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Deinstitutionalisation as a Challenge for the Development of Community-based Care for Older People
Dezinstitucionalizacija kot izziv za razvoj skupnostne oskrbe starih ljudiJana Mali 1
Care for older people in Slovenia is extremely institutionalised. The lack of community-based care is one of the persistent problems obstructing the development of care for older people. Care for older people is dominated by a rigid system of institutions, which do not meet the needs of the heterogeneous group of older people. A particular problem is access to help – it is often unavailable. This state of affairs definitely calls for a change based on research and assessment of old people’s needs including quantitative indicators (the number of formal types of help needed) as well as qualitative ones (needs which are currently not met, kinds of services needed). To be able to meet the needs of its residents, large institutions should initially be sized down, reorganised and converted into smaller units and new living arrangements should be introduced. The process of deinstitutionalisation in the area of care for older people creates an opportunity for the kind of change that would meet the needs of the current older population as well as the future ones that are bound to grow larger – given the demographic trends.
Keywords: Deinstitutionalisation; Institutional Care; Community Care; Social Work; Older People
Demographic changes and forecasts have been inspiring debates in political and expert circles for many years now. Unfortunately, the conclusions most often boil down to recapitulation of disquieting demographic trends that show that the population is aging. To avoid the trap of bad practice we want to place emphasis on the fact that the aging population is a multi-faceted phenomenon that can be studied from different points of view ranging from individual and social to the national and global.
The term used in certain contexts to denote population aging is ‘demographic scare’ (Wilson, 2005, Bytheway, 2005, Mali, 2009b). However, longer life expectancy (or shorter aging period) can also be understood as the greatest achievement of our civilisation never witnessed before in the history of humankind. We should be proud of getting old (Mali, 2009). When within the field of social work we encounter the issue of aging, we should keep in mind that this is not a topic that is specific to just one age group of social service users. It is rather a topic that is closely intertwined with all spheres of our lives; it is related to our own aging, the aging of our close family members, friends, acquaintances, workmates. We all get old and we are all the potential users of various services and help for older people, with social work being just one among these.
During the past decade, Slovenia intensely developed care services and programs for older people who need help with the activities of daily living; this resulted in an extensive network of services and social care programs for older people. While service providers are the members of the middle generation, the younger generation is involved through various forms of volunteering. This has led to the closest intergenerational cooperation and coexistence seen so far, creating an excellent basis for the bridging of the generation gap and providing examples of good practice on which intergenerational cooperation should be built according to the Green Paper ‘Confronting demographic change: a new solidarity between the generations’ (2005).
One of the key problems in Slovenia that has been recognised for some time now, and one that obstructs the development of care for older people, is excessive institutionalisation and lack of community-based care. In brief, the care system is rigid and it cannot meet the needs of older people who make up an expressly heterogeneous population group. Access to help is a special problem; help is often inaccessible in both urban and rural areas. In the latter, both institutional care (homes for older people) and community-based care (e.g. home help) are often unavailable. The reason is that home help is, in most cases, provided by homes for older people, so in places where there are no homes for older people there is no home help either. By contrast, in urban areas the range of available assistance is quite large, but still it does not adequately meet older people's needs. During the past years, we have been witness to long waiting lists for both, admittance to homes for older people and for obtaining home help.
The purpose of this paper is to draw attention to the shortcomings of the more than 50 years old institutionalised care for older people. It definitely needs to be changed, but the questions raised in this connection are many. Based on the analysis of existing care for older people and their needs, this paper attempts to show how the deinstitutionalisation process could encourage changes in this area.
Care for older people in Slovenia
Over the past decades, Slovenia has seen the extensive development of services and programmes for older people who need help with the activities of everyday living. These types of help, often called formal types of help, fall within three sectors: (1) the public sector, where assistance is provided by centres of social work, homes for older people, home help centres, and providers of other public services in various living environments, e.g. special residential arrangements such as sheltered apartments; (2) the private sector, and (3) the voluntary sector, where help is provided by NGOs and voluntary organisations such as the pensioner's association and older people self-help groups (Mali, 2009b, pp. 249-250). For many years, the public sector played the central role in the area of care for older people and it continues to provide the widest range of services within its various institutions for older people: centres for social work, homes for older people, day care centres, centres for home help and sheltered housing as a type of institutional care.
There are three dominant types of formal care for older people: care provided within homes for older people, care provided at home and day care. While elsewhere various types of help beyond those provided by homes for older people are available, Slovenia is characterised by an explicitly institution-oriented approach. There are various reasons for this, ranging from social, cultural, political to professional (Mali, 2008a, p. 9). For many years, homes for older people have been the driving force behind the development of care for older people, including community-based care. Homes for older people provide not only the institutional protection in the narrow sense of the word (residential facilities and care), but also assistance to older people in their homes and within a community (the most intense development of day care centres has been seen within the framework of homes for older people, and the same can be argued for help at home, social services, sheltered housing and respite care). Homes for older people therefore play a critical role that is specific to Slovenia, but debates on how to approach care for older people has been underemphasised, or even neglected, by both professional circles and the media. Moreover, it would even be possible to argue that the placing of homes for older people under the institutional care category is inappropriate. In reality, homes for older people have become the centres for comprehensive care, where health care and social services co-created a mutually complementary model of collaboration.
In the developed world, 25% of people over 60 need help with activities of everyday life; of these, 15% need relatively little help, while around 10% need extensive care and nursing. Put differently, of the total number of 400,000 people over 60 in Slovenia, around 100,000 need some help, while around 40,000 of them regularly need relatively extensive care (The strategy for the protection of older people until 2010). In 2009, 16,978 people resided in homes for older people, most (80%) of these operating within the public sector. The network of state-run homes for older people is supplemented by homes within the private sector, while the voluntary sector does not offer residential facilities of the institutional type. In 2009, one year before the end of the period covered by the National Program for Social Protection 2006-2010, help at home was provided for 1.7% of persons 65 years of age or over, which amounts to slightly more than 56% of the planned target. The analysis of help at home (Smolej, Nagode, Jakob Krejan, 2010, pp. 35-36) has shown that the number of users of home assistance has been slowly rising since 2006, or in other words, during this period the number of home help users has increased by 18.1%. Accordingly, the share of older people (65 years and over) receiving these services has also been rising, but too slowly to attain the goal of the National Program for Social Protection 2006-2010 (2006), i.e. the inclusion of 3% of older people until 2010.
The question that suggests itself in the light of these data is who provides help for 17,000 older people who need relatively comprehensive help but do not receive it from institutions or from services providing assistance at home. The logical conclusion is that in their case help is provided by the informal sector, that is, by their relatives, neighbours, friends and acquaintances. Unfortunately, accurate data on the extent of informal care is unavailable, for quantitative data on formal care are also very difficult to collect, because institutions authorised to collect such data do not keep records of actual services providers. Consequently, we can only speculate on the real extent of needs and the types of help that should be developed. Even so, there is enough data to argue that the ratio of formal to informal help should be changed. The informal and unpaid care work is based on values according to which family members and other members of older people's social networks are obliged to provide care because of emotional ties (Hlebec, 2010a). However, social policy undervalues their contribution and share, even ‘looks down on them’ by failing to give support for providing good quality care in informal sector.
Although we encountered a number of difficulties when collecting simple quantitative data on the number of older people who use formal types of care, these difficulties are negligible in comparison with those encountered when trying to collect data on the quality of formal types of care mentioned above. Information on the systematic evaluation of care services is not available, and we also do not know what the extent of this care is or how individual care providers monitor their operation. No one monitors the needs of older people, or the needs for existing or new types of help. When planning care for older people, social policy makers resort to rough estimates based on demographic data and the trends adopted by the European Union (i.e. Confronting demographic change: a new solidarity between the generations 2005) as the only valid guidelines for planning.
Deinstitutionalisation as a challenge: methodological approach
Obviously, deinstitutionalisation is an important process that should be seriously considered. The area of social protection has been undergoing changes everywhere around the world, and in the manner that encourages the introduction of community-based care for people with various disabilities, with an emphasis on users’ participation in care services and tendency towards pluralisation. The changes are reflected in the shift away from large institutions offering normative and standardised forms of help towards dispersed and differentiated forms of help that are oriented towards meeting individual needs (Flaker et al., 2008a, p. 8). Various types of emerging community-based care focus on individual needs, taking into account and activating all individual potentials with the aim of preventing exclusion and increasing older people's capacity for equal participation in everyday life. The basic guiding principle is to provide support without passivizing people or further setting them apart (unnecessarily) from other community members.
The process of deinstitutionalisation had begun in Slovenia relatively early. Various experiments in the area of work with young people and children began in the late 1960s and continued during the 1970s and the 1980s (Flaker, Mali & Urek, 2008). As early as 1964, Slovenia adopted gerontological principles that should enable the development of community-based care for older people. Acceto (1968, p. 33) writes that the main gerontological principle is the one according to which society is obliged to take care of its older population in the way that enables them to continue to live as long as possible in the environments where they spent the most active period of their lives. Although the gerontological principles of the time were strongly influenced by the medical approach1, the starting points for the development of community-based care for older people thus created were, on the whole good.
Unfortunately, the first evidence of these new types of help emerged only during the second half of the 1980s (Vojnovič, 1988) when home help for older people was introduced. This was followed by home-based care for older people provided by community nurses who were employed within the health sector (Ramovš, 2003). The biggest changes could be observed in the beginning of 1990s, but even so the scope of organised home-based services (e.g. day-care centres, centres for home help) determined in 1997, according to which the needs of 15% of older people should be met, has not been achieved to date.
Community-based care for older people is a necessity, but the question is how to boost its development. For more than one decade now Slovenia has been waiting for the legislation on long-term care, but older people's increasing need for help has already become so acute that not passing laws can no longer be an excuse for underdeveloped community-based care. The positive experience with the reorganisation of special social institutions into smaller and more user-friendly institutions could serve as an example. The analysis of the process of deinstitutionalisation of special social institutions (Flaker et al., 2008a) alerted us to the fact that new organised forms of living in a community also create the need for new approaches that will represent a paradigmatic shift from traditional methods. It is suggested that these new approaches should be based on a personalised approach, advocacy and by adopting a pro-active stance, taking account of the concept of the social construction of disability (disorders, incapacities), and a sound knowledge of the context and everyday life of the users. Providers should have expert knowledge about their users, should be willing to take calculated risks, and should be gender and culture sensitive.
In the face of the economic crisis, the political and professional debates in Slovenia neglect the financial aspects of institutional care for older people. The exact cost of the institutional care is guesswork because the financing of care is not transparent. Flaker et al. (2011, pp. 249-254) estimate that 49,39 percent of the total expenditure for long-term care is set aside for the institutional care for older people and the preservation and maintenance of institutional infrastructure, while the users and community do not directly benefit from it. Institutional system cannot adequately meet the needs of users, community and society. The shift of expenditures from present institutional care to community provides an opportunity for good quality life in old age. It is an investment in social network, preservation of significant roles of older people in society; it is an investment for strengthening the solidarity among all the age groups in society.
When arguing for the process of deinstitutionalisation of care for older people, we can refer to two sets of data. One stems from the analysis of the operation of homes for older people as total institutions (Mali, 2008b), and the other describes old people's needs for long-term care (Flaker et al., 2008b).
Homes for older people as total institutions
Goffman's notion of the ‘total institution’ warns us of the dangers of a complete set of care services. Goffman uses this term to denote institutions that care for all aspects of a person's life (residence, work, entertainment, recreation etc.) (Goffman, 1961). The salient features of such institutions are: isolation from the outside world; mortification (role dispossession, programming, (interpersonal) contamination; control over the life of an individual; all-encompassing care for various aspects of one's life; rationalisation of life; an uncommon living arrangement (non-household, factory-style living); the disciplinary system (house rules, rewards and privileges, punishment, fraternisation); controlled leisure time; secondary adaptations; the world of staff vs. the world of inmates; the climate and culture of the institution. It is important to remember that these features only further impair inmates' social and personal identity already seriously damaged by stigmatisation.
If we look into the parallels between homes for older people and total institutions (Mali, 2003; Mali, 2008b) and compare the ideal type of the total institution and the actual conditions observed in older people’s homes, the results show that residents in homes for older people are cut off from life outside the institution, so for older people an institution represents a singular world set apart from the outside world. During the initial phase of adjustment to life in the institution, older people go through the process of mortification. They have to become adjusted to ‘the home’ more than ‘the home’ must become adjusted to them, which is pointed out in the narrative of one resident who describes typical problems of admission procedures:
‘I came to the home in order to have some peace, to be able to rest and have a regular diet which I no longer had after my wife died. Never in my life was I at the doctor’s and I did not expect his help in the home. But already on the first day in the home everybody wanted to know what medication I am on, whether have high blood pressure or diabetes, they measured my blood pressure, stung me with injections, they even took my urine and had it analysed. They did all this to me, someone who never saw a healthcare centre in their life! On the first day in the home I met a doctor and I talked to a physiotherapist for the first time in my life. The first day was really strenuous, and the next even more so.’
Intrusions into privacy occur quite often. In the multibedded rooms which exist in numerous homes across Slovenia the interpersonal contamination is present, especially amongst immobile users. They belong to the most vulnerable users’ group which is forced to allow that other users – their neighbours – watch them while they are being nursed. Their privacy is also disturbed by the entrance of staff to a room often without knocking. Some of them are aware of these cases of bad practice which has become a routine, while others consider it adequate considering the existing living conditions.
In order to enable coexistence in a very large group of residents, rationalisation of institutional life is also present. Although there are house rules providing order in the home, life is quite flexibly adapted to the personal requirements of the individual. The users can, for example arrange distributions of meals, nursing time, payments of services, determination of place, time, mode and form of boarding in agreement with the staff and the given spatial and human resource possibilities.
The care affecting all spheres of one's life is not present to an all-encompassing extent as described for other total institutions. Immobile residents depend on the staff especially in terms of the provision of basic life needs (eating, dressing, washing), as well as other needs (like socialising, making sense of life). The residents’ dependence on the staff decreases comparatively with their mobility. Residents who only temporarily depend on personal care can independently provide for some of their basic needs, while mobile residents can provide for most of their needs. Self-care is desired and it is emphasised.
Discipline is established by the house order. Retaining behaviours associated with a ‘previous way of life’ can generate a violation of house rules whereby a resident is likely to come into conflict with the staff. However, the conflict can be settled if both sides seek a constructive solution to the problem. In order for the staff to meet such needs of the residents, they need to harmonise as much as possible the requirements of the institution with the interests and wishes of the residents. In the case when either residents or staff feel threatened, they try to solve problems in dialogue with each other.
Time spent in homes for older people should not be wasted time. The residents spend their free time in employment activities in which they participate in accordance with their emotional state and health condition. For mobile and independent residents several activities are available, while there are fewer for immobile residents; the spending of one’s free time proves to be a problem for the latter and for those who do not know how or cannot find a purpose in their new environment.
In sense of the Goffman’s secondary adjustments we identified an adjustment akin to colonialisation – adapting to life in the home, shown as a humble and non-critical attitude of the residents towards life in the home.
In their work with the users, the staff are likely to experience the involvement cycle or other exigencies of emotional labour that have become a necessary part of work with older people when considering the user’s individuality. It requires the relinquishing of one’s personal interests and the dedication of oneself to work, as mere routine work is not enough. On the other hand, emotional labour is also a condition for good and quality work with users and requires the employees to be mature personalities and emotionally stable. Emotional labour leaves negative emotional consequences behind. After finishing their work, most employees still think about certain older people in their care and their problems. In the event of the death of a resident staff need to know how to regulate and control their own emotions Although they try to understand that death is part of everyday life, and especially their employment, any death of a resident affects them emotionally. They use the technique of introversion (repression) by focusing on good events, or the technique of projection (redirecting) to the living people in the home. So here is a typical statement of a nurse who has worked in a home for 15 years:
‘Of course, every death shocks me, I am only human. I cannot be only a medical nurse. When you work with old people in the home, you get attached to them. But amongst my fellow workers we do not speak about this. We also don’t have the time. The work goes on and the people who are alive are waiting for you. So I’d rather think of pleasant things. It helps me quickly redirect my thoughts to those residents who are alive. ‘
Our research into the presence of the elements of the total institution in homes confirmed that not all of its features are present in any concrete institution. Homes for older people do not display all of its characteristics, and the data show that even those characteristics that are present do not appear in their ideal (extreme) form. Residents’ needs are taken into account and the employees adjust to their needs and demands within the boundaries of the institutional framework. Nevertheless, the main goal of the institution – care for a multitude of people living in one place – remains in the forefront, and thus life is governed by rules and bureaucratisation.
Older people's needs
Over the past few years, we have conducted several research projects (Flaker, V. et al., 1999; Flaker, V. et al., 2000; Flaker, V. et al., 2004a, Flaker, V. et al., 2004b; Flaker, V. et al., 2007; Čačinovič Vogrinčič, G. et al., 2008; Mali, J., 2007) that looked into the everyday life of people who need long-term help, support and care in order to lead independent lives outside total institutions, in a community or their home environment. We tried to determine their needs and establish to what extent the existing services satisfy these needs. The qualitative data that we collected provided an insight into the situations of older people’s everyday lives.
We compiled an index of needs, by means of which we recorded and described the situations of people with long-term needs and the main factors that ensure autonomous and independent life in a community. At the same time, we drew attention to the negative and aspects of life in an institution. The catalogue comprises the following clusters of needs and situations: dealing with stress, certainty and purpose; dwelling; employment – work and money; everyday life (routines, daily activities, leisure and errands); discontent in interaction; social contacts and ties; institutional career; disembeddedness and affiliation.
Work can be seen as one of the basic needs of people. In modern society it is inseparable from the need for material well-being. This need is present through all stages of our lives – from youth to old age. Many people in their early and middle old age still work, some of them even until very old age. Unpaid work, or informal work (e.g. care for grandchildren, gardening) also contribute to the material prosperity of older people. Work is also an instrument for ensuring a means of livelihood and living. Older people have the need to be active, to do some kind of work. Retirement often creates a crisis, since a person who has been active suddenly has too much time on his/her hands and does not know how to handle it. Therefore, it is important that such a person finds new activities and new occupations, either through socialising, workshops, activity-circles or other similar involvement. On the other hand, leisure time, i.e. time not filled with activities, is also necessary.
Another basic need of every individual is dwelling, the need for shelter, somewhere to live. A living place ensures privacy. This is especially obvious in institutions where private rooms are a place for residents to withdraw, be alone and exercise their right not to be disturbed. A living place also ensures the permanent address, which is one of the bureaucratic prerequisites for our identity. In older people, the need for a living place is sometimes associated with the need for a special room or for a special arrangement of a living place. A living place should be adjusted to the needs of older people as much as possible (Flaker at al., 2008b, p. 111).
Human beings are social creatures, so contacts with other people are a physiological necessity, and the need for contacts and sociability is one of the basic human needs. Older people's social networks are usually small and limited to a narrow circle of people, primarily family members and rare friends. Important members of these networks are people who assist older people, either for payment, as employees who work for formal assistance providers, or as volunteers. It often happens that ‘paid friends’ make up the major part of an older person's social network and represent their only contact with the outside world. It is important to try to encourage as much as possible socialising among older people, since they often want contacts with others but do not know how to establish them.
Discontent in interaction, which occurs every day, is usually not associated with any special need and is not even expressed as need. It is dealt with in passing, mistakes are corrected and forgotten. The stigma of old age causes uncomfortable feelings in the members of the young and middle generation, and such feelings are experienced as burden by both sides. To eliminate such burdens, more interpersonal collaboration is needed. It could enable intergenerational coexistence and eliminate the stereotyped approach to generations.
People need a degree of certainty in everyday life, but life in old age is subject to uncertainties. The situations that once were taken for granted and sure often appear different in old age. The feeling of certainty can be guarded by ensuring a sufficient number of stable social ties, material well-being and physical security, a greater number of pleasurable events with good outcomes, and circumstances that will create the feeling of certainty, safe social and personal status, the opportunity to create, desire and activities with others (Flaker at al., 2008b, pp. 58-59). For an older person who moves to an institution, some certainties of life are terminated. It is important to help these people reconstruct these certainties and enable them to rehabilitate. It is also necessary to minimise losses experienced by a person who moves to an institution, or still better, to eliminate the experience of loss.
The need for disembeddedness and affiliation also appears in old age. This is a dynamic need, arising from the clash of the need for detachment and belonging. Older people are often dependent on their family members, who indeed provide an important support for older relatives, but can also suppress their autonomy. The need for disembeddedness and affiliation is manifested as the need to be autonomous and independent from others, which clashes with the need to have other people close by and depend on them (Flaker at al., 2008b, p. 346). Diminished capacity for an independent life in old age means that this need is difficult to satisfy. The solution should be sought in the work methods, services and means that would enable older people to recognise and satisfy this need and create room for the overall satisfaction of the needs in old age.
The increase in the number of older people and their needs, plus the over-institutionalised care for older people and underdeveloped community-based care are the factors that call for changes in the existing system of care. Both care systems, the institutional and community-based, should undergo changes. One possible course could be the implementation of deinstitutionalisation processes.
Deinstitutionalisation entails not only organisational changes but also changes on the all other levels of operation. On the micro level, it encourages older people to recognise that they have the right to live in a community, with other people, to be included in social developments and to decide about their life regardless of whether they are sick, weak or even less accountable. On the macro level, deinstitutionalisation creates the need for the development of individualised care for older people and of community-based care as an alternative form that will supplement institutional care. The individualisation of care leads to the restructuring of large institutions for mass care (homes for older people) and development of new work methods, including new methods of social work, as well as new types of community-based care (i.e. cooperatives). Community-based care complements informal help; in the current circumstances, the area of informal care is hamstrung by ignorance, impotence and excessive burdens shouldered by relatives who care for older family members and therefore need adequate support and assistance. These changes cannot be implemented unless the conditions on the macro-level are fulfilled, i.e. on the state level where relevant legislation must be adopted to enable the implementation of the deinstitutionalisation process.
Older people need all-encompassing care provided by experts in various areas. The over-institutionalisation of care for older people suggests good collaboration of the health and social care sectors, so positive experience gained so far should be utilised and transferred to the area of community-based care via the deinstitutionalisation process. Professions that provide care for older people must collaborate learn about each other’s methods and identify profession-specific approaches. The team approach and integral, holistic care are the basic trends that could be introduced into the institutional and community-based models of care through deinstitutionalisation. This is one of the reasons why it is not sensible to continue with practices that do not ensure the collaboration and partnership between social work and health care services. Deinstitutionalisation presents a challenge leading to the collaboration and establishing of connections among educational institutions (for social work, nursing and medical sciences), individual sectors (the Ministry of Labour, Family and Social Affairs and the Ministry of Health), and professionals on the practical level.
At the time of writing this paper, it became obvious that data needed for quantitative and qualitative analyses are not available in Slovenia. Available data collections suggest that various institutions follow particular interests – the data collected serve to support their own activity, while not indicating any interest in the development of care for older people or their own development. Without such a database of quantitative and qualitative data, it will be very difficult to justify the need for deinstitutionalisation. However, the current state of affairs definitely does not predetermine the future one. The current situation can be changed. The stimulation of research by inviting research projects is a simple and quick way to eliminate the current anomalies.
It is important to note that the ideas about deinstitutionalisation in the area of care for older people have come from the academic sphere. The need for deinstitutionalisation was discerned from previous qualitative researches we consulted during our research on the needs in old age. The initiatives proposed by older people are few and limited, and even when put forward they are overlooked and dismissed by people in authority. This reflects the characteristic stance of older people who surrender to destiny and are satisfied to have a roof over their heads, food and a warm room. We hope that the ‘baby-boom’ generation that initiated a series of social changes in various historical periods will continue to be active in old age and change the circumstances in the area of care for older people. This paper has indicated the types of changes needed in this area.
 These principles, among other things, were responsible for the fact that the activity of homes for older people was defined gerontological-geriatric (Mali, 2008, p. 51). The basis for the activity was provided by medicine, or gerontology of the time that was based on medicine. Consequently, the number of medical employees radically increased during the years that followed and they introduced into the work of homes for older people primarily medical concepts.
Accetto, B. (1968) Starost, staranje in starostno varstvo [Age, Ageing and Age Care], Rdeči križ Slovenije, Ljubljana.
Bytheway, B. (2005) ‘Ageism’, in The Cambridge Handbook of Age and Ageing, eds M. L. Johnson, V. L Bengtson, P. G. Coleman & T. B. L. Kirkwood, Cambridge University Press, Cambridge.
Čačinovič Vogrinčič, G., Grebenc, V., Kodele, T., Mali, J., Miloševič Arnold, V., Rihter, L., Škerjanc, J. & Urek, M. (2008) Oblike bivanja in podpore za ranljive skupine prebivalcev (oseb z demenco, ljudi z dolgotrajnimi duševnimi stiskami in intelektualno oviranih oseb) v Mestni občini Ljubljana [Living Arrangements and Support for Vulnerable Groups (people with dementia, people with long-term mental health distress and people with intellectual disabilities) in the City of Ljubljana], Fakulteta za socialno delo, Ljubljana.
Flaker, V. (1998) Odpiranje norosti [Opening of Madness]. Založba / *cf, Ljubljana.
Flaker, V., Rode, N., Jurančič, I., Vončina, M., Škerjanc, J., Kavar Vidmar, A., Zaviršek, D.,
Kastelic, A., Videmšek, P., Zorn, J., Zupančič, D., Cigler & M., Šircelj, J. (1999) Oblike bivanja za odrasle ljudi, ki potrebujejo organizirano skrb in podporo: Analiza in predlog ukrepov [Residential Care for the Adults Who Need Continuous and Organised Care: analysis and proposal of measures], Visoka šola za socialno delo, Ljubljana.
Flaker, V., Rode, N., Mesec, B., Turnšek, N., Jurančič, I., Urek, M. & Grebenc, V. (2000) Modeli in metode za merjenje učinkov razvojnih in preventivnih programov na področju socialnega varstva: Evalvacija stroškovne učinkovitosti in uspešnosti 5-letnih socialnovarstvenih programov [Models and Methods for the Evaluation of the Impacts of Development and Prevention Programs in the Area of Social Care; the evaluation of cost efficiency and success of 5-year social care programs: final report], Visoka šola za socialno delo, Ljubljana.
Flaker, V., Jurančič, I., Kresal, B., Nagode, M., Rode, N., Škerjanc, J., Urh, Š., Videmšek, P. & Zaviršek, D. (2004a) Individualiziranje financiranja storitev socialnega varstva: Načrt pilotskega projekta uvajanja neposrednega financiranja [Individualisation of the Funding of Social Care Services: A Draft Pilot Project Introducing Direct Funding], Fakulteta za socialno delo, Ljubljana.
Flaker, V., Kresal, B., Mali, J., Miloševič Arnold, V., Rihter, L. & Velikonja, I. (2004b) Delo z dementnimi osebami – priprava modela obravnave oseb z demenco: Sklepno poročilo [Working with People who Suffer from Dementia: preparation of the model of treatment: final report], Fakulteta za socialno delo, Ljubljana.
Flaker, V., Cigoj, N., Grebenc, V., Kodele, T., Kranjc, B., Pirnat, T., Smole, A., Urek, M., Videmšek, P., Žnidarec Demšar, S. (2007) Krepitev moči v teoriji in praksi [Empowerment in Theory and Practice], Fakulteta za socialno delo, Ljubljana.
Flaker, V., Mali, J., Urek, M. (2008) ‘Deinstitutionalisation process in long-term mental health institutions in Slovenia’, in Conference monograph: Vilnius Lithuania 2007, ed M. London, European Network for Training Evaluation and Research in Mental Health, Cambridge.
Flaker, V., Čačinovič Vogrinčič, G., Grebenc, V., Kodele, T., Mali, J., Miloševič-Arnold, V., Rapoša-Tajnšek, P., Rihter, L., Rode, N., Sedmak, M., Škerjanc, J., Urek, M. & Zaviršek, D. (2008a) Evalvacija procesov dezinstitucionalizacije v posebnih socialnih zavodih v Sloveniji (V5-0287: končno poročilo [The Evaluation of Deinstitutionalisation in Special Social Care Homes in Slovenia (V5-0287): final report], Fakulteta za socialno delo, Ljubljana.
Flaker, V., Mali, J., Kodole, T., Grebenc V., Škerjanc, J. & Urek, M. (2008b) Dolgotrajna oskrba: očrt potreb in odgovorov nanje [Long term care: outline of needs and responses to the needs], Fakulteta za socialno delo, Ljubljana.
Flaker, V., Nagode, M., Rafaelič, A. & Udovič, N. (2011) Nastajanje dolgotrajne oskrbe. Ljudje in procesi – eksperiment in sistem [The Becoming of Long-term care. People and process – experiment and system], Fakulteta za socialno delo, Ljubljana.
Goffman, E. (1961) Asylums, Doubleday & Co..
Commission of the European Communities (005) Confronting demographic change: a new solidarity between the generations, Green Paper, Commission of the European Communities, [Online] Available at: http://www.abuel.org/docs/stat01_greenpaper.pdf
Hlebec, V. (2010a) ‘The post-socialist transition and care for older people in Slovenia’, Eur. papers new Welfare, [Online] Available at: http://eng.newwelfare.org/2010/10/20/the-post-socialist-transition-and-care-for-older-people-in-slovenia-2/.c.
Hlebec, V. (2010b) ‘Oskrba med državo in družino: oskrba na domu’ [Care between the state and the family: home care], Teorija in praksa, vol. 47, no. 4, pp. 137-157.
James, N. (1989) ‘Emotional labour: skill and work in the social regulation of feelings’, Soci¬ological Review, no. 37, pp. 5–42.
Mali, J. (2003), Koncept totalne ustanove in domovi za stare [The concept of total institution and homes for older people], MA dissertation thesis, Fakulteta za družbene vede, Ljubljana.
Mali, J. (2007) ‘Raziskovanje demence v socialnem delu’ [Researching Dementia within So¬cial Work], Kakovostna starost, vol. 10, no. 4, pp. 25-34.
Mali, J. (2008a) Od hiralnic do domov za stare ljudi [From Almshouses to Homes for the Older People], Faculty of Social Work, Ljubljana.
Mali, J. (2008b) ‘Comparison of the characteristics of homes for older people in Slovenia with Goffman's concept of the total institution’, European Journal of Social Work, vol. 11, no. 4, pp. 431 - 443.
Mali, J. (2009a) ‘Sožitje med generacijami kot ga razumemo v socialnem delu: sožitje genera¬cij’ [The understanding of intergenerational solidarity in social work], in Vloga stare¬jših v sodobni slovenski družbi ed S. Bezjak, Inštitut Hevreka, Ljubljana.
Mali, J. (2009b) ‘Medgeneracijska solidarnost v obstoječih oblikah skrbi za stare ljudi’ [The intergenerational solidarity in existing forms of care for older people], in Brez spo¬pada: kultur, spolov, generacij,eds V. Tašner, I. Lesar , M. Antić Gaber, V. Hlebec & M. Pušnik, Faculty of Education, Ljubljana.
Mali, J. (2010) ‘Social work in the development of institutional care for older people in Slove¬nia’, European Journal of Social Work, vol. 13, no. 4, pp. 545-559.
Ministrstvo za delo, družino in socialne zadeve (2006) National Program for Social Protection 2006-2010, Ministrstvo za delo, družino in socialne zadeve , Ljubljana (39/2006).
Ramovš, J. (2003) Kakovostna starost – Socialna gerontologija in gerontagogika [Good qual¬ity of old age – social gerontology and gerontagogy], Inštitut Antona Trstenjaka in Slovenska akademiija znanosti in umetnosti, Ljubljana.
Smolej, S., Jakob Krejan, P., Žiberna, V. & Nagode, M. (2010) Spremljanje izvajanja pro-gramov socialnega varstva. Poročilo o izvajanju programov v letu 2009. Končno poročilo [The evaluation of providing social care programs. The report on providing social care programs in 2009. Final report], Social Protection Institute, Ljubljana.
Smolej, S., Nagode, M. & Jakob Krejan, P. (2010) Izvajanje pomoči na domu. Analiza stanja v letu 2009. Končno poročilo [Providing of home help. The analysis of the situation in 2009. Final report], Inštitut za socialno varstvo, Ljubljana.
Ministrstvo za delo, družino in socialne zadeve (2006) Strategija varstva starejših do 2010 – Solidarnost, sožitje in kakovostno staranje prebivalstva,[The strategy for the protec¬tion of older people until 2010 – Solidarity, living together and quality of old age], Ministrstvo za delo, družino in socialne zadeve, Ljubljana, [Online] Available at: http://www.mddsz.gov.si/fileadmin/mddsz.gov.si/pageuploads/dokumenti__pdf/strategija-SI-starejsi.pdf.
Vojnovič, M. (1988) Organizacija gospodinjske pomoči starim na domu [Organisation of household care for older people], Zdravstveno varstvo, vol. 27,no. 1, pp. 1-44.
Wilson, G. (2000) Understanding old age. Critical and global perspective, Sage, London.