefers staying in their home rather than  accepting institutional care. The provision of services in patients’ homes is eventually more cost-effective than in stationary care institutions and may result in lower use of expensive specialist and hospital services, particularly if available informal care is used effectively (Tarricone & Tsouros, 2008).

Culturally, elderly people in Eastern Europe and CIS rely on inter-family support, i.e. informal care at home provided by family members or neighbours. However, due to the economic recessions labour migration of the young population is high and leaves the elderly without their traditional family support. Similarly, resources for Government services are cut and result in re-organisation of health services adapting present and  developing new models of care and service provision, especially in rural areas, where services have generally been scarce.

(Photo: © SRC Belarus)

A dignified ageing and life at home

The Swiss Red Cross (SRC) is supporting local partners in Eastern Europe and CIS in developing active ageing and home care to allow elderly a dignified ageing and life at their home. Important for the Swiss Red Cross is to promote integrated medico-social home care services in agreement with the local partners, their strategies and their capacities. In many post-Soviet countries the cooperation between the Ministry of Health and the Ministry of Social Policy (depending on the country this Ministry is as well called Ministry of Labour and Social Affairs) is very weak. In Home Care, elderly people suffer from multimorbidity and are in need of nursing and/or medical care, and of household- (shopping, cooking) or social support (paying  medicines, applying for allowances and entitlements). Many elderly people live alone and feel socially excluded. These people need someone to talk to, to spend time with. Thus, the SRC  promotes a strong collaboration between health and social care policy makers and fosters exchange in program advisory boards, steering committees or in working groups.

The aim in all home care models supported by SRC, “help to self-help” is crucial besides the provision of good quality low cost service, accessible for all people in need.


The “Home Care” model of the SRC sees four pillars of care provision:

1. Medical/nursing care provided by professional nurses (injections; wound care etc)
2. Household services (washing, cleaning etc.) provided by home helpers
3. Social care trained home helpers, care assistants, auxiliary nurses and
4. individual support provided by younger and older volunteers trained in psycho-social support.


The work of SRC started in 2003 in Bulgaria and has expanded over time to the six countries Belarus, Bosnia-Herzegovina, Moldova, Kyrgyzstan and Armenia (Provision of services in Armenia will only start in 2017) providing home-based care services to more than 13’000 clients. 

(Photo: © SRC Belarus)


How to implement an integrated home-based care model in Bulgaria

The “Home Care and Assistance Services towards Independent and Dignified Life” Program (2012-2017) is implemented by the Bulgarian Red Cross in partnership with the Ministry of Health, Ministry of Labour and Social Policy and the Swiss Red Cross. The goal of the project is firstly to support the development of a model for integrated health care and social services at home as a form of long-term care for older people with chronic diseases and permanent disabilities drawing on the Swiss experience. Secondly, the project aims at establishing an institutional framework for sustainable provision of this type of services in Bulgaria, including legislative regulations, payment mechanisms, national quality standards and unified training programs for the staff. Among the main priorities of the project is to raise the awareness on integrated home care services at all levels of the Bulgarian society and get a buy-in and cooperation from all relevant stakeholders, such as the Ministry of Health, the Ministry of Labour and Social Policy, the Bulgarian Doctors’ Union, Bulgarian Association of Professionals in Nursing, National Health-Insurance Fund, municipal authorities, patients’ organizations, etc.

1. Ageing population with nearly 20% over age 65 in 2011
2. High and rising prevalence of comorbidities, disabilities and chronic disease
3. Too narrow a scope of services to manage the full range of health and social care needs.
4. Restricted access to providers leading to overuse of expensive institutional or specialized services.

The role of nurses and home helpers in Bulgarian home care centres

In 2013, the first Bulgarian home care centre opened and began offering services to its local elderly population according to defined criteria for the choice of selection of clients, in cooperation with national and regional authorities. In the region of Vratza, three more home care centers opened in 2013.The centres employ nurses and home helpers. Approximately 25% of home care centre staff are from the Roma population, providing patient-centered tailored care for this at-risk population group and the native Bulgarian population. Both nurses and home helpers are required to complete a nationally licensed training at the medical university in Sofia.

Home Care Centre employees work as a team to provide services, with nurses managing and leading patient care in a coordinating role. Home helpers assist patients with daily tasks including managing personal hygiene, preparing meals and cleaning the home. Nurses provide services such as blood pressure monitoring, heart checks, bandage changes, wound care and other primary care services. An important aspect of the activities of home care centres is their support of patients’ capacity for self-care and independence. Nurses provide training to patients and their relatives with the objective of strengthening patients’ ability for self-care and increasing personal motivation to invest in health.

Hava Tagić, member of AA group from Turija Lukavac, paying a house visit and bringing a warm meal to lonely, Paša Burgić, Bosnia/Herzegovina. (Photo: Alfred Mikus, Belarus/ © SRC)


Challenges of integrated medico-social home care services

The introduction of integrated medico-social home care services in Bulgaria has challenged existing laws that require nurses to be supervised by a physician and prohibit payment for the provision of nurse-led services in homes. Adjusting the institutional context for the widespread availability of integrated medico-social home care services has been put to the health system which is now in the process of reforming legislation to allow autonomous, nurse-led services. While this process has not yet been completed, an important mileston was achieved at the end of 2015, when an amendment was made to the Health Act ensuring that not only elderly, but also children and disabled can receive home-based care services.

A new profession: the “social care assistant”

Multi-actor and cross-sector partnerships have supported the development of unified national quality standards for health and social services provided in home settings. In 2015, a newly designed curriculum was developed and endorsed by the introducing a new profession in Bulgaria named “social care assistant”, which will replace the present home helpers.

With the support of the Technical Universities in Sofia a software programme was elaborated for data and cost-management of the home care services and introduced in December 2013 in all home care centers. The data gathered serve to better analyse the performance, effectiveness and efficiency of the services and will serve as the basis for cost-pricing and cost-effectiveness analysis of the services.


1. Integrated health and social services in the community are recognized for the first time in Bulgaria and are included as a priority in government policy documents.
2. Since 2003, a total of 10 home care centres have been established across the country, providing services to over 800 patients by nurses, home helpers and volunteers.
3. New staff cadre and profession introduced.
4. Legislative changes for nurse-led care and integration of medical and social services under way.

First conclusion: the improving of mental wellbeing

In order to demonstrate the cost-effectiveness of the services, already at the start of the project, data were gathered on Health Related Quality of Life of the beneficiaries, as well as time-based cost prices were established (SRC: Home care and assistance services towards independent and dignified life). Results showed large improvements in the areas of mental wellbeing and moderate improvements in the area of physical well-being. In order to further compare services to other forms of public and private social and medical services provided in domestic environments, as well as in health and social institutions in Bulgaria a benchmarking study will be conducted later this year, on which the Government can base funding decisions and establish relevant mechanisms to fully integrate home care services into the health and social care system.

Older people living in deserted high mountain village Delchevo /Gotse Delchev municipality - region Blagoevgrad/ had just received basic foodstuffs from volunteers belong to IG in Gotse Delchev. (Photo: Alfred Mikus, Belarus/ © SRC)

In many countries a shift of paradigm is required

There is no unique solution to the increased demand of home based care due to the social and demographic changes in Eastern Europe and CIS. In each of the mentioned countries the social, legal and demographic background is different. The services to cover the health and social needs of the elderly population need to be adapted to the specific context of a country and needs to be demand-driven.

Experiences show the following issues as being crucial for the success in providing home care services:

  1. The need for home care services and type of service to be provided needs to be confirmed by in depth surveys and assessments.
  2. The existing legal framework is an important factor if economical sustainability in the medium- and long-term will have to be achieved.
  3. Integrated medico-social home care services are nurse-led and nurse-managed services, of course, in close cooperation with General Practitioners, medical specialist, out-patient clinics and hospitals. Hence, in many countries in Eastern Europe/CIS state budgets or if health insurance funds are existing, reimbursement of services accept only medical doctor led services. Promoting nurse-led services requires a shift of paradigm and a change in the legislative framework, which requires evidence based advocacy to withstand a strong doctor lobby.
  4. The continuous training of home care staff is crucial. In many countries there is a lack of experience in quality of care issues. Other present and increasing challenges are dementia and palliative care issues. Countries often lack legislation, regulations and guidelines in how to care for such persons. Home care staff often are the only persons responsible caring for patients, living alone, with dementia or terminally ill and no one else taking care of them.
  5. Important is the exchange between different countries and different home care models, to learn from each other. The SRC has developed a knowledge-management platform for the above mentioned intervention countries in the Europe/CIS region. In all six countries, active aging including home care services and empowerment of elderly people are the priority topics. Nurses from Belarus train volunteers in Kyrgyzstan. Bosnian/Herzegovina staff exchanges with Moldovan colleagues. And once a year, all SRC supported partners meet to discuss impacts, standard indicators for certain activities in order to see of what changes in the six countries, to compare and adapt.

Given the positive experiences, successes and competence of the programmes in Europe/CIS on active ageing and home-based care, the SRC integrated a new thematic priority on ageing and health in its health policy (SRC: Helath Policy for International Cooperation), aiming to look beyond Europe and CIS in terms of care for elderly people.


Note: For more detailed information please contact or
Christine Rutschmann & Alexandra Papis

Alexandra Papis Swiss Red Cross

   Christine Rutschmann, Swiss Red Cross,


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Related Resources

Ressource: Home care and assistance services towards independent and dignified life

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Ressource: Health Policy for International Cooperation

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Related Resources

Ressource: Home care and assistance services towards independent and dignified life

Download (d | 1.2 MB| PDF document)

Ressource: Health Policy for International Cooperation

Download (d | 1.3 MB| PDF document)