Learning from the leaders: a knowledge exchange with Denmark

The aroma of fresh-baked bread wafted through the corridors of the nursing home in Horsens, Denmark, as the Canadian visitors marvelled at the open-concept kitchen, herb and vegetable gardens, open-to-the-public restaurant and library, and other remarkable features of this leading-edge seniors’ care facility.

“They have very strong principles guiding their approach to eldercare in Denmark,” says Dr. John Muscedere, Scientific Director and CEO of the Canadian Frailty Network (CFN). “Among these are that food must be treated as medicine and that communities must support their older citizens to be as active, independent and as healthy as possible for as long as possible in their own homes.”

In keeping with CFN’s mandate to learn from international partnerships, Dr. Muscedere mobilized a group of Canadian healthcare leaders, researchers and clinicians to visit Denmark  in May 2018. Their goal was to see first-hand why Denmark is widely recognized as a world leader in providing effective healthcare and practical living support to its older citizens, and to consider how Danish approaches might be translated to the Canadian context.

“It was amazing to see how they’re integrating nursing homes into the community by creating public spaces that draw people into the facilities to interact with the residents,” notes Dr. Muscedere. “And they’re using technologies like ‘smart floors’ that light up when a person steps on them and ring an alarm if someone falls, as well as lifts and other devices that make it a lot easier for staff to provide dignified and efficient personal care.”

More amazing than the progressive nursing homes, however, is the fact that no new nursing homes have been built in Denmark for the past 20 years. Instead, the nation has focused on encouraging citizens to take responsibility for their health, increasing its complement of home care nurses, and building “close-care dwellings” that connect individual apartments with common rooms and gardens and provide varying degrees of assistance and care to the residents.

Perhaps most importantly, Denmark has delegated responsibility for eldercare to its municipalities, which focus on “adding life to remaining years, rather than years to remaining life” through reablement programs. These proactively assess older people’s abilities to look after themselves in their homes and provide customized short-term training to help them regain, retain or build essential skills for independent living.

“The concept of reablement is something that could really fly in Canada,” Dr. Muscedere says. “It’s an upstream approach that intervenes early to teach people how to continue to live well at home, before a crisis occurs that sets them back. It could involve physical rehabilitation after a stay in hospital, or teaching a widower how to cook more nutritious meal… whatever is needed most to help the person regain their abilities and confidence.”

Danish officials say reablement programs have reduced home support and home care expenditures as well as admissions to long term care institutions in the country. Better yet, most participants report that their quality of life has improved thanks to the intervention.

Locally-driven home care and reablement programs also resonate with Cynthia Martineau, Vice President of Strategy, Planning and Integration at South East Local Health Integration Network in Belleville, Ontario, one of the Canadian delegates to Denmark last spring. She says embracing local models of service delivery could help overcome one of the biggest stumbling blocks Canada faces in caring for its older citizens.

“We are struggling with our health human resources in Canada, especially in rural and remote areas,” notes Martineau. “Local models of service delivery that compensate workers for travel time could really help us in our efforts to recruit and retain home care and home support personnel in smaller communities, and would give us something to build upon to create reablement programs.”

Some proactive programs for seniors are already in place in southeast Ontario, such as loneliness assessments that identify people who need support to make social connections and may also need help for depression. There are also exercise and falls prevention programs, but Martineau would like to see these isolated efforts knit together into a comprehensive reablement program.

“We need to adopt standardized approaches for identifying who’s at risk and find ways to enhance our communities’ capacity to deliver proactive assessments and interventions,” she says. “The visit to Denmark has really stayed with me, because you can see how deeply their commitment to proactive wellbeing is ingrained in their culture, and how they are reaping the benefits now of a forward-looking senior care strategy that goes back 30 years.”

Many jurisdictions in Canada are already pilot testing and applying new approaches to assessing and addressing frailty, many with funding and other kinds of partnership support from the Canadian Frailty Network.

“We are trying to gather evidence about what works,” says Russell Williams, Chair of CFN’s Board of Directors and Senior Vice President, Mission with Diabetes Canada. “The visit to Denmark was one way for us to learn firsthand from a recognized leader in proactive seniors’ care.”

As William notes, it’s one thing to do the research, it’s another to change policy and culture. He says the good news is, a lot of people are looking for solutions in Canada and governments do respond well to solid evidence.

“We’re hoping to raise the volume of the conversation and get more momentum going in the public policy arena,” Williams says. “We also want to share what we have learned, not just from Denmark but from our CFN-funded research here in Canada.” To that end, Williams says CFN is embarking on a cross-country tour this year, to engage with communities on the topic of frailty and discuss creative solutions to the increasingly heavy burden of frailty on caregivers and the healthcare system.

“If we continue on the same course in Canada, we will run out of capacity in our healthcare system,” notes Williams. “But a lot of our budget challenges could be addressed from non-healthcare sources, such as community-based programs that help people function well in their homes. We saw a lot of that in Denmark.”

Williams sees many opportunities for Canada to adopt Danish-style approaches—such as treating food as medicine—and notes that CFN is supporting research led by Dr. Heather Keller to improve the nutrient intake of people who are frail or vulnerable to frailty in Canadian hospitals.

“We need to continue to involve citizens in the research and in building partnerships to address frailty and also loneliness in our communities,” he says. “Mixing generations in innovative living accommodations, learning from our immigrant communities how they care for their senior members, taking pets and children into nursing homes… even small initiatives can add up to a big impact.”

In April of 2019 a Danish delegation visited Canada to learn more about frailty innovations in the works here—such as those featured in CFN’s Innovation Showcase in September 2018, like the COACH program in PEI and the Hospital Without Walls in Ontario.

“I think we can do a lot better at understanding our own success stories,” Williams says. “Sharing them with our Danish visitors will really help us highlight the excellent work underway in Canada. We can all learn from each other in this vast undertaking to improve the health and well-being of older citizens all around the world.”