INGE – integrate4care

As a consequence of our aging society, the number of people in need of nursing care in Germany will increase from the current figure of about 3.5 million to an expected 4.4 million in 2040.¹ Providing care for these people requires considerable efforts in our society, with home care by informal caregivers being the main pillar. At present, about 70 percent of those in need of nursing are cared for by family members as informal caregivers. This allows older people to live in their homes as long as possible, as most of them wish to do.

Many informal caregivers struggle to reconcile the multiple burdens of family life, paid work and care-giving. Often, they do not even have the information necessary to take advantage of available services to ease their care burden such as daycare or to provide care in a more efficient way, e. g. to avoid excessive strain on their back.

To support informal caregivers and to safeguard the quality of home care, §37.3 Sozialgesetzbuch XI (SGB XI) established the home care counseling visit. In these regular visits, a professional nurse will assess the health situation of the person in need of care and the resources available for care-giving, and may recommend immediate improvements, e. g., a suitable medical aid or a fall prevention program. The visits also aim to assess the burden on informal caregivers and to reduce it to sustainable levels, in order to stabilize the home care situation and keep it going for as long as possible, taking into account the needs of all the people involved.

As a §37.3 SGB XI counseling visit requires substantial geriatric care expertise, it is typically conducted by a professional nurse from a mobile nursing service chosen by the people involved. In 2017, 2.66 million people were being cared for at home, 1.9 million of them exclusively by their relatives.² As a consequence, 3.61 million §37.3 SGB XI counseling visits took place.³ However, to date there are no quality standards that define concrete content of counseling visits. Thus, they are carried out very unevenly, their findings and recommendations being documented in widely differing formats. This makes it very difficult for a nurse to prepare for a follow-up visit and almost impossible to pass on information about the health status of a person in need of care and the home care situation to health care providers such as family doctors or hospitals.

To fully exploit the potential of §37.3 SGB XI counseling visits to improve the home care situation, the INGE project aims to:

• Develop an IT-support for §37.3 SGB XI counseling visits to deliver a standardized, high-quality service tailored to the individual home care situation.
• For this purpose, the project is building a set of counseling instruments. It is based on the Neues Begutachtungsassessment (NBA), which the Medizinischer Dienst der Krankenkassen (MDK) uses to determine the type and amount of care needed by a person in long-term care. Assessment items relevant for home care counseling will be supplemented by additional items for determining the burden on care-giving relatives.
• In addition, the project is developing a catalog of measures that the system will use to suggest steps to improve or stabilize the health status of the person cared for and the home care situation, based on the documented assessments.
• IT-supported documentation of the counseling interview as well as of observations by nursing staff. The documentation will make it possible:
  • to monitor the care history as well as proposed measures, to enable continuous care planning for the first time;
  • to make a summary of the latest counseling visit available to other health care providers to facilitate cross-sector cooperation and help prevent faulty diagnoses, misguided therapies or double prescriptions.
• Well-informed preparation of the follow-up visit, even if a different nurse goes to see the care-giving relatives and the patient.
• Machine learning technology can be applied to find patterns and trends in the collection of documented care histories, which can later be used as an early warning system to assess the potential risk to an individual patient. The system can point out potentially effective measures to the nurse who can decide to recommend them in the specific case at hand.
• Establishment of a service platform for care-giving relatives, patients and health care providers such as general practitioners, specialist physicians, doctors in hospitals, or physiotherapists. They can use it to make their own documents available, e. g. discharge letters, but mainly to access the documentation of §37.3 SGB XI counseling visits, which will provide patient information that is not available elsewhere but may be essential for effective treatment.

In the INGE project, Fraunhofer FIT is involved in user requirements engineering, in the design of the system architecture, and the development of the machine-learning component. FIT also provides the service platform.

¹https://www.aok-bv.de/imperia/md/aokbv/hintergrund/dossier/pflege/pressemitteilung_pflege_report_2019.pdf
²see Destatis (2018)
³Home care counceling visits are mandated by §37.3 SGB XI every 6 months for care level 2 and 3 patients and every 3 months for care level 4 and 5 patients.