Policy advice report on Intercultural Elderly Care On behalf of Ms Astrid Thors, Minister of Migration and European Affairs, Finland From the European Network on Intercultural Elderly Care (ENIEC) Ms Astrid Thors, Minister of Migration and European Affairs of Finland, opened the 4 th Annual Meeting of ENIEC on Thursday 18 march 2010 at The International Cultural Centre Caisa in Helsinki, Finland. She raised certain questions and addressed some specific issues about intercultural elderly care in Finland of which she would be interested to hear the opinions on of the ENIEC members: all professionals with expertise in the field of intercultural elderly care. These issues were: 1. Could the Patient Bounded Budget (PGB), an instrument which is used in The Netherlands to give clients more freedom of choice to choose their own care provision and allocate budget directly towards the care providers they choose, be applicable in Finland and if so, how can it best be implemented? What are the experiences in The Netherlands with elderly migrant clients who use the PGB? 2. How to use the care system as an instrument which can be used to give migrants more freedom to choose their own care provision and how this is best implemented and how to sensitize the health care professionals towards working with clients with diverse ethnic and cultural backgrounds? 3. How could Finland get more flexibility in its health care system for elderly migrants? 4. How to establish intercultural personnel policies within the health systems and at the same time sensitize the educational system? For example, how can they recognize cultural signals? 5. What to do with the problem of loneliness of elderly migrants, especially men? 6. What is the opinion of the ENIEC-members on the circulation of migrants, is this good or not? And how can Finland adapt its social systems to the mobility of (elderly) migrants? 7. How can we create more exchange programs for students within Europe, where they can learn from different cultures and backgrounds? In this policy advice paper we address the above mentioned topics, on the basis of the experiences, knowledge, expertise and opinions of the ENIEC members. ENIEC s main objectives are to contribute to defining and developing good quality care for elderly migrants in Europe. ENIEC focuses on the welfare aspects through suggestions for improvement in preventive efforts among elderly Europeans with foreign ethnic background. ENIEC is a European forum for sharing experiences, developing new practices, providing inspiration and help across borders in the European countries. ENIEC members are professionals cooperating in an atmosphere of tolerance and understanding, and more importantly meeting the ethnic elderly with respect and a person-centered approach. Furthermore ENIEC is independent of all political interests. We hope our contribution will be helpful to the development and improvement of the Finnish policy with regard to intercultural elderly care. ENIEC s advise on specific issues of intercultural elderly care in Finland 1
ENIEC s advise on the questions raised by the Minister of Migration and European Affairs of Finland: 1. Could the Patient Bounded Budget (PGB), an instrument which is used in The Netherlands to give clients more freedom of choice to choose their own care provision and allocate budget directly towards the care providers they choose, be applicable in Finland and if so, how can it best be implemented? What are the experiences in The Netherlands with elderly migrant clients who use the PGB? Clients, who have an inpatient indicator, can choose a personal budget (pgb) and purchase their residential care themselves. In the memo on further development of the future Exceptional Medical Expenses Insurance Act (AWBZ), the State Secretary for Health, Welfare and Sport wrote that the pgb is an important tool in strengthening clients' choices. Consequently, the pgb must also remain in the future. Older migrants need sometimes help with the PGB (because the system is a bit difficult to understand, especially if you have problems with reading and writing). A lot of the older migrants are not familiar with this way of arranging help. Children of older migrants could help them or welfare/care organizations (elderly advisors). The advantage is that people can arrange their own help. The disadvantage is that there is a lot of paper-work to do. Pro s and con s of PGB. It gives the patient more choices and freedom. But for people with for example dementia, you need a good advisor/someone who will arrange it properly and in an honest way. It makes the system more flexible, demand-driven but clients and providers need to get used to it. That takes time. Elderly migrants can benefit the best of PGB if there is assistance enough and good explanations/introductions. (More info at the end of this document : <Interesting i-sites> ). In Germany the Patient Bounded Budget is still in a experimental stadium. But nevertheless there are some aspects that have shown as important: - there has to be a free market for care services. If there is no competition between caregivers there is no possibility to use the advantage of the budget, because the patient has in fact no choice of different services. Especially in rural areas this can be a major problem. - There has to be a case management to empower the patient to make his choices. This is for migrants even more important then for the rest of the population. The problem is, that it is very difficult to provide a culture sensitive case management for smaller groups of migrants. - The relation between costs and benefits are only good, if a large target group meets a large variety of services. This is for elderly migrants the most negative aspect, because the number of elderly migrants in total is even in Germany very low compared to the elderly Germans. If we look on different nationalities only the Turkish population is large enough to be a possible target group. ENIEC s advise on specific issues of intercultural elderly care in Finland 2
2. How to use the care system as an instrument which can be used to give migrants more freedom to choose their own care provision and how this is best implemented In the Netherlands migrants, like the Dutch, pay their health contributions and therefore have the same rights for health care that suits their needs; even if it is culturally determined. Nevertheless, studies have shown that particular the elderly migrants groups, do not have equal access to the care facilities. The reason for this is that many forms of care are unknown to them. They are not accustomed to it and they don t know how they can use it. Another phenomenon is that in the various migrant groups the image of age is experienced differently. One feels already old at a younger age (50-55 years). Obviously, to obtain the right care provision the language often is a large problem. Of course, an institution that is interculturally well organized, will be able to provide a satisfactory care supply. Intercultural personnel policies can offer a big help in equal access to the care facilities. It will be attractive for both the elderly people as for the younger ones, who are often bilingual, and look for a good job in health care. Elderly migrants in the Netherlands feel strongly about living at home for as long as possible, which is not strange for Dutch elderly also. They would love to have a good kitchen. But we see also changes. Elderly realizes more and more that their children cannot take care for them in their houses. It s not an easy subject to talk about, but it s on the agendas now and elderly and children realize that they need care organizations trained and ready to take care for people with a lot of cultural backgrounds. An increasing part of them find professional care in nursing homes a possibility. Important is that those organizations are prepared. But over the last few years we also see that there are initiatives in which ethnic groups set up their own health care organizations to provide cultural care at home. They guarantee that one s own language will be spoken. These organizations are welcomed, but the quality of care sometimes lies under pressure by the restrictions that different cultures can bring. This development has several points in it. It says something about not modernizing of existing elderlycare- and welfare organisations. But it also puts pressure on the market. Nowadays it is a challenge to maintain sufficient care. The future labour market shows a shortage of nurses, in particular healthcare staff. To secure our health care for both migrants and natives, recruitment of more young second generation migrants is needed. This clearly means that intercultural care is needed in two ways: 1. that care is accessible to everyone, and 2. That all personnel must be able to nurse or to take care of everyone. That means that you have to work on cultural sensitive organizations (Interculturalisation). The essence is: Cultural sensitivity reflects all aspects of an organization When it influences all the aspects, like, vision and mission, communication, opinions about care, food and beverage, religion, HRM, marketing, management, decision-making, finance, architecture, design, etc. it s a strategically topic ENIEC s advise on specific issues of intercultural elderly care in Finland 3
Strategy is the responsibility of the board of directors So Top Down and Bottum Up For the 1 e generation migrants, we will, however, never quite be able to do so. Nostalgia won t subside when they get older. Sharing those feelings with fellow countrymen can help to alleviate the solitude. Thus, sharing one s past in one s own language is important. (More info at the end of this document : <Interesting i-sites> ). 3. How could Finland get more flexibility in its health care system for elderly migrants? From the experiences with health care for elderly migrants in different European countries we have learned a lot about creating more flexibility in order to meet the specific needs of elderly migrants. Especially those migrants from the first generation, who do not master the language of the host country and emotionally withdraw into their own culture, are in need to take their ethnic-cultural backgrounds as a starting point for offering care. To make care and the provision of services commonly available, it is necessary for all care givers to offer culturally sensitive care with a vast amount of flexibility. For the elderly in The Netherlands also care in foreign countries gains importance. Several initiatives, amongst others in Spain and in Turkey, were set up to enable Dutch elderly to spend their old day in a warm country. Elderly migrants have to choose between growing old in The Netherlands, remigrate to their country of origin or commute between the two countries. The internationalization of the elderly care is a fact. Internationalization of elderly care means on the one hand offering care facilities, under which care holidays, to older migrants (remigrants) in the country of origin (Surinam, Morocco, Turkey and The Dutch Antilles etc.); on the other hand offering care facilities (care holidays) to overwinteraars, the Dutch elderly in foreign countries (like Spain and Portugal). 4. How to establish intercultural personnel policies within the social systems in Finland? When thinking about establishing intercultural personnel policies within social systems, it is important to first define the arguments why they are needed or perhaps necessary for European countries. Of course, the numbers of migrants and the variety of persons with different ethnocultural backgrounds increases due to the world wide processes of globalization and migration. But especially for the elderly care there are more arguments that count: 1. First of all the aging of the population of European countries and especially in Finland; 2. Together with a growing need for personnel in the elderly care; 3. The growing numbers of young migrant people within a decreasing number of young people on a whole. So there are valid arguments to develop and implement intercultural personnel policies within social systems in Finland from a strategic policy point of view. ENIEC s advise on specific issues of intercultural elderly care in Finland 4
From the experiences with intercultural personnel policies we can learn that we need a long breath. Working on a project basis can help to put the issue on the agenda and to raise visibility by achieving concrete results in a fixed time period, but to be effective on a longer term, it really needs to be part of the policy process. In this process different phases can be distinguished: 1. Agenda setting: the formulation of a vision and obtaining a basis for changing; 2. Problem formulation: being as specific (smart) as possible in defining the specific problems and possible solutions. Preferably as well in changing the personnel policy as in changing the policies and processes towards clients c.q. in service delivery. Especially in the development of intercultural personnel policies the views and having/setting up a network of professionals with different cultural backgrounds can help a lot. Because they are the experts in knowing how to recruit in their own ethnic/cultural group, what works and what not and they can open up their networks as well as behave/be used as a role model (for example to make migrants more aware that working in the elderly care can be interesting for them, for example in advertising); 3. Policy forming and execution: important is to pay attention to all relevant aspects: the content and the organization, the organizational structure ànd culture, and to managing the changing process itself. 4. Policy evaluation and feedback: to make it a circular process with vast moments in time to evaluate and make improvements is the only way to successfully implement the results in the policy cycle. Intercultural personnel policy can also be divided in a process with certain phases and products: Process in phases Preparation: opening up Understanding Willing Enabling Changing: doing Rooting: keep doing Following Product Attention Overview Plans Training/Learning Execute Rooting/Anchor Evaluate Important is that in every care education (from helping person, nurses, to specialized doctors and managers) interculturalization and the development of cultural competence is a compulsory subject. For example in The Netherlands this is the case in most of the education in the field of health care. A method which is effectively used in the training of cultural competence amongst health care practitioners, especially doctors, is the use of video registrations of consults of practitioners with clients with diverse ethno-cultural backgrounds. Especially because the component attitude in the tripod attitude, knowledge and skills (of which cultural competence is composed) is the most essential one for delivering culturally sensitive care. When the practitioners, but also the management, and all the other employees, become aware of their behavior (because they are confronted with it on the video) they are more open and reflective to change their attitude and become more sensitive. ENIEC s advise on specific issues of intercultural elderly care in Finland 5
With regard to the development of cultural competence of employees, it is very desirable to pay attention to the specific training functions within the care, nursing, support services and management. ENIEC sees it as an important task for the total health care in Europe to make their institutions intercultural. This means that an organization should invest in diversity in personnel, culture sensitive education and organization in order to increase accessibility and culture sensitive care for migrants. They have to acknowledge the cultural differences and have to provide an answer. But is needed that also the (elderly)migrants themselves have to take a hospitable attitude towards the organization in this process. Another important item in making the health care system sensitive to cultural differences is that research is done into common diseases in the various immigrant groups. Such as diabetes, heart and vascular diseases. Prevention is the next step. Now a lot is done in health education, prevention and supporting a healthy life pattern aimed at cultural groups. It is important that the staff/personnel develops intercultural expertise to keep track of cultural differences. They have to know the subjects and beliefs different cultures can have of ideas of God, etc. It is the responsibility of the health care organization to deal with that by means of training (Also see DVD, The Schildershoek). Furthermore it is important that interculturalization becomes a an integral part of care training for all employees, not only caregivers. Thereby is working in the care business not so popular under immigrant youths. Because as for now, working in care has no status. Attention must be given to this topic. 5. What to do with the problem of loneliness of elderly migrants, especially men There can be multiple reasons to become lonely. Language and physical restrictions seem important risk factors for the occurrence of solitude. Research carried out in the Netherlands shows that day care plays an important role in the fight against loneliness. The people who reported solitude, indicated that they have experienced stress complaints. Attention must be paid to the fact that respondents may use socio desirable answers when it comes to the topic of solitude. For it is for some people a taboo subject. They would prefer not to admit that they suffer loneliness. Striking is the fact that none of the male respondents said to have been lonely. Perhaps the taboo plays a greater role for men than for women. It is therefore possible that loneliness is more common then research results show. The probability that older migrants get lonely increases with their preference to live as long as possible in their own homes. After all, you only leave your home when your family is no longer able to take care of you. In addition, the institutionalized care (at least in the Netherlands) has not a good image under (elderly) migrants. As a result, without the proper care and attention they tend to fall ENIEC s advise on specific issues of intercultural elderly care in Finland 6
into isolation. In the Netherlands, the image of the institutionalized care needs to be improved, both for 1 e and 2 e generation migrants. Empowerment is a relatively new way of dealing with problems of loneliness of the elderly. Empowerment is a good and respectful way of sharing and caring for both migrants and natives. See annex 3 to learn more of the methods of empowerment. In the Netherlands we have also good experience with 'meeting places' for older migrants. For older immigrants it is important that there is a place where people can meet and where they can organize activities together. This also contributes to empowerment and reduces isolation. Sometimes the meeting is part of 'The house of the neighborhood " that is jointly managed by welfare and care institutions. Home visits by volunteers from the local community are a possibility to enable more people to participate in society. It is important that volunteers are trained in advance and are supported by professionals There are also projects with "neighborhood fathers Especially in neighborhoods where the youth cause problems the "neighborhood fathers' keep in touch with young people, guide them and and try to " keep them on track". The neighborhood fathers, often without jobs, have again a social function which is good for their self esteem. 6. What is the opinion of the ENIEC-members on the circulation of migrants, is this good or not? And how can Finland adapt its social systems to the mobility of (elderly) migrants? The term circular migration constitutes a global and a rural concept. In a global context, circular migration is used as a triple win discourse, promising gains for host countries, home countries and migrants themselves. Promising accelerated economic growth, remittances, relative high wages and brain gain (brought in expertise), by means of full circles of migration: immigrants should be able to come, go and come back again, with few restrictions and making use of contemporary transnational networks. At this point in time it is difficult to get insight in who is actually gaining from this global circular migration. Circular migration in an urban context is a form of migration by which migrants move to the city for a few months and then return to the village when they can be most useful there. It is often part of a larger household strategy that seeks to diversify income streams and maximize consumption. In The Netherlands for instance this is a relatively new group of people like the Polish people. ENIEC s advise on specific issues of intercultural elderly care in Finland 7
In her presentation 18 March 2010, the advisor of the Minister of Migration and European Affairs of Finland explained that it is sometimes difficult for elder to get an indication for care services when their children don t live in the same municipality. This is due to the fact that Finland is the most decentralized country in the EU with no less than 350 municipalities who all have their own freedom in social and health care service delivery. In Germany the municipality where the person in need of care lives has to pay all needed care if the person moves to another municipality. This is independent from the fact that services and costs differentiate a lot between the municipality. Noone can be forced to stay in his municipality. The responsibility to pay lasts until the death of the person. One effect of this way to handle it is that the municipalities are interested to find standards of costs and services. There is return migration, when a person will finally return to his / her country of origin. Commuting is travelling to and from between the land of immigration and the homeland. A growing number of elderly migrants want to stay in their home countries during a certain period of the year, especially during the cold winter time in Western and Northern European countries. We call this commuting.there are different forms of commuting: seasonal migration of seasonal workers, hibernation and regular travel between home and remote working. From research is known that most immigrants have ideas and fantasies of going back to their homeland. Migrants often think about going back, but it doesn t really happen. This is also called `the myth of return`. In most groups about one third wants to commute. (Re)migration has its affects on personal health. Positive factors for health are the desire for known and trusted care and the idea that one feels happier and healthier in the land of origin. Inhibiting factors are the knowledge of that the quality of the care provided in the homeland is not as good and the dependence of high quality care in the western and northern European countries. Migration itself form a burden for good health. This could have to do with the climate, but also with stress and a reduced resistance to infections. It is possible that the ongoing desire to return will lead to fysical and psychological complaints. Furthermore, the return to the land of origin is inhibited because of the financial situation of the elderly migrant. They often have a low or no education, and therefore a low income. So they have not enough money to return. Lots of older migrants have children and grandchildren who were born in Europe. That is the most important reason not to go back. The family is important. They will take care of them when necessary. It is possible that our experience with migrants from non-western countries like Moroco and Turkey, is about the same as the Somaly migrants in Finland. In that view this following information can be useful. Lots of older migrant are more and more emancipating. It is noted that the first step is participation and the last is integration. ENIEC s advise on specific issues of intercultural elderly care in Finland 8
7. How can we create more exchange programs for students within Europe, where they can learn from different cultures and backgrounds? Within the European Union, the Program Youth In Action finances the exchange of youngsters of 16-60 persons from at least two countries in the age of 13-25 years. The aim is that young people via an out of school intercultural program get to know each others backgrounds and culture. Youngsters have to be actively involved in the preparation, execution and evaluation of the exchange program. It would be very interesting to combine the annual meeting of ENIEC with an exchange of young people from the countries involved in ENIEC, who are working in the intercultural elderly care or following a care education. Especially as these students or young care workers themselves are from migrant origin. For the annual meeting next year in Sweden, ENIEC will try to get this exchange financed from the EU Youth in Action Program. There are already some Dutch young students (social care) and health sciences with diverse migrant backgrounds (Turkish, Moroccan, Surinamese Hindostan and Javanese) interested to work on this. They are collaborating in a research amongst elderly migrants in The Netherlands, which is carried out for one of the members of ENIEC and supervised by another ENIEC member. For the next annual meeting in Göteborg, Sweden, in March 2011 we try to combine the annual meeting with the exchange of students in intercultural elderly care. Also the Finnish members of ENIEC will be approached to participate in this initiative and find students e.g. young people (with diverse ethno-cultural backgrounds of origins) working in intercultural elderly care. Finally In this paper we had to make a selection of all the information we have gathered in the past 4 years of the existence of ENIEC. Therefore we have attached 4 annexes and 1 DVD. In the annexes 1 to 4 you will find additional information: 1. (criteria for) Best Practice 2. Golden rules of interculturalization, 3. empowerment and 4. interesting internet sites. If you feel the need to learn more about a certain subject, please don t hesitate to let us know. ENIEC is always willing to provide additional information if you so desire. Again, we are most grateful for the warm welcome you gave us in March and hope that you will benefit from our contribution to the Finnish policy of migration affairs. ENIEC s advise on specific issues of intercultural elderly care in Finland 9