Providing home care to vulnerable populations in Albania
De Besim Nuri,
Sajmira Aderaj,
Ehadu Mersini et
Altina Peshkatari
The population of Albania is aging rapidly. The census of 2023 showed that 19.7% of the population is 65 years of age or older, compared to 11.3% in 2011. Health for All (HAP), an SDC funded project, has been introduced and is supporting home care services targeting homebound patients and elderly living alone. In October 2024, 54 Primary Health Care (PHC) centers of Albania were implementing this new typology of services. By the end of HAP in 2027, 120 PHC facilities will be capacitated to deliver good quality home care services. Albanian authorities adopted the model of home care services and are supporting the upscale in many regions of Albania.
The population of Albania is becoming older. The census of 2023 (Albania Population and Housing Census 2023) showed that 19.7% of the population is 65 years of age or older, compared to 11.3% in the 2011 Census. The old-age dependency ratio[1] increased to 30.4% in 2023. Several factors explain this situation:
A decreasing fertility rate
The pace of external migration
A long life-expectancy of 79 years in 2022 (INSTAT, 2023).
Aging population - complex health and social problems
Elderly people have higher health needs along with the need for social support. According to the Census 2023, the prevalence of disability in the Albanian population aged 5 years and over is 6.5% and 59,5% of people with disability belong to the age-group 65+ (INSTAT, 2023). As a result of external migration, many elderly people live alone. In some cases, they benefit from remittances of their children living abroad. Nevertheless, this situation leads to loneliness and social isolation.
According to the Ministry of Health and Social Protection (MoHSP), 8% among the 65 and above have no contacts with families or friends (National Action Plan on Ageing, 2020-2024). The capacities of Albania to provide residential care for elderly people are very limited. Moreover, in the Albanian culture it is considered "disgraceful" to be sheltered in nursing residential centers. Consequently, elderly people stay in their homes. This makes it imperative for the country to provide home health care and social services to elderly living alone.
Increasing need for health services targeting the elderly
Elderly people who are unable to access health centers due to physical disability face the need for periodic and specific health services, which in most cases are only available in hospitals. They face major challenges in accessing health services, including the inability to secure transportation. Consequently, they face a high risk of deterioration of health situations and permanent loss of functional abilities. Elderly people need continuous health care for the treatment of chronic diseases. In Albania, it is estimated that around 20’000 individuals, mostly elderly, are unable to leave their homes to access health care services due to disabilities from chronic diseases (MoHSP, 2023). There are some private nursing facilities, but their costs can be afforded only by wealthier elderly people or their families.
Health for All - a project of SDC
Health for All (HAP) is an SDC funded project that aims at strengthening primary health care services in Albania, with a focus on improvement of accessibility and quality of care.The project is implemented in Albania since 2015 by the Swiss TPH through the HAP Center. The project is presently in the Consolidation Phase (2023-2027). During the two previous phases the project has implemented successfully different interventions and innovative approaches such as new treatment and prevention practices in relation to NCDs, rehabilitation of PHC infrastructure and supply of medical equipment, establishment of a full set of job profiles for PHC providers, and new continuing education tools and approaches for family medicine teams. The project has enhanced the role and autonomy of nurses in the prevention and management of NCDs as well as in the support to homebound patients and the elderly.[2]
Enhancing capacities of PHC providers on elderly people care
HAP has provided support for the elaboration of guidelines and protocols for prevention and treatment of the most frequent NCDs treated in PHC such as diabetes, hypertension, chronic obstructive pulmonary disease, dyslipidemia, and asthma. Moreover, two important guidelines were elaborated and rolled out:
i) a manual on elderly people care in PHC services;
ii) a health education manual targeting elderly people specifically. The guidelines and protocols were approved for implementation by MoHSP in December 2022.The protocols are distributed electronically and in paper version, while HAP trains selective trainers to disseminate the new skills in many PHC facilities of the country.
The concept of home care services was introduced with the support of HAP
From 2021 onwards the project designed and piloted home health services targeting homebound patients and elderly living alone. As mentioned earlier, about 20’000 patients have a very limited autonomy, and they cannot visit health centers. Therefore, it was agreed with the country authorities and stakeholders to develop a new typology of home care services that would be carried out predominantly by PHC nurses.
The concept is the following:
nurses make a comprehensive assessment of the patients that are assigned a Karnofsky score[3] of less than 40 points (loss of autonomy);
a follow-up treatment plan is proposed and agreed with the patient and their carer(s);
nurses working at the level of health centers in close collaboration with the family physicians make the follow-up of these patients and provide the necessary clinical services, including advanced procedures such as stoma care, manipulation of urinary catheters, care of bed sores etc. in order to avoid the transfer of the patient to the hospital;
nurses provide also health advise and education to the carers of the patients in order to strengthen their health literacy;
all the information is noted in the nurse record that is attached to the record of the patients;
data on home care visits are recorded into the database of the Health Insurance Fund in order to make a follow-up and eventually an assessment of the home care services.
In order to implement home care services, the project and the local partner organizations in Albania operated as follows:
HAP supports technically PHC center teams targeted by national authorities to identify the patients with limited autonomy in their catchment areas;
PHC nurses are trained and qualified to assess the health conditions and provide advanced clinical care to homebound patients based on a treatment plan elaborated by them;
PHC nurses and physicians are supplied with personal medical equipment that make possible a better provision of services to their patients.
Health centers are supplied with medical and para-medical equipment necessary for a better quality of care of the targeted patients;
In the initial steps of the process, nurses are coached by HAP mobilized experts during home care services they provide to homebound patients and elderly;
HAP supports regional and local health authorities to implement home care services in their respective areas and to enhance their monitoring capacities for this purpose.
The range of services we offer is no longer the traditional one such as simply measuring parameters, - states S. Abazi, family nurse, Primary Health Center Xhafzotaj, Durrës. - Now, we delve deeper into the services we provide but also address the psychological aspect of the patient. The services we offer have become more frequent and more specialized as we utilize the equipment we've acquired from HAP. We certainly feel more independent in our role, and thanks to the training, we've improved and can perform patient assessments that we couldn't do before.
National authorities endorsed home care services piloted by HAP
The Ministry of Health and Social Protection of Albania decided in January 2024 this new typology of services to be upscaled at national level. Since then, HAP has been directly involved to support implementation of home care services in 120 PHC facilities out of a total of 360 health centers of Albania.
Outputs and impact of interventions in target areas
During the period March 2022-September 2024, more than 80 health centers have been directly supported for introducing and implementing home care services and 54 of them have already started to provide home services to the identified beneficiaries. More than 800 nurses have been trained in advanced clinical procedures. Nurses operating in the target health centers have been able to provide about 20’000 home care consultation to more than 1650 homebound and elderly patients in the last two years.The pace of this intervention is accelerating with more patients being enrolled and an increase of the frequency of home visits/patient. By 2026, it is expected that 120 PHC facilities will be capacitated by HAP to provide home care services. The implementation of the home care service model introduced through the Swiss-funded project is gaining momentum and is being disseminated in other areas of the country, as well.
Providing personalized health services in the home is the best option available to seniors to ensure continuous and personalized care. Through this service, elderly people with chronic diseases who cannot move from their homes due to physical disability benefit from home health care, including health monitoring and the provision of health services that they previously received in the hospital, such as stroke rehabilitation, oxygen therapy, urinary catheterization, etc. The provision of health care in their home environment helps the elderly to maintain their independence and benefit from the necessary treatment without having to go to service providers, whether these are health centers or hospitals. This service also affects the reduction of direct out-of-pocket expenses of the patients, as it reduces the cost of transportation if the service were to be received at the health center or hospital (Assessment of Quality of Life and Home-Based Care, 2024) and ultimately leads to improved quality of life for the elderly.
"Before... I hired a transport car, I paid 300 thousand Lek[4]"- says a 76-year-old patient from the Municipality of Korça, who suffers from chronic obstructive pulmonary disease. "Now the nurse of the health center comes once a week or once every ten days. When I had an injection therapy, she came twice a day at a fixed time, and they are willing to come whenever I ask. This relieves us and comforts us a lot", he adds.
Challenges related to upscaling of home care services.
The expansion of home care services in Albania faces several challenges. Although the MoHSP has expressed political will to extend the service nationwide, in practice, there is a lack of strong leadership of governmental authorities, which hampers service expansion beyond the areas where HAP operates. Furthermore, the MoHSP should allocate additional financial resources to fully support home care, which are essential for the efficient implementation of the service and for motivating the personnel (Home health services for elderly people with mobility problems, 2024, unpublished report). While primary health care financial resources have increased over years, this growth remains insufficient to meet the population’s needs, particularly for the most vulnerable groups. Home care services implemented with the support of HAP can be considered a success story in the context of Albania, but these services require further attention and support from national authorities to fully upscale and sustain them across Albania.
Assessment of Quality of Life and Home-Based Care (HBC) needs in Dibër, Fier, Durres and Shkoder regions, Albania.May 2024. A. Knoblauch, C. Furer, A. Peshkatari, B.Nuri, K. Wyss.
Home health services for elderly people with mobility problems. Prepared by Together for Life.November 2024 (unpublished report).
Ratio
of the number of people above the working age (65+ years) with the number of
people of working age (15-64 years old).
For more information on HAP you can visit the following link: www.hap.org.al
The Karnofsky Performance Scale is an assessment tool intended to assist clinicians and caretakers in gauging a patient's functional status and ability to carry out activities of daily living. Patients assigned 40 or less points are considered disabled that require special assistance. https://ww.hiv.va.gov/provider/tools/karnofsky-pe...
The equivalent of about 300 CHF.
Dr. Besim Nuri, MD, MScPH is Manager of HAP and Executive Director of the HAP Center. Dr. Nuri is a Public Health expert with extensive experience in design and implementation of health cooperation projects in Canada, Eastern Europe and many countries of West Africa. His areas of expertise are health systems and policies, strategic planning, development of training programs, human resources and continuing education in health and project management. E-Mail
Sajmira Aderaj, RN, PhD candidate in Nursing Science and Public Health, studies self-care behaviours of chronic patients and their caregivers. With extensive experience as a community health nurse, she has coordinated projects that unite academia, communities, and policymakers. Currently working as technical expert at HAP, she contributes to implementation of homecare interventions for vulnerable populations.
Dr. Ehadu Mersini, MD, PhD, is a Quality of Care Specialist and Deputy Manager for the Swiss-funded "Health for All" project. She has extensive experience in designing, monitoring, and evaluating health policies, conducting health system analyses, and implementing quality and performance measurement systems for healthcare services focusing on institutional strengthening and capacity building. Her expertise spans a range of public health issues, including management experience with donor-funded health projects.
Altina Peshkatari is Monitoring & Evaluation and Social Inclusion officer at HAP.She oversees project’s research, monitoring activities, advocacy in health and gender equality as a transversal theme. With over 20 years of experience in public health and international development projects and a background in Social Sciences, Altina has been instrumental in driving project activities, aiming for the best health outcome for beneficiaries.
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