projects
Home Care and Assistance Services
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  External Review Report


Home Care and Assistance Services towards Independent and Dignified Life Project

Swiss Bulgarian Cooperation Program, Thematic Fund "Reform Fund Linked to the Inclusion of Roma and Other Vulnerable Groups concerning Home Care Services Activity

The Home Care and Assistance Services towards Independent and Dignified Life Project (2012-2017) is implemented by the Bulgarian Red Cross in the capacity of an Executing Agency (EA) in partnership with the Ministry of Health, Ministry of Labour and Social Policy and the Swiss Red Cross. The Swiss Red Cross is also performing the role of a Swiss Intermediate Body (SIB). The goal of the project is to support the introduction in Bulgaria of a model for complex provision of health cares and social services at home as a form of long-term care for older people with chronic diseases and permanent disabilities drawing on the Swiss experience.

Except for provision of home care services to beneficiaries in the target region and improving of their quality of life, the project aims at establishing an institutional framework for sustainable provision of this type of services in Bulgaria, incl. proper legislative regulation, payment mechanisms, national quality standards and unified training programs for the staff. Among the main priorities of the project is to raise the awareness on home care services at all levels of the Bulgarian society in order to validate them as a form of integrated provision of health and social services to older people with chronic diseases and disabilities.

For the achievement of these tasks the experts from the Ministry of Health, the Ministry of Labour and Social Policy as well as from the Swiss Red Cross play a crucial role. Besides, in each area, the project envisages wide partnership with other competent institutions and stakeholders, among them Bulgarian Doctors Union, Bulgarian Association of Professionals in Nursing, National Health-Insurance Fund, municipal authorities, patients organizations, etc.

Main results:

1. Legal regulation adopted
A significant success towards sustainability of home care services was achieved in September 2015 when the legal changes elaborated by the Bulgarian Red Cross jointly with the Ministry of Health and Ministry of Labour and Social Policy were adopted by the Parliament. The texts approved in the Health Act regulated for the first time in Bulgaria the integrated provision of health and social services for various target groups at home, among them older people with chronic diseases and disabilities, pregnant women and children. The next step will be the establishment of an expert group with regard to the elaboration of the sub-legislative regulation. According to the texts adopted in the Health Act, the organization, provision, control of home care services, training requirements, criteria for selection of beneficiaries, etc. should be regulated by a joint order of the MH and MLSP in 2016.

2. Approbation of the home care model in the region of Vratza - Four Home Care centres were established in the region of Vratza in the municipalities of Vratza, Byala Slatina, Oryahovo and Krivodol /December 2012/. Since then regular cares are provided to more than 400 beneficiaries on the basis of the individual needs of each patient and in constant communication with their relatives, General Practitioners, other medical specialist, Social Assistance Departments, etc.

3. Creation of workplaces - By establishment of the HC Centers 50 job positions were created in the region of Vratza a total of 33 home-helpers and 17 nurses have been trained in the project and employed to work at the centers.

4. Continuous training of the staff - The nurses and the home-helpers employed at the HC Centers receive regular support and practical trainings by experts of the SRC with profound experience in home care. The trainings include different topics, among them: planning of cares, prophylaxis of decubitus, hygiene of the services provided at home, wound management, etc. These trainings raise the qualification of the staff and improve the quality of the cares provided leading to more adequate satisfaction of the needs of the beneficiaries.

5. Inclusion of Roma into the home care services provision - A feasibility study with the objective to explore the specific needs and opportunities of the Roma community in terms of provision of home care services among them was performed. The study was implemented in the region of Vratza in the period June-August 2013 and the final report was published in December 2013. On the basis of the results from the study, eight additional job positions for Roma home-helpers were created, two in each HC Center. They were successfully trained in September, 2013 and employed at the HC Centers. Currently, the percentage of Roma working at the HC Centers reaches 25% from the total number of job positions opened in the project.

6. Introduction of a data and cost-management software in the HC Centers - With the support of the Technical Universities in Sofia a software programme was elaborated for data and cost-management of the home care services. It was introduced in the HC Centers in December 2013 and the staff was trained accordingly. The data gathered will serve as the basis for cost-pricing of the services and a minimal standard for a service catalogue will be elaborated.

7. National information campaign
A national information campaign on the project was organized in partnership with the biggest national TV in Bulgaria bTV and within the period of two months April-May, a series of interviews and reportages on TV and on the radio were organized. Personal stories of the beneficiaries were in the center of the campaign and eight short films in the target municipalities were shot with the participation of representatives of the municipal authorities, the Regional Health inspection, the Regional Social Assistance Department, relatives of the patients as well as the HC Centers staff. At national level Mr. Ivaylo Kalfin minister of labour and social policy, H. E. Denis Knobel Ambassador of the Confederation of Switzerland, Mrs. Milka Vassileva Chairperson of the Bulgarian Association of Professionals in Nursing Care, the President of the BRC as well as representatives of patients and other non-governmental organizations took part in the discussions on TV. A short film in Bulgarian and English was produced uniting fragments from all films and interviews shot within the campaign.

8. Cost-pricing on home care services
In 2015 experts in health economics as well as in financing of medical care and social services in Bulgaria were engaged in cost-pricing of home care services provided by the Bulgarian Red Cross. Based on the activities and the data gathered in the Home Care Centers in the region of Vratza, a preliminary analysis was worked out. The results will be presented and further discussed with other relevant stakeholders among them the Ministry of Finance, the National Health Insurance Fund, the Association of the Municipalities in Bulgaria, the Bulgarian Medical Association, patients organizations, as well as with the Swiss Red Cross.

9. New qualification requirements elaborated for professionals engaged in integrated medico-social services provision
An important step directed towards achieving quality of home care services was the elaboration of new State Educational Requirements for the Social Assistant profession. The work in this area was provoked by the needs of adequate preparation of staff to be able to provide integrated services in the future. The Requirements were officially approved by the Management Board of the National Agency for Vocational Education and Training in November 2015 and after that submitted for approval to the Ministry of Education. Their decision is expected in 2016.

Benchmarking study of the cost of home care services
The study was performed in 2017 and its overall objective was to provide a costing-study of the socio-medical services provided at home within the Project to final recipients. The study is associated with a benchmarking to compare the actual costs incurred in comparison with other forms of public and private social and medical services provided in domestic environments, as well as in health and social institutions.
The objectives of the study also included: definition of the actual costs of home care services per recipient on annual basis; sensitivity analysis (projections with a set of scenarios) to examine the effect of increasing of the number of patients on the costs of provision of the services and the net effect on public expenditures on social services and healthcare by the implementation of this service model, including in terms of ill health.

External evaluation
An external evaluation of the project results was performed in October 2016 by experts from the European Centre for Social Welfare Policy and Research, Vienna backed by one expert from the Institute for Community Social Services, Bulgaria.
The main purpose of the external evaluation was twofold:
a) At sectoral level (National scale policy relevance), to provide insights with regards to the piloted model coherence and relevance in the present reforms context in Bulgaria - provision of affordable, integrated health care and social services. For this need, the review had to examine if main reforms ingredients - political will, institutional set up, resource viability including financial and human resources but also horizontal aspects pursuant to the project and BSBCP (like Roma integration and know-how exchange) - are covered and tackled by the project.
b) At project level, the external review should validate the attainment of the project objective (impact and outcomes focus), and extract the main lessons learned.

The final report provides clear statements about the applicability and the need to continue the development of home care services in Bulgaria. The experts give recommendations not only to the BRC but to all relevant stakeholders in short-term and long-term aspect about the necessary steps to be taken in order to ensure sustainability and replication of the model, including new target groups. The entire report can be found in the attached file.