Residential care services and value creation.

This case study looks at a for-profit housing and care provider for older people and people with disabilities in Scotland. The organisation provides care at home, housing support, care homes and responder-type services in ten local authorities in Scotland. This organisation is skilled in providing services through the support of digital systems, such as the emergency alarm system that aims to customise services for individuals and to give users more control over the service.

Stakeholders & Beneficiaries

Co-creation process

Three key points of value co-creation have been identified in this case study. First, at the stage of service design, the service users co-create value through joining the Tenants’ Group, using the complaints procedure, attending the organization’s AGM and filling in survey questionnaires. The service users are also involved in the development of the digital system to offer opinions on the look, feel and functionality of the system. Service users are also involved in the staff recruitment. Second, at the operational planning, value co-creation process is recognized during the collection of information about service users, where the role of service managers is highlighted. The care package is developed with individual service users, who thus participate in operational planning and co-create value for the service. Third, at the stage of service delivery, the service users play a pivotal role in creating value through their day-to-day involvement in service interactions. The service users and frontline staff build a service relationship through service interactions, which facilitates the service users to create value. Moreover, supporting processes and technology are recognized as an important interface to facilitate value creation, by enriching the experience of service users, increasing their social contact with family and friends, and helping staff to better understand user needs and to handle emergencies more effectively.

Digital Transformation Process

We have not looked at the digital transformation. However, technology and digital systems were mentioned as facilitating the effective provision of services in this case study.

Results, Outcomes & Impacts

The outcomes and impacts are identified in two aspects. First, the service users’ involvement in service interactions and operational planning has contributed to the service improvement at the micro level and thus has impacted the value that individual service users receive from the housing and care services. Second, the frontline service staff have learned through service interactions with service users, which enables the service staff to perform their job more effectively and thus impacting their capacity to facilitate value creation and co-creation.

Challenges & Bottlenecks

There are some challenges related to the stages of service design and service delivery. At the service design stage, the service users are less likely to be involved in the design of service while various respondents have attributed the low involvement to the service users’ apathy to involvement outside service interactions. Three main challenges are identified at the service delivery stages. First, ‘too much care’ and a disparity in care offered by different frontline staff could result in service users’ unrealistic expectations of service and therefore, value destruction. Second, a lack of continuity in care to foster relationship building; personality clashes; a lack of resources; and a lack of knowledgeable or appropriately trained staff are seen as four ways to hurdle fostering service relationships and thus, pose challenges for value creation.

Transferability & Replicability

The case study organisation is a Scotland based organization, but its idea may be applicable to other contexts. However, this case study has not explored this aspect.

Success Factors

One central success factor identified in this case study is that knowledgeable, skilled staff who take a caring approach are important to value co-creation. For human-centred services in particular, this supported the development of the service relationship and trust.

Lessons learned

Four practical lessons have been learnt from this case study. First, frontline service staff play an indispensable role in co-creating value during service interactions. It was necessary, therefore, that staff were appropriately trained and knowledgeable. They needed the appropriate soft skills to manage the service relationship and engage with and understand service users’ narratives to co-create value. Second, services need to be accessible to service users and support the co-creation of value. Third, the organizational culture enabled or constrained value co-creation for service users. Culture had implications for the extent to which service users view themselves and public service staff view service users as capable of contributing to value creation processes. Finally, qualitative performance management tools should be developed to capture the multi-dimensional, subjective nature of value.

Ageing with intellectual disabilities

The Spanish case study of the Alas Foundation project to serve ageing people with intellectual disabilities describes the co-creation and delivery efforts of a Public Service Innovation Network for Social Innovation (PSINSI) formed by the foundation management, employees, families, and to a minor extent, the disabled elderly. Current services for this population group are limited to their earlier life expectancy. But the improvement in their life conditions and health have led to extended life expectancy and the need of new services that must combine specialized professionals and care of, in many instances, mature and autonomous persons.

Stakeholders & Beneficiaries

Stakeholders and Beneficiaries include:

Fundación Alas and the Special Employment Center Trefemo
The families that support the Foundation
The disabled elderly supported by the Foundation
The regional government of the Comunidad de Madrid (Spain)

Co-creation process

The content of the participation process included three related innovation elements:

The services model. This affects the facilities and types of services the elderly demand. But it also affects the type of professionals involved in providing the services. Finally, the measurement of the relevance and impact of the services is subject of review.
The facilities’ design. Residences need adaptation, but also the Foundation must develop new facilities to train and fulfil the needs of ageing disabled.
The relationships with other agents. If the earlier two might be related to services innovation, this concerns the processes and how the Foundation launches and consolidates new relationships with different public and private agents to help elderly sustain themselves and fulfil their rights to autonomy and proper care.

Digital Transformation Process

No digital transformation process involved.

Results, Outcomes & Impacts

The ageing project of Fundación Alas is centered in solving wicked problems associated with the longer life-expectancy of people with disabilities (Plena inclusión, 2014) thanks to the improvement on their life conditions and treatments. Far from technological, the types of social innovations the foundation designs and executes are related to a public function that public agents in Madrid (Spain) have traditionally left to private agents. Indeed, at least in Madrid, the public agents have failed providing adequate services to this community and currently acts as mere funder of private initiatives – mostly supported through conventional tenders. The effectiveness of the intervention strategies for elderly with intellectual disabilities depends on the ability of the technical teams to develop and communicate clearly the plans to other professionals (Morgan, 1990; Shaddock et al., 1986 in Novell, et al., 2008), but also on the capacity, training and motivation of professionals who have the direct responsibility to carry them out (Aylward, Schloss , Alper and Green, 1995 in Novell, et al., 2008), as well as the coordination between all of them.

Challenges & Bottlenecks

Dimension: Physical fitness

Lack of health care standards
Communication and identification difficulties of pain threshold
Participation in the promotion and living a healthy lifestyle
Lack of specific resources and standardised protocols for the evaluation of elderly with intellectual disabilities
Insufficient training of socio-health professionals in ageing issues and intellectual disabilities
Insufficient physical therapy

Dimension: Emotional well-being

Integration of the information from the field of dual diagnosis[1] and the gerontology area[2]
Environmental situations having a negative impact on the adaptive abilities of elderly or could raise behavioural problems or stress
Training professionals in ageing and dual diagnosis

Dimension: Material well-being

Adaptation to the needs of elderly with intellectual disabilities
Less opportunities to participate in meaningful leisure activities, less stimulating environments, lack of staff preparation and relationship difficulties between individuals
Lack of experiences with the rest of the ageing population
Segregated and expensive environments
Existing geriatric or gerontological intervention models are scarce and are not easily transferable to services
Decreased productivity associated with ageing, difficulty to make personal and social adjustments beyond the 50
Few work or occupational itineraries to support elderly with this condition
Pension plans different to those available for those without disabilities
Lack of assessments due to disability and ageing to maximise compensation when leaving work activity

Dimension: Human Rights

Physical access
Access to information
Disability recognition associated with ageing
Right to decide where and with whom to live
Right to health, training and rehabilitation
Barriers to keeping an adequate standard of living and social protection
Right to develop and keep plans and goals

Dimension: Self determination

Lack of information necessary to identify or recognise abuses
Transition to retirement getting actively involved in self-care

Dimension: Social inclusion

Opportunities to participate actively in their environment
Lack of relevant social goals and aspirations
Greater contact with people without disabilities and greater autonomy
Lack of promotion of the inclusion of the elder with intellectual disability by the support professionals
Ageing of the main carers
Lack of coherence in the implementation of an inclusive model
Shortage of personnel

Dimension: Interpersonal relationships

Continuous changes of professionals
Housing size
Physical and social barriers
Long stories of institutionalisation and change of services that make it impossible to consolidate a social network
Behavioural problems
Adaptive and communication skills

Dimension: Personal development

Feeling of ‘disconnection’ with the activities carried out in earlier stages
Favouring free-time of their main carers
Lack of a process of active ageing
Lack of services and opportunities that promote rest, fun and personal development

[1] For example, to know the most frequent psychiatric conditions in the population with ID or specific etiologies that present a higher risk of certain types of mental illness. [2] Identification of which behavioural and psychological changes are associated to the overall ageing process.

Transferability & Replicability

The institutional needs and problems detected in the main services that might affect the project of Fundación Alas are summarised below (Novell, et al., 2008):

Services of homes-residence / supervised homes

Personnel ratios are insufficient, both in residential homes and in homes, when it comes to addressing needs arising from cognitive deficits, behavioural issues and the functional deficits associated with ageing.

Occupational Centres

The ageing process generates continuous adaptation needs that pose an opportunity for the innovation of these services. Most generally, personnel in the occupational centres are not well prepared to carry out the work of Psycho-geriatric Day Centres – e.g., they are not provided with physiotherapy services. These centres usually lack transition services from the world of work towards a compatible satisfactory activity able to meet the needs of people who cannot continue in Special Employment Centre but still can work and get paid and that enhances their skills.

Leisure and educational activities

Elderly with intellectual disabilities need enough and varied social activities, adjusted to their age, to choose from according to preferences and accessibility. Enjoying free time and leisure is one of the most rewarding activities and making them accessible is a good indicator of the quality of a service. The elder with disability has motor and cognitive difficulties to self-organise and, depending on the level of disability, also to enjoy leisure. Promoting adapted leisure for elderly would benefit them normalising activities and improving adaptive behaviours, socialisation, fun and distraction, and quality of life.

Individual level

The need to enhance their self-esteem and personal growth, fighting loneliness; the need of full social acceptance; and the need to make decisions about aspects of one’s life in the most similar way possible to people without disabilities.

Success Factors

Dimension: Physical fitness

Sleep, food, activities of daily living
Health (physical and mental), health care and access to socio-health services (including technical aids)

Dimension: Emotional well-being

Community environments, ordinary or supported employment, significant learning opportunities, absence of problems social or emotional behaviour and support
Depression and anxiety, stressors – social exclusion, stigmatisation or lack of social support
Healthy lifestyle and food, access to valued activities, health and well-being in the housing environment, adequate emotional response to separation or death of parents

Dimension: Material well-being

Economic status (i.e., having enough income to buy what one needs or likes), employment (i.e., having decent work and an adequate working environment), or housing (i.e., having a comfortable home where one feels comfortable)
Adequate standard of living
Social protection
Searching, getting, keeping the employment and having the possibility of returning to it
Having the right to choose where and with whom to live

Dimension: Human rights

Rights that may be violated at ageing
Proposals to empower disabled elderly to educate them to self-manage their lives and defend their rights

Dimension: Self-determination

Autonomy or personal control self-regulation or setting own goals and values
Training or psychological competence
Self-realisation or own elections

Dimension: Social inclusion

Active participation of the elderly in their community
Residence or housing options that favour social inclusion during ageing

Dimension: Interpersonal relationships

Natural supports: significant relationships with family and friends
Interpersonal relationships through leisure experiences integrated into the community
Collaboration with community services belonging to the network of services for the elderly
Interpersonal relationships (friends, partners): emotional, sexual and social

Dimension: Personal development

Education, personal competence, performance, functional skills
Use of support technology and other alternative communication systems

Lessons learned

This case presents the collaboration process of a private institution with users and their families to provide a public service that is not properly covered by the public sector. It answers a pressing concern of the families and the elderly with disabilities, as this latter group has become a relevant part of the total disabled population. This is not the normal case of a PSINSI, as the public agent is just one of the actors involved by the initiating agents, and mostly covers what relates to the overarching legal or normative framework of the caring for the ageing disabled people. Besides those differences with other social innovation cases, we appreciate similarities that even in the absence of a strong public actor are well covered by the PSINSI theoretical framework. This is relevant as it may indicate that the focus on the social innovation aspect might drive agents, independent of their ascription, to form similar types of networks.

Carpe Diem Dementia Village

This case centres around dementia care and concerns the development of a ‘dementia village’ in one of Norway’s largest municipalities. The project is based on inspiration from the Dutch dementia village, the Hogweyk, and was initiated by politicians in the municipality after a visit to the Hogweyk in 2013. The new dementia care facilities are scheduled to open by the fall of 2020.

The village will have room for 158 residents suffering from dementia, with 8 residents living together in 17 smaller buildings with surrounding gardens. Inside the village there will be access to different facilities, such as a small shop, café, hairdresser and gym, and indoor and outdoor spaces for social gatherings and activities.

The idea behind the dementia village is to create an environment where residents can be free to move around in a safe environment, with more access to activities and recreation. This is contrasted with the more traditional nursing homes, which are often criticized for being too focused on the somatic aspects of care, which limits room for socializing and meaningful activities. By creating a more ‘homely’ atmosphere both inside and out, the municipality is seeking to provide dementia care services that enable seniors to continue living their life as before, as much as possible.

Stakeholders & Beneficiaries

Various actors in the local community become relevant stakeholders in this case, since one of the aims is to create more active links between the community and the elderly care services. Private businesses, civil society (NGOs and volunteers) and other public sector actors are invited in to provide inputs in the ‘co-creation’ of the village at the ideation and planning stages of the process. Moreover, local stakeholders are invited to ‘co-create’ the services when the new care facilities open. This can be volunteers taking part in arranging activities, schools or nurseries setting up performances, or private businesses providing services such as hairdressing, cafés etc. The main beneficiaries of the case are senior citizens suffering from dementia and their next of kin.

Co-creation process

The municipality has placed emphasis on co-creating the new services with potential residents, their next of kin, and other local stakeholders. To co-create the new services, the municipality is drawing on inspiration from service design and co-design. The design processes are mainly being carried out ‘in-house’ and facilitated by a development team with experience and training in facilitating innovation processes.

Digital Transformation Process

We have not focused on the technological aspects of the dementia village in the case study. However, introduction of new technology will be important for the development and operation of the new services.

Results, Outcomes & Impacts

There are two ways of understanding ‘results’ in the context of this case. First, the main results of the dementia village project are linked to the construction of the new care facilities. Second, we may also highlight the results of the co-creation processes undertaken to create new solutions in this new service setting. These processes have generated a range of ideas for new solutions that will shape the new services. In this case, it is too early to assess outcomes and impact of the dementia village and the various new solutions within the new care facilities because it has not yet opened. We understand outcome and impact as the effects of new solutions which may be measured in various ways.

Challenges & Bottlenecks

There are some obvious challenges involved in co-creating dementia care. When the end users have cognitive impairment, and may even lack the ability to communicate verbally, co-creation and co-design is difficult. Finally, the challenges and constraints of service design in this context largely concern the complexity of the project and in providing high-quality services in dementia care. Dealing with dementia is inherently challenging.

Transferability & Replicability

The dementia village concept is already spreading across countries and communities (I.e. from the Netherlands to Norway) and across municipalities in Norway. However, the concept may be implemented with more or less focus on involvement and co-creation. We find that there are potential for inspiration, learning and transferability in the way Bærum has aimed to co-create the new dementia services with users and other stakeholders.

Success Factors

Not relevant.

Lessons learned

One of the central lessons learned from this case is that co-creation of innovations with services users is possible also when service users suffer from cognitive impairments.

Anonymous – An internal innovation and quality unit in a middle-sized municipality

The unit has two main focal areas; quality assurance and innovation; the former is seen as ensuring order and securing the quality of service offerings, whereas the latter is understood as experimental and risk-driven. The case study has taken to innovation unit as point of departure: The main activities of the innovation unit are; to mature the whole organisation in regards to an innovative mindset, to disseminate and share knowledge externally, to monitor projects as either project initiator, project lead or as sparring partners and to manage a yearly innovation fund. Both public (that is, from within the municipality itself), private and civil actors can apply for project money via the fund as long as the projects are finalised within a year.

Stakeholders & Beneficiaries

Key stakeholders are the internal functions in the municipality, private sector organisations and, despite to a lesser extent, academia. Beneficiaries are both elderly citizens and care takers.

Co-creation process

The unit is based on the logic of living labs – understood as a certain innovation methodology. From the perspective of the municipality, this living lab approach is seen as a platform where especially external actors can get an entry to collaborate with the public sector and herein access target groups, such as elderly that they could not otherwise have approached. Hence, most innovation processes are inherently co-creational since citizens, users and employees across sectors are engaged. Mostly, and across types of projects, the unit is primary lead regarding the research design, which is based on traditional user studies e.g. citizens interviews in their private homes or at care centres and public servant interviews and feedback, whereas the experimental aspects of living labs are enacted as test set-ups in homes and care centres – which seems to be part of most projects. In the projects the initial phase is considered crucial, which is why the unit emphasises how idea generation and herein reality checking need to involve various actors. This way they want to ensure that perspectives and input from the ones who are going to enact the solutions, and hence make the solutions live in the organisation, have been part of the development processes. Thus, even though the projects are inclusive processes with different stakeholders collaborating during the projects, and not necessarily with a dominant partner, the municipality is the sole decision-maker regarding the outcome of the processes.

Digital Transformation Process

There has been an outspoken focus on welfare technology, as both a means to make the citizens more self-reliant and as a way to address that there might be fewer employees in the sector prospectively (the idea is to replace all the work routines that do not imply human interaction with technological solutions). But despite the unit’s focus on technological development, it is emphasised that technology is not solely a solution in itself, but that the organisational change that might follow, be that cultural and/or procedural, is key.

Results, Outcomes & Impacts

All projects should create value by addressing the following three bottom lines: increased quality for the citizens, better work environment to employees and value creation for the organisation – as either money or resource savings or increased efficiency or quality. These are the three main success criteria written into all projects, but they do not need to be fulfilled equally or have the same weighing in all projects. Besides the three bottom lines, it is emphasised that the activities of the innovation unit, and the municipality in general, hopefully support community building by creating new jobs and making it attractive to live in the region. Also, the overall societal challenge of more elderly and a reduced work force is understood as a concern and a responsibility that reaches beyond the single projects.

Challenges & Bottlenecks

Barriers to conducting co-creation processes for innovation are both internal and external. Internally, the on-going focus on resources makes it important to the unit to be able to argue for spending time and money on the specific projects carried out. Externally, the collaboration between a huge public sector organisation with 6000 employees based on political leadership and e.g. a small one to two persons company is sometimes challenging – basically due to profoundly different work processes.

Transferability & Replicability

An important dimension regarding the value of a project is the ability to spread and disseminate the outcome, be that technology implementation or work processes. On the one hand, the innovation unit has been able to create a demand within the organisation and in the entire administration, which was not there from the beginning. But on the other hand, it is also recognised that change does not happen by itself and that both knowledge sharing and implementation can be a huge challenge, even though it is within the same organisation. Moreover, there is a focus on spreading in a wider sense not bound to the local context of the municipality; to other municipalities in Denmark and internationally. The reasoning behind is that if the unit is able to share best practices, hopefully they will also receive ideas and inspiration from the outside – and as such upscale both the solutions and the approach to innovation.

Success Factors

Increased quality of life for elderly citizen.

Lessons learned

To the innovation unit, the term and the initiatives that living labs comprise legitimise the municipality as a matchmaker between and translator of public and private sector logics. Moreover, it is revealed that living lab both refers to and enables a certain discourse and a sort of organising – making the perceived strength of the living lab concept – that it is a signifier – open towards a variety of interpretations without influencing the shared experience among the actors involved; that the collaboration is highly meaningful.

“Cycling Without Age” (CWA)

Cycling Without Age is a foundation that was established in Denmark 2015, but is now represented in 47 countries.

The main idea is that elderly people living in care centres or elderly people offered home care are given the opportunity to get a bike ride in a trishaw. The trip involves what is referred to as the three P’s: pilots, passengers and personnel. The pilot (driver) is either a volunteer or an employee from the care centre or home care, the passenger is the elderly person and personnel refer to the employees and/or administration at the care centre/home care. The main objective of Cycling Without Age is presented as giving the elderly the right to wind in the hair by ensuring mobility and active partaking in society.

Stakeholders & Beneficiaries

A key stakeholder in a Danish context is the municipality, and more specifically the managers and employees at care centres and home care. The service of the bike ride cannot be outlived without these. Another key stakeholder is thus the politicians, who have been part of pushing the idea forward. Besides the public sector stakeholders, a key actor is the volunteers and the beneficiaries are the elderly.

Co-creation process

The idea and the service of getting a bike ride is not the outcome of co-creation, understood as deliberative innovation processes. Anyhow the idea has been developed and tailored to countries outside Denmark, where the public sector is not the main provider of elderly care.

Digital Transformation Process

CWA offers a digital booking platform, but the interviews revealed that for some care centres it was easier to use a manual calendar. And in the cases using the platform, it is not transforming practices and procedures.

Results, Outcomes & Impacts

It is difficult to highlight specific results and outcomes of the bike ride in itself (see success criteria), but the success of CWA as a foundation and the many countries that now also offer bike rides for elderly can be seen as evidence for impact regarding the service/idea.

Challenges & Bottlenecks

The public managers stress that fiery souls are key when it comes to implementing the initiative – either positioned in the administration or within elderly care, and these need managerial back-up. Another barrier relates to the operation of CWA. The public managers tell how they are left alone with the initiative after the implementation phase. This experience is both related to the awareness from the municipality and from the CWA secretariat. To exemplify, it is the responsibility of the care centre/home care to maintain the trishaws and they are not granted any funding for repairing or buying new bicycles if they are damaged.

Transferability & Replicability

The initiative has been easily transferred to municipalities in Denmark and to other settings internationally.

Success Factors

The impact of the initiative is not perceived by CWA and public managers in traditional quantitative metrics but rather in qualitative aspects, such as the general enhancement of the joy of life among the elderly. Another positive aspect of the visibility of the elderly in the local community is an increased awareness of elderly, dementia etc. among citizens in general. Still, CWA is working on more concrete evaluation criteria to professionalise and legitimise the bike ride as a method and an approach to increased life quality among the elderly.

Lessons learned

The case of CWA is interesting due to the high degree of positivity that surrounds the movement. The initiative and the foundation do not seem to meet a lot of resistance concerning the cause per se; to ensure that elderly stay mobile and part of society. Thus, it seems that if the cause is perceived highly legitimate the room for manoeuvre increases. Externally, since it becomes easier to engage in strategic collaborations and to recruit volunteers, and internally because the organization, based on trust in their own raison d’être and main objective, becomes flexible in regards to development and organizing, as long as the main objective stays the same. Another key aspect is how the innovation is positioned in the eco-system of public elderly care services. CWA is mainly an add-on to formal elderly care, since the foundation does not overtake tasks or roles of the public sector. In this manner they are not subject to competition regarding resources and legitimacy, making it less problematic for the municipalities to engage in collaboration.