Providing Healthcare Services at Home-A Necessity in Iran: A Narrative Review Article.

BACKGROUND: Increasing hospital costs and its social and cultural problems has led to the idea of providing healthcare services at home. Because of infrastructural and implementation problems, providing healthcare at home in Iran has not been initiated yet. Therefore, this study set out to elaborate the need for a comprehensive system in order to provide this service in Iran.
METHODS: All articles published in indexing sites with the defined keywords in English or Farsi were gathered. The indexing websites included Iran Medex, PubMed Central, Elsevier journals, WHO publications and Google scholar from 1985 to 2014 were surveyed. Other documents included the related books and regulations.
RESULTS: Despite of having dominant religious values and constitution laws related to stability of family relations and establishment of clinical services and health care at home in Iran, providing health care services faces some harsh challenges including ignoring entrepreneurship and lack of required infrastructures such as lack of required insurance regulations, the inappropriate and indifferent performance of some activists home services and absence of registration and identification system in this domain.
CONCLUSION: Because of the increasing number of elderly people in Iran and healthcare costs becoming more and more expensive, establishing a system for providing healthcare at home is inevitable.

Introduction

One of the basics of controlling and treating diseases in a country is how healthcare is provided to those in need of it (1). Change of priorities in policy-making and using modern, community-based solutions for solving healthcare problems, plus demographical changes and the increasing need for care, the changing formation of families from extended into nuclear, prevalence of chronic and non-communicable disease, more participation of women in the society as work force, changes in peoples’ attitudes and expectations regarding medical services and more demand for private individual care has increased the need for providing healthcare at home (2–6).

An overview on healthcare system of developed countries shows that providing services in the hospital is giving its place to mobile care, home care and society-based care. Indeed, the aim of these approaches is to achieve more satisfaction from the people in providing them with healthcare services at their homes with the help of professional healthcare providers and use of advanced technology (7).

The increasing urbanization and aging population, changing lifestyle, changing patterns of mortality toward deaths because of chronic diseases such as asthma, diabetes and heart failure, plus accidents and cancers make changes in the healthcare system of Iran necessary (8, 9). Seventy percent of deaths had occurred because of chronic diseases in the world (10). Managing chronic diseases requires long-term care and providing healthcare at home can facilitate this process (11, 12).

The increasing costs of hospital stay and infections has made healthcare at home be more welcomed by the people. In addition, since the recovery of a patient with chronic disease is not anticipated in the near future, taking care of that patient in home seems more reasonable. This will be more approved by the families who desire to have their patient at their side. It will also decrease the burden of high bed occupation for hospitals (13, 14). However, providing healthcare at home is beneficial for both the patients and their families and for the healthcare system (15–17).

Today, this phenomenon has led to development of healthcare business markets outside the medical centers such as hospitals and clinics. In fact, providing healthcare services outside medical centers, i.e. in homes, schools and industries, are becoming ever more essential (18, 19).

This study set out to elaborate the need for a comprehensive system in order to provide this service in Iran. It can present some of preliminaries of providing healthcare at home for revising the current care model of Iran’s healthcare system and help more healthcare workforce be employed in ways that are more efficient.

Methods

In this narrative review article, an initial screening of publications, based on titles, was performed by two researchers. In the second screening round of the remaining publications, titles and abstracts were evaluated by pairs of reviewers independently. All articles published in indexing sites with the defined keywords in English or Farsi were gathered. The keywords were as follows: (“healthcare at home” or “healthcare systems” or “nursing care” or “respite care” or “day care” or “home care” or “consumer directed care” or “elderly care”) and (“Iran” or “providing” or “establishing$”). The indexing websites included Iran Medex, Scopus, Index Copernicus, DOAJ, EBSCO-CINAHL, PubMed Central, Elsevier journals, WHO publications and Google scholar.

Papers were excluded based on the following criteria:

- Published before 1985 (if describing organization or financing of home care)

- Not relevant to the study question

- Published in languages other than English and Persian

- Not related to the countries specified

- Not in line with the working definition

- Reviews (as relevant individual papers would be included)

After final selection of the papers, information was extracted from the full texts. Other documents included the related books and regulations. From among 160 retrieved sources (22 in Farsi and 140 in English), 28 sources were chosen based on complete relevance, originality, and expertness of the authors in providing healthcare services at home. Sensitive search for controlling publication bias was done. Limitation of the study was that very few papers in the literatures and documentations were Iranian, so Iranian literatures were less.

Results

The results of this study can be explained in six categories:

Dominant values system: The dominant religious values of Iran emphasize taking care of patients and elderly in their own homes. The religious values of this country also recommend all family members to participate in taking care of the elderly and the disabled. This can be an influential component in starting the discussions on establishing a thorough system of providing healthcare at home in Iran (20).

Governmental documents: Reducing unemployment and creating more jobs is one of Iran’s goals for its vision. Thus, developing domestic jobs has become part of the policies in economic, cultural and social domains. Providing healthcare services at home can be an objective for this goal (18, 21).

According to the 10th article of Iran’s constitution, “Since the family is the fundamental unit of Islamic society, all laws, regulations, and pertinent programs must tend to facilitate the formation of a family, and to safeguard its sanctity and the stability of family relations on the basis of the law and the ethics of Islam.” Based on this article’s emphasis on family and family relations, providing healthcare services at home can facilitate the implementation of this law by helping family members be aside their patients and can help in taking care of the elderly within their homes (18). Thus, the preliminary regulations for providing healthcare services at home and establishing nursing consultation centers to this end were passed by the Ministry of Health, Treatment and Medical Education of Iran in 1999. These regulations insisted on providing all the necessary medical care at the patients’ home, minimizing the patients’ referral to medical centers. These regulations were revised in 2014 (22–24)

Entrepreneurship: Based on current statistics, there was eight thousands of them were physicians. These physicians were working much less than the standard working hours with little payment (24). In addition, there were more than 20 thousand unemployed nurses in Iran until 2013. Only some of them have the opportunity to immigrate to other countries for work (25). This high number of unemployed healthcare personnel can be used to provide healthcare services at homes (26). Some of the possible services, which they can provide, can be regular visits and examinations, vaccinations, online and offline consultations, etc. (23).

Healthcare insurance: Providing healthcare services at home lacks the required insurance in Iran. In fact, there are no regulations for this type of service even for the elders (10). This is a main reason for confusions in commencing the system of providing such services in this country. Although many Iranians prefer to take care of the elderly at home and not at a nursing place, there is no program for helping the people and no particular social or health insurance in this regard. So setting the required insurance legislations for providing healthcare services at home seems inevitable (27).

Healthcare-at-home centers: An evaluation of the current situation of the few available healthcare-at-home centers shows that they have been performing inappropriately and indifferently. This added to their invisibility in the decision-making and implementing the requirements of healthcare system in this country has led to a negative view toward those who are currently active in providing healthcare-at-home services in Iran’s society. So, this makes their job even harder (18). The society’s point of view regarding healthcare services is very important and if they distrust the healthcare providers, healthcare objectives and goals cannot be attained (28).

The inspectors of healthcare-at-home centers have sometimes encountered with cases in which an incompetent person with low healthcare literacy, who has had the experience of working in a clinic or for a doctor, became a healthcare-at-home service provider. In many of such cases due to lack of knowledge and experience, the healthcare provider has harmed the patient or healthcare receiver. This has resulted in distrust in receiving healthcare at home and in those who provide such services among the people harmed and their friends and families (29). On the other hand, there are domestic residents for home services they uneducated and sometimes illiterate that do not able to good primary care and household chores. There is no exact information about this group. The number of centers, which provide healthcare services at home, is increasing. Because of financial problems, many of these centers are recruiting more incompetent personnel to provide their services with less costs and this vicious cycle is reinforced (30). In addition, many of such centers do not have the required permissions and there is no complete, thorough list of all the available legal and illegal healthcare-at-home centers of Iran (31).

Registration and identification system: Up to now, no special organization has been in charge of inspecting and evaluating healthcare-at-home centers. After the deputy of nursing was established in the Ministry of Health, Treatment and Medical Sciences of Iran, this deputy has done some surveillance of these centers. This deputy seeks to identify the legal and competent centers and find a system for following up patient complaints. Even the medical universities do not have an exact statistics of such centers within their region or province. Until now, 700 centers have asked for a legal permission to work in this domain, but the numbers achieved it is not known (31).

Discussion

Although in the review of the literature, there have been some developments in healthcare-at-home services; this system of care requires an established organization in Iran.

Considering the dominant value system of Iran, taking care of the elderly, patients and children in the family is a virtue and some of the policies are in this regard. However, if families encounter problems in doing this task, most of them have no choice to refer to a medical center since there are not enough or in some regions none healthcare-at-home consultants. With regard to aging population, changing lifestyles and increasing the need for home care, religious values about help maintain family become stronger (20). In many countries, chronic and non-communicable diseases constitute a big part of healthcare problems. A reason for developing healthcare-at-home services is helping those who are suffering from such diseases with less cost at the comfort of their homes (13).

According to the governmental documents, one of the objectives of healthcare policy-makers in promoting health in the society and standardizing healthcare-at-home services has been setting regulations for finding nursing care and consultation centers for providing healthcare-at-home services (22). Still these regulations have considered expanding self-care and people’s participation in promoting healthcare. However, there has been no mention of the role of a patient’s family in his/her recovery and treatment. In contrast, in a country such as United States, healthcare-at-home nursing includes choosing a family member or someone who the patient desires for participating in the treatment and care process at home beside the healthcare provider (32–34).

This domain of healthcare has half a century of history in some developed countries (31). However, this type of providing care is lacking in Iran and requires some infrastructures and resources so that it can be implemented successfully (18). Learning from other countries experiences in finding such a system and including all the socio-cultural characteristics of Iran’s society can be helpful in this regard (15).

Since there are many unemployed healthcare graduates in Iran, including physicians and nurses, establishing an organized healthcare-at-home system can help in reducing their unemployment and increasing entrepreneurship. A study by Nancy and colleagues has verified this claim (35). Moreover, Barati and colleagues have stated some of the social benefits of providing healthcare services at home which include entrepreneurship, improved access to services, reducing traffic congestion in cities because of less need for driving to a healthcare center, improved health literacy, better social support, developing a cultural example and improving community culture, more participation in community activities, and increasing respect for the general population (36). So healthcare-at-home can reduce unemployment among healthcare graduates too (18).

In European countries and Japan there is insurance for long-term care and treatment. It is used for the physically and mentally disabled people until the end of their lives. It can include a person of any age since it includes accidents, diseases and aging and it covers even bathing, dressing, eating, taking medication, and inability to move for the disabled and patients. This type of long-term healthcare insurance is not under insurance companies’ obligations and is provided by the government. Such insurance does not exist in Iran and if it is provided, it can help in establishing a more qualified healthcare service (37–39).

The quality of the current few healthcare-at-home services is not satisfying. Part of the problem is because of the human resources, i.e. lack of healthcare literate and responsible personnel. Besides, selecting and employing the required personnel for providing this service is of great importance. Right now this is not done appropriately and needs the authorities’ consideration (18). In this regard, there is a standard license in Japan. To achieve this license, each organization must have at least 2.5 full-time nurses (usually, 5–6 part-time nurses or five full-time nurses including four registered nurses and the rest public health and clinical nurses or midwives). Some even employ occupational therapists and physiotherapists (40).

According to the professional regulations, this business needs a network of licensed partners. A network of partners means all individuals and businesses that are working independently but must cooperate with each other to launch or organize a work. In our case, it consists of physicians, nurses, social workers, psychologists and healthcare workers, and graduates. Team members should consist of both sexes so that each sex can offer its services to its own sex. They must be supervised by a consulting physician at their center and have regular contact with him/her. Currently in Iran, such a network does not exist in all the available cases and in case of existence, is not adequately monitored (41, 42).

The team composition is also important. The results showed not considered team composition in Iran seriously. In Europe since providing healthcare at home is an important public service, which emphasizes on having many formal and informal clinical and social services. This team can consist of nurses, therapists in such area as physiotherapy, occupational therapy and speech therapy, plus home-care workers, nutritionists, physicians, housewives, family members and volunteers (43, 44).

Inter-disciplinarily healthcare-at-home groups are more efficient than groups consisting of only nurses (45). This clinical inter-disciplinarily helps in arriving at better decisions and leads to better organization for providing care. In teams with diversity of expertise there was an association between cooperation, conflict resolution, collaboration, and cohesion with more patient satisfaction and team effectiveness (45).

The lack of knowledge about the capabilities of the nurses has resulted in less participation of nurses in providing healthcare-at-home services in this country. Visiting the patient at home, evaluating his/her lifestyle, consulting with the family members, and suggesting corrections for the treatment and recovery of the patient in his/her home and lifestyle are the things that a nurse can do in providing healthcare-at-home services (46).

In Iran, four types of people usually receive the limited healthcare-at-home services including children, elderly, patients and the disabled. The target population, diseases in need of care at home and the composition of healthcare-at-home team is still in debate (47). Right now healthcare-at-home discussions are focused on the age groups that need the help and support of the healthcare system due to constraints (48). Based on principles of public healthcare, all people can be the recipients of healthcare, although each group has its own specific needs. However, development of services in area from prevention to rehabilitation could lead to a greater converge of public needs (49, 50).

Registration and identification home care system in Iran is incomplete but in United States, the home nurse is obliged to report to the federal state. These reports are used to evaluate the quality of care, payments and inspections (51).

Limitations

One limitation of our study was that few researches about home care in Iran were down and we did not have enough sources for home care and its necessity in our country.

Implications for Health Policy and Nursing

The most important health policies are economic implications, patient and family satisfaction. It suggested that comprehensive and applicable home care services system was designed and implemented in Iran.

Conclusion

Because of the aging population and changing lifestyles in Iran, providing healthcare-at-home can become the primary method of receiving care if organized and integrated system is established. In addition, this type of service does not require costly high technology, bureaucratic problems, and high personnel payment as much as providing healthcare at medical centers. Therefore, it can help in employing more healthcare graduates and increase people’s satisfaction of the healthcare system. It is recommended that healthcare-at-home services become part of the main national care providing system. Other countries experiences should be used to reduce the large gap that exists in this regard between Iran and the developed countries.

Ethical considerations

Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.