Process-oriented Home Care System Transformation

in Central Finland

Jing Tang

, Toni Ruohonen

, Junichi Iijima

and L. G. Pee

Department of Industrial Engineering and Management, Tokyo Institute of Technology,

2-12-1 Ookayama, Meguro-ku, Tokyo, Japan

Agora Center, University of Jyvaskyla, Mattilanniemi 2, Jyvaskyla, Finland

Keywords: Business Process Modeling, Central Finland, DEMO, Home Care.

Abstract: Due to aging population and rising expenses in health care, Central Finland’s local governments and author-

ities are increasingly promoting home care rather than relying solely on institutional care. To increase the

adoption of home care, it is necessary to create a mutual understanding of the current home care system, and

to improve the cooperation of stakeholders. From the process perspective, after analysing 6 related organi-

zations in Central Finland, this study created a general model of the current home care system in Central

Finland by using DEMO Construction Model, and pointed out several problems in its real implementation.

This study demonstrates that DEMO is applicable to the examination of essential processes in health care

systems and can offer suggestions for improvement.

1 INTRODUCTION

The trend of aging population creates increasing

demand for various resources in a healthcare system

such as financial resources, staff, and facilities.

However, the limited capacity of nursing homes and

hospitals does not allow a universal coverage of in-

stitutional care, even in developed countries. There

are also many senior citizens who prefer to live at

home together with families, or even alone. Home

care is therefore becoming an alternative to institu-

tional healthcare. However, seniors in home care are

often monitored less closely and they often face

higher risks of falls, strokes, and heart attacks. It

calls for a relative system transformation to support

home care, especially the caring relationship be-

tween care professions and the aging people even at

their home.

In Finland, local governments manage health

care system. As Central Finland is sparsely populat-

ed, healthcare facilities are often located far from the

patient’s home and are not well equipped. Moreover,

Finland is experiencing the problem of aging popu-

lation (CIA, 2012), because of low birth rate and

increase of life expectancy (Kunz, 2007). Therefore,

it is vital to improve the effectiveness of healthcare

and reduce the burden on institutional healthcare.

The municipal authority of health care is aiming to

increase the usage of home care to cover 90% of the

domestic aging people. In this study, we selected

DEMO (Design & Engineering Methodology for

Organization) to create a general model for home

care system in Central Finland. Based on it, we iden-

tified areas for improvement in the current imple-

mentation and provide suggestions for home care

system transformation.

2 DEMO

Design & Engineering Methodology for Organiza-

tions (DEMO) is a cross-disciplinary method that is

used to studies communication, information, and

action within the context of an organization, based

on PSI-Theory (Dietz, 2006). Unlike previous meth-

odologies, DEMO considers communication as links

to connect processes within or across organizations.

DEMO is used in this study to describe authority and

responsibility of abstracted actor roles, create a mu-

tual understanding of business processes among the

stakeholders, and compare similarities and differ-

ences of organizations. Comparing with other busi-

ness process models, DEMO base on ontological

modelling and has no limitation of requirement for

detailed information in the implementation level. In

addition, DEMO has also been applied to the domain

455

Tang J., Ruohonen T., Iijima J. and Pee L..

Process-oriented Home Care System Transformation in Central Finland.

DOI: 10.5220/0004179704550460

In Proceedings of the International Conference on Knowledge Engineering and Ontology Development (SSEO-2012), pages 455-460

ISBN: 978-989-8565-30-3

 2012 SCITEPRESS (Science and Technology Publications, Lda.)

of healthcare in prior studies such as Habing et al.

(2001), and Maij et al. (2000).

Based on Dietz (2006), DEMO contains methods

for developing ontological models. The ontological

aspect models consist of Construction Model (CM),

Process Model (PM), Action Model (AM), and State

Model (SM), which are highly correlated and inter-

dependent. The CM explains the identified transac-

tion types and their tree logic, as well as the associ-

ated actor roles. It defines the authority and respon-

sibility of actor roles. The CM is also the most basic,

concise and easy-to-understand model among the

four aspect models. It is widely used in previous

case studies and business consulting.

3 CASE STUDY BACKGROUND

In Central Finland, while the population is more than

270 thousands, 17.8% are aging people (i.e., >65

years old). The ratio of healthcare staffs to the popu-

lation is only 1%. As a rule, the national health in-

surance, provided by KELA (Social Insurance Insti-

tute of Finland), basically covers all permanent resi-

dents of Finland, but Finnish health care system has

been criticized for being inefficient due to the exces-

sive number of units, health centres, hospitals, diag-

nostic services, and the density of administrative

units in the system (Kokko, 2009). Health care is a

critical and expensive service managed and financed

by local municipal authorities. They decide domestic

basic rules and laws. And they are also main contac-

tors to access health care services under the cover-

age of national health insurance. Most of public

health care institutions (e.g., hospitals, nursing

homes, and home cares) are sub-organizations of

municipal authorities. Nowadays, private health care

gradually becomes the alternative to overcome the

limitation of service availability from the public sec-

tors.

In Central Finland, home care services under

the coverage of national for demanders need to ap-

ply from the municipal authority of health care. Its

main responsibility is to establish a home care policy

(e.g., period, basic services, devices, potential care-

giver list, and fee) according to the health and living

situation of demander, together with the local annual

budget for home care. After that, a home care care-

giver (public or private) from potential caregiver list,

selected by the demander, will execute the home

care policy.

4 RESEARCH DESIGN AND

ANALYSIS

4.1 Research Design

In order to create a general model for home care

system in Central Finland, we mainly studied six

related organizations (one municipal authority of

health care, three public home cares, and two private

home cares), based on interviews and document re-

views. In each organization, we interviewed two to

three managers, team leaders and key staffs about

key business processes and their daily works. We

also matched the data from the interviews with the

provided documents. Interviews and documents are

mainly in Finnish, and cooperated Finnish research

team translated team into English. According to

these, we created CMs for each organization. Then,

by comparing the similarities and differences in

these six models, we generated the general CM for

the home care system. This general CM was final

validated by the Finnish research team and home

care workers. In next part of this paper, we describe

the general model by using Actor Transaction Dia-

gram (ATD) and Transaction Result Table (TRT).

TRT is considered from both ontological and im-

plemental level by including the real initiator and

real executor of each transaction.

4.2 General Construction Model for

Home Care System in Central

Finland

Figure 1 and Table 1 show the general CM for home

care system in Central Finland by demonstrating key

transactions, actor roles and information bask. Ac-

cording to the Finnish rule, it has been split into two

parts: (1) health care policy establishment, executed

by the municipal authority of health care; and (2)

home care policy execution, executed by a public or

private home care caregiver.

For the municipal authority of health care, the

whole process is started by the health care demander

(CA01), who is the aging people, requesting health

care policy establishment form the health care policy

establish manager (A01) by phone calls, emails, or

face-to-face visits. Moreover, other people, such as a

relative of the patient, social workers, and doctors

etc., can also contact the authority on behalf of the

patient in some cases. After received the require-

ment, for new demanders (CA01), the health care

policy establish manager (A01) will build a new

health care client account in the health care clien

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Figure 1: Action Transaction Diagram of Home Care System.

Table 1: Transaction Result Table of Municipal Authority of Health Care.

No Transaction Type Result Type Real Initiator Real Executor

T01 Health Care Policy Establishment Health Care Policy p for Demander d has been established

Demanders or Relative

or Social Worker etc.

Care Manager

T02 Doctor Referral Provision

Doctoral Referral to establish Health Care Policy p for has

been received

Care Manager Demander or Relative or Doctor

T03 Health Care Policy Planning

Special Care Policy sp in Health Care Policy p for Demand-

er d has been established

Care Manager Special Case Handler

T04 Patient Visiting

Patient visiting of Demander d to establish Special Care

Policy sp was finished

Special Case Handler Special Care Handler or other

T05 Home Care Policy Execution Home Care Policy hp for Demander d has been executed Demander or Relative Service Manager

T06 Care Plan Completion

Care Plan cp for Demander d according to Home Care

Policy hp has been completed

Service Manager Service Manager

T07

Family Member Home Care

Execution

Family Member Home Care care in Care Plan cp has been

executed

Service Manager Relatives or Neighborhood

T08 Payment Home Care Policy hp for Demander d has been paid Service Manager Aging People and Insurance Company

T09 Daily Care Activity Management Daily Care Activity Schedule s has been managed (Vice) Service Manager (Vice) Service Manager

T10 Meal Service Meal service has been provided

(Vice) Service Manager

Municipal Kitchen or other

T11 Cleaning Service Cleaning service has been provided

(Vice) Service Manager

Cleaning Company

T12 Transportation Service Transportation service has been provided

(Vice) Service Manager

Taxi Company or other

T13 Catering Service Catering service has been provided

(Vice) Service Manager

Nurse or other

T14 Device Providing Necessary device has been provided

(Vice) Service Manager

Nurse or other

T15 Nurse Visiting Nurse visiting has been provided

(Vice) Service Manager

Visiting Nurse

T16 Medical Advice Medical advice has been provided

(Vice) Service Manager

Doctor

T17 Medicine Pick-up Medicine m has been picked up from pharmacy

(Vice) Service Manager

Nurse or other

T18 Medicine Preparation Medicine m has been prepared Nurse Pharmacy

T19 Medicine Delivery Medicine m has been delivered to client

(Vice) Service Manager

Nurse or other

T20 Therapy Therapy has been provided

(Vice) Service Manager

Therapist

T21 First Aid First Aid f for Demander d has been provided Aging People Nurse (Day) Taxi Company (Night)

T22 Stock Management Stock for Stock Management Period st has been managed

(Vice) Service Manager

T23 Stock Replenishment Stock for Stock Management Period st has been replenished

(Vice) Service Manager

Goods Provider

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457

data (PB01) for them. If the necessary information

of personal medical history (PB02) and health care

provider availability (PB03) is not available, the

health care policy establish manager (A01) have to

request them from the information taker, on a case-

by-case basis. The doctor referral provision (T02) is

also required in some specific cases to check the

patient’s health condition. Based on all these infor-

mation, for a simple case or a temporary care case

that requires common health care package they have,

the health care policy establish manager can estab-

lish the health care policy (T01) directly. More com-

plicated cases are passed to the health care policy

plan manager (A03) for more detail health care poli-

cy planning (T03). If necessary, the health care poli-

cy plan manager (A03) may request a patient visit-

ing executor (A04) to visit the demander at home or

care institute (T04) to examine his/her actual health

and living situation. When the health care policy

establishment (T01) is completed, the health care

demander will be informed about the type and peri-

od of service he/she can receive, the potential pro-

viders, and the fee for the service.

According to the health care policy, if the policy

assigns the health care demander (CA01) needs

home care, he/she should select one of caregivers

from the potential providers list, and contact or meet

an officer there. The home care policy executor

(A05) will check whether the demander has com-

pleted the processes at the administrative office from

municipal authority of health care before executing

the home care policy (T05). The home care plan

manager (A06) will then be requested to complete

the care plan (T06) for demander. In some cases, the

home care plan manager may request potential fami-

ly caregiver (CA02), to execute the family member

home care (T07) at home. When the home care ser-

vice finished or the end of each month, the payment

(T08) is then paid by the payer (CA03) (e.g., insur-

ance company, and demander). For the daily job, the

daily care activity is managed (T09) by the daily

care activity manager (A09). Based on the daily care

activity schedule, the daily care activity manager

(A09) will assign the job to nurses or outsource the

job to other companies (e.g., meal provider, cleaning

company). Meal provider (CA04) serves meal (T10)

according to the request from the daily care activity

manager (A09). Cleaning service (T11) is done by

the cleaning company (CA05). When the aging peo-

ple need transport (e.g., shopping), transportation

provider (CA06) will provide transportation service

(T12) according to the booking appointment. The

catering executor (A13), who may be a nurse in pub-

lic home care or a non-medical worker in private

home care, executes the catering service (T13) such

as taking a shower for the aging people, feeding

food, and giving medicine, etc. Devices for aging

people such as forearm crutch, wheelchair, etc. are

provided (T14) will be delivered and set up by the

device providing executor (A14). The visiting nurse

(A15) does temporary or regular nurse visiting (T15)

to give medical checking and basic treatment for

demanders. If the health situation of a demander

changed, the home care workers need to contact to

the doctor (CA07) for medical advice (T16). In some

organizations, the visiting nurse (A15) will also reg-

ularly communicate the doctor (CA07). It can be

seen that most of the medical jobs are carried out by

the visiting nurse. Medicine pick-up executor (A17)

will go to pharmacy to pick up the medicine (T17)

for health care demanders. The pharmacy (CA08) is

responsible for preparing and packing the medicine

(T18). Then, the medicine deliverer (A19) will be

requested to deliver the medicine (T19) to the de-

mander. In most of cases, a nurse is assigned to de-

liver medicine when he/she provides other home

care services for the same demander. The cooperated

therapist (CA09) does the home visit therapy (T20)

for demanders when required. After all the home

care workers finish their job everyday, they have to

update client data (PB04) and report transportation

fee (PB06). In addition, most of home care demand-

ers will be provided an emergency alarm at home.

When there is any emergency case, the first aid ex-

ecutor (A21) will provide first aid service (T21) to

the health care demander (CA01), and then report

the result to daily care activity manager (A09). Dur-

ing the daytime, there are some nurses in charge of

picking up the phone call. But at the nighttime, the

first aid service (T21) is always outsourced to other

institutes, which provide 24 hours services, as the

private nursing home or the taxi company. The taxi

company will be called to send a taxi to the aging

people’s house. For the serious case, the taxi has to

go to the hospital to take the night nurse to the de-

mander’s house. The stock manager (A22) is in

charge to manage the stock of goods (T22), and or-

der goods from providers (CA10) to replenishment

the stock (T23). There are four information banks

inside: home care client data (PB04), shift data

(PB05), travel expense data (PB06), and cooperated

home care provider data (PB07).

In addition, in the implementation, a key differ-

ence between the public home care and the private

home care is that the private one tends to outsource

all medical services (T15, T16, T17, T18, and T19)

to others, as private clinics or private visiting nurses.

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5 DISCUSSIONS

In previous section, we identified the general model

of home care system in Central Finland based on

DEMO. It provides a mutual model for us to under-

stand the main transactions in the home care policy

establishment and execution, as well as their inter-

dependencies (illustrating by two information links).

In Figure 1, the information link from T01 to A05

refers to that health care policy establishment (T01)

in municipal authority of health care is the premise

for home care policy executor (A05) to provide

home care services to demanders. And the infor-

mation link from T05 to A01 demonstrates that

home care policy execution (T05) is critical re-

sources for health care policy establish manager

(A01) to follow up the current situation of demand-

ers to improve the health care policy.

5.1 Problems in the Implementation

One benefit of DEMO is to abstract essential trans-

actions and related actor roles in the ontological lev-

el, which define the authority and responsibility of

actor roles. In turn, it helps to assess the real imple-

mentation related to define and distribute responsi-

bilities across functions. In this part, using the vali-

dated general CM model as a stepping stone, we will

discuss several critical issues in the implementation

of the previous general construction model.

First, in the implementation, necessary infor-

mation related to one transaction can be provided by

the real initiator or found out by the real executor.

For the transaction, the home care policy execution

(T05), the initiator of this transaction is the home

care demander. Because of that the demander, espe-

cially aging people, is lack of capability to fully un-

derstand and explain the health situation of him-

self/herself, the executor, home care policy executor

(A05), has to find out information. Moreover, it is

also difficult for home care nurses to assess it from

the appearance and behavior of demanders. In addi-

tion, because of the security consideration and the

difference of e-health record system among organi-

zations, the exchanging of data across organizations

is difficult (Invest in Finland, 2011). So, before

promising the home care policy execution (T05), the

home care policy executor (A05) has to contact with

related information holders to access the data. It is

an extremely time consuming step in most of our

examples.

Second, as the general CM of home care systems

has been split out into two parts. Not only their sepa-

rated domain, a mutual understanding and definition

of their interdependency is also critical for the

alignment. However, it has been missed in the cur-

rent home care system of Central Finland. The in-

formation sharing efforts have not been standardized

and highlighted between the municipal authority of

health care and the home care caregiver.

Third, the home care demander can get the regu-

lar treatment and health checking from the visiting

nurses (A15) at home. For better service, the visiting

nurse (A15) needs to communicate with the doctor

(CA07). Currently, there are multiple ways as e-

mail, phone call, or the Pegasos, instead of face-to-

face visiting. Pegasos is a patient information system

widely used in Finnish public health care sector (In-

vest in Finland, 2011). However, because of the in-

charge visiting nurse and doctor are usually not

fixed for each home care demander, the transaction,

the medical advising (T16), is still full of challenges.

It needs to emphasize the responsibility of the visit-

ing nurse to initiate T16, and to develop better

methods and technologies for better health situation

control and more efficient communication between

the visiting nurse and the doctor.

Fourth, the process of delivering medicine (T19)

to the demander (CA01) seems to involve various

actor roles such as the medicine pick-up executor

(A17) and medicine deliver (A19). The long and

multi-actor process may increase the possibility of a

drug misadventure (i.e., (1) “an inherent risk when

drug therapy is indicated”; (2) “incident created

through either omission or commission by the ad-

ministration of a drug or drugs during which a pa-

tient is harmed”; (3) “incident whose outcome may

or may not be independent of pre-existing disease

process”; (4) “incident which may be attributable to

error, immunological response, or idiosyncratic re-

sponse”; and (5) “incident which is unexpected and

thus unacceptable to patient and prescriber”

(Schommer, 2000)). Therefore, it is better to enforce

clear steps on the process to reduce the risk.

Fifth, emergency management is a key aspect of

home care system. Because of the real executors of

first aid (T21) at the daytime and night time are dif-

ferent, as well as some non-professional caregivers

such as taxi drivers are included, it is a transaction

integrating multiple actors. It not only needs a high

coverage of the new equipment, as emergency

alarms, but also requires a clearer description of ac-

tor’s responsibility and action steps.

Additionally, according to Table 1, a nurse is as-

signed to complete the jobs as catering (A13) and

medicine deliver (A19). This can be a hidden prob-

lem. Based on the expertise from special training,

nurses can carry out various medical and non-

Process-orientedHomeCareSystemTransformationinCentralFinland

459

medical tasks. For example, serving meals, taking a

shower for aging people, and cleaning the stuffs, We

can see that instead of doing more medical related

tasks, nurses need to spend time on many non-

medical tasks, which do not require their profession

and expertise.

5.2 Suggestions for Home Care

Transformation

Based on previous discussion, the following sugges-

tions are proposed.

First, in order to support the information shar-

ing among stakeholders in the home care, we sug-

gested establishing the national healthcare database

for all the residents to provide a basic standard. By

applying this method, both public and private home

care caregivers as well as home care demanders can

access the same database and retrieve the necessary

information such as medical history and health situa-

tion. For the security consideration, the related

health card can be launched as a method for stake-

holders to access the national healthcare database.

Especially, it is likely to increases the efficiency of

ordering phase (including request and promise) in

the demander-initiated health care process, as T01

and T05 in Figure 1.

Second, as mentioned before, in current home

care system, a main difference between public and

private home care caregivers is that the private ones

tend to outsource all of their medical services to oth-

ers and the nurses who have a rich medical expertise

and capacities have to do many non-medical tasks.

Therefore, the effectiveness of the whole home care

system is likely to improve if the public and private

sectors can collaborate to complement each other in

providing medical and non-medical services. Fur-

thermore, it can solve the problem of informational

sharing from public sectors to private sectors as an

alternative to the national healthcare system, because

the public sectors can access the client information

from Pegasos while the private ones cannot. They

may start exploring how to collaborate by consider-

ing and resolving issues related to law, culture, pri-

vacy, etc.

6 CONCLUSIONS

As Michael Porter pointed out, the health care in 21

century is currently delivered by the business model

of the 19

century (Porter and Teisberg, 2006).

Health care services and systems need to keep up

with shifting technological improvements, medical

development, and changing aging people needs. It is

also essential to establish a mutual understanding

about the home care system. Based on the interview

and document, we identified CMs for six home care

institutes in Central Finland, and then extracted the

general model of home care system. Next, we also

assessed the home care implementation related to the

attribution of responsibilities among real actors. This

study contributes to practice by creating general

construction model, identifying some critical issues

in practice, and showing some potential solutions to

enhance the home care system in Central Finland. In

this study, only the construction model has been

developed, other DEMO aspect models can be fur-

ther analyse. They may give some foundations of an

integrated model of healthcare services.

REFERENCES

Central Intelligence Agency (CIA)., 2012. The World

Factbook-Finland, available at

https://www.cia.gov/library/publications/the-world-

factbook/geos/fi.html (accessed June 2012).

Dietz, J. L. G., 2006. Enterprise Ontology - Theory and

Methodology. Springer. Heigelberg.

Habing, N., Dietz, J., Zwetsloot-Schonk, B., 2001. Activi-

ty Patterns in Health Care-Identifying Building Blocks

for the CPR. SIGGROUP Bulletin, 22(2), 9-15.

Invest in Finland., 2011. E-health in Finland. Invest in

Finland. Helsinki.

Kokko, S., 2009. Integrated primary health care: Finnish

solutions and experiences. International Journal of In-

tegrated Care, 9(25), 1-9.

Kunz, J., 2007. Population Aging – Problem or Opportuni-

ty? Lessons from the Case of Finland. Journal of So-

ciology, 1(1),

Maij, E., Reijswoud, V. E., Tousaint P. J., Harms, E. H.,

Zwetsloot-Schonk, J. H. M., 2000. A Process View of

Medical Practice by Modeling Communicative Act.

Methods of Information in Medicine, 39, 56-62.

Porter, M. E., Teisberg, E. O., 2006. Redefining health

care: creating value-based competition on results.

Harvard Business School Press, Massachusetts.

Schommer, J. C., 2000. Pharmacists’ New Communicative

Role: Explaining Illness and Medicine to Patients. In:

Whaley, B. B., editor. Explaining Illness: Research,

Theory and Strategies. Lawrence Erlbaum Associates.

New Jersey, 209-233.

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