3.1. The LTC Context and Specialized Services: Results from Context Forms
The centers participating in the study were integrated into the health and LTC context with significant differences. The analysis of data collected through context forms enabled us to gather relevant suggestions on three main themes potentially influencing the implementation of the SCU-B: (a) LTC strategy, (b) residential care, and (c) memory clinic.
LTC strategy: General practitioners are universally recognized as the focal point of the evaluation and care path. Second, in many countries, dependent older people receive social care. For example, in Germany, social care for people with dementia is graduated by the level of dementia and is specifically designed to cover the related care need [
34]. Moreover, dementia care in central and Nordic countries is managed as a social issue and local institutions (such as municipalities) provide support services for families and caregiver stakeholders.
Residential care: Residential care is a crucial component of the dementia care system in all countries, but it is only in Nordic countries that the provision of dementia care is virtually entirely publicly funded. In Norway, the full public funding of the cost of residential care results in a high percentage of persons with BPSD entering a nursing home. In other countries, families must contribute at least in part to cover the overall cost. For this reason, most families in Greece are unable to afford the high expense of a nursing home. Beneficiaries of partial cost assistance for residential care in Italy are those families with specific socioeconomic traits and care recipients with a high level of dependency.
Memory Clinic: Memory clinics are widespread across the countries participating in the study. Memory clinics grant diagnostic assessment, pharmacological treatment, and follow-up. According to the general rules of cost cover in these countries, access to these clinics may be free or may require co-payment (depending on income and age). For example, there is an active day care center in Thessaloniki (Greece) that functions as both a memory clinic and a day care center and also serves as a training center for family and informal (paid) caregivers.
3.3. SWOT Analysis for the SCU-B
The main points from interviews and FGs will be schematically summarized using a SWOT matrix with four categories: strengths, weaknesses, opportunities, and threats (
Table 5).
3.3.1. Internal Factors: Strengths
The person-centered approach and personalized style of care are seen to be part of the unit’s culture and are equally established through specific training and the team’s prevailing culture.
“We use the ‘TIME’ (The Targeted Interdisciplinary Model for Evaluation and Treatment of Neuropsychiatric Symptoms) [
39]
to create a goal for the assessment and treatment of each patient” (FC, O). “
We were considering how to better respond to challenging symptoms when we came across the Kitwood approach [
40]
, and we decided to try it out” (I, G).“Working in a large, multidisciplinary team presents a significant advantage in terms of being able to provide in-depth differential diagnoses and person-centered care for PwD” (FG, Be).
The service’s mission is defined by the ability to respond promptly and flexibly to highly critical situations, avoiding improper hospital admissions.
“This type of intervention relieves the familyand reduces the sense of helplessness of local doctors, geriatricians, or general practitioners” (FG, Mo).
High pharmacological competence is another strength that enables real pharmacological wash-outs to put an essential drug therapy in place that is better suited to actual needs. Furthermore, the SCU-B model “offers the possibility of optimizing medical treatment and medication under close surveillance, communicating with caregivers to find common treatment goals, and transferring knowledge and ideas for the period following discharge” (FG, M).
In addition to drug therapy, psychologists and occupational therapists seek to lessen BPSD by identifying those activities that are the most suitable and appreciated by the patients or, with the help of a nurse or physiotherapist, by restoring functional levels in order to support the person in difficulty.
“It is necessary to be open-minded and creative and to have strategies other than pharmacology (music or other activities). It is a matter of using all the involved components of effective treatment and tailoring it to the patient. However, this is sometimes impossible because hospitalization at the SOMADEM unit is of a short duration. Nevertheless, when families function well, they can help by describing the behaviors observed at home as well as their own behavior. Patient observation is also critical. There are times when patients are more agitated than others and it is necessary to recognize these moments” (FG, GE).
The decision about the care approach is strongly correlated to the professionals’ level of motivation.
“The team is incredibly driven and psychologically invested to support our patients, and they (the patients) can tell the difference” (FG, G).
“Can I point out an essential aspect? The staff’s humanity. We never leave the patient or his family alone; we didn’t even do that during lockdown when we were all busy in the Covid wards” (FG, B).
The Modena experts highlight how “a solid socio-health network, which shares a global vision of care and health centered on the person, is a great support to the SCU-B experience” (FG, M).
Beyond the pathology, commitment at the various levels of the network is linked to assessing and satisfying the needs of the individual and his family, as well as producing better and sustainable widespread psychophysical health at home.
The involvement of in-patients’ families is another significant strength of the SCU-B. Families are welcomed in the ward and are invited to participate in activities to acquire strategies suitable for managing their family member’s illness at home.
“…also, caregivers should receive training on how to cope with these symptoms at home. In addition to training, caregivers should also receive necessary information about dementia so that they know what to expect” (FG, T).
3.3.2. Internal Factors: Weaknesses
The weaknesses that emerged from the FGs are diverse and are often dependent on the local socioeconomic and sociohealth context. However, there is a common concern about the suitability of the SCU-B’s environment. One such concern is the suboptimal architectural design of some units, which are either not considered to be dementia-friendly or have no access to a secure garden or balcony.
“The ward space is similar to a standard hospital ward unit, and certain areas are not suited for supporting psychosocial protocols (…), e.g., the doors or the room area, the bed (…); many aspects of the ward are similar to those in other hospitals” (FG, G).
This point is linked to the weakness that emerged at the SCU-B of Geneva: the mirroring effect, that is, patients exposed to the agitated behaviors of others. This occurrence takes place in everyday interactions and often goes unnoticed by the person engaging in mirroring behaviors and the individual being mirrored. The person unconsciously imitates another’s gesture, way of speaking, or attitude [
41,
42].
“Mirroring behaviors can be another risk (…). The patient may be confronted with other very agitated patients or patients with advanced dementia; that kind of situation can be morally difficult for the patient” (FG, GE).
An element of reflection that emerged in Gazzaniga is the facility’s isolation, both geographically and in relation to the network of local services. Some units, including Modena, complained about the lack of resources, including the lack of a psychologist for family members, the limited number of hours of physiotherapy, and the non-optimal ratio between the number of healthcare professionals and beds.
“Stakeholders outside of the local area seem to be less aware of the SCU-B unit; the SCU-B’s geographic location makes it difficult to access, and the lack of new public funding prevents improvements to these activities” (I, G).
“The general public as well as local practitioners are not so familiar with the memory clinic. Even within the hospital, many professionals do not know what we are doing” (I, MA).
This aspect is undoubtedly linked to the weaknesses identified in the various FGs concerning the difficulty of providing follow-up visits after discharge, including by telephone, the brevity of the hospitalization period observed by the Geneva center, and the length of the waiting lists for admission found in Gazzaniga.
3.3.3. External Factors: Opportunities
The regions that host the SCU-B seem to be more sensitized to the subject, and natural dementia-friendly communities are being created to foster prevention and social promotion activities. The SCU-B’s integration into the network of services it is placed in also enables other structures to communicate and collaborate more effectively; one example is the outpatient service of a center that links extra-clinical care and a nursery home.
“The unit is part of a clinic and a research institution and this has fostered a climate of striving for continuous improvement” (FG, M).
“Maybe we should be more interdisciplinary in our work. Perhaps what we lack is somatic services. Patients frequently have comorbidities” (FG, O).
The majority of experts expressed hope for a higher level of involvement from general practitioners, both in the pre-admission phase to improve family and patient compliance during the stay and just before discharge to get the home ready for the patient’s return.
“In the case of complex patients and difficulty returning home after being discharged, the subsequent assistance project will be organized through reporting to the local unit for multidimensional assessment. Patients return home in all other cases” (FG, MO).
“As soon as the patient is hospitalized, it is important to prepare for discharge by thoroughly understanding both the patient’s and caregiver’s circumstances at home. The caregiver must be contacted for this purpose within 24 h of admission” (FG, GE).
The connection between SCU-B and hospital wards could be strengthened to simplify patient referral procedures, particularly with the geriatrics ward as this is the ward that most supports the SCU-B’s distinctive approach to care.
The involvement of family and caregivers is invaluable for overall patient care. Patient-training activities and psychological support to caregivers improve personal, relational, and environmental dynamics that prevent the onset of BPSD. In addition, these activities ensure that the benefits of hospitalization in the SCU-B are maintained after returning home.
“It is essential that caregivers become an integral part of the therapeutic process. It is impossible not to include them because, once the patient is discharged, they will be the caregivers, the spouses, the children, etc.” (FG, GE).
3.3.4. External Factors: Threats
It should be noted that when caregivers attend training courses concurrently with the patient’s hospitalization in the SCU-B, this could make an already stressful situation worse. As emerged from the FG of Perugia, “the risk may also be that the caregiver’s compliance and the practical effectiveness of the psychoeducational intervention will be reduced” (FG, P).
Caregivers’ commitment to care prevents them from having free time to dedicate to other family members or to themselves. For this reason, many caregivers decided not to participate in the Modena FG because they perceived the invitation to the SCU-B as an additional task associated with their caregiver role.
A significant threat that was discussed is the high staff turnover, which reduces the time required to ensure that new team members get the supervision and training they need for their work.
Financial pressure and its consequences is often an omnipresent challenge in the healthcare system. For example, experts highlight the discrepancy between the amount of time allotted to each appointment and the actual time that a patient and their family members would need.
“We sometimes need to respond to a string of emails about pharmacological therapy to alleviate a patient’s situation. However, this approach is not structured; it is based on the individual’s goodwill” (FG, B).
Last but not least, there is still a stigma associated with residential facilities for the elderly, which are considered to be a “last option”. “The fragmentary care pathways and the global taking charge of the patient and caregivers also contribute to the stereotype that considers residential structures for the elderly as a last resort” (FG, P).
The FG participants in Norway also pointed out that the current social discourse does not necessarily support prioritizing older people with severe BPSD when it comes to offering high-quality health services. This issue could be considered as institutional ageism, defined as “laws, rules, social norms, policies, and institutions that unfairly restrict opportunities and systematically disadvantage individuals because of their age” [
43].
“I think the old way of thinking about being old still exists. You are placed in an institution when you do not manage things at home. You are not worth anything anymore. You should just be kept safe, and you are done with your life” (FG, O).
“The stigma surrounding dementia and mental illness and its impact on staff need to be activelyaddressed” (FG,A).
As acknowledged by the World Health Organization (WHO), the Member States in the Global strategy, and the action plan on “aging and health and through the Decade of Healthy Ageing: 2021–2030”, ageism must be combated on a global scale [
44,
45].
3.4. Potential of the SCU-B’s Social Innovation
In accordance with the SI definitions in the literature, the SCU-B can be regarded as socially innovative insofar as it satisfies a social need that is largely unmet (or only partially met) in participating countries. Additionally, the unit provides patients and their families with strong crisis support from a skilled compassionate team that acts in accordance with the patient-centered approach. The SCU-B is also a privileged place for the training of caregivers under the expertise of healthcare professionals dealing with dementia.
Most participants concurred that the SCU-B does fulfill previously unmet needs of patients and caregivers. There is also a potential to share and expand knowledge about the disease, ways to cope with it, and ways to lessen stigma by fostering communication and exchange regarding the topic.
“SCU-Bs could play an important role in the dementia care network, as they seem to be a missing part of the puzzle. Currently, there are no similar units in Greece, so SCU-Bs could be a step towards a better quality of life for dementia patients with behavioral and psychological symptoms and their caregivers, especially if these units are easily accessible to everyone and free of charge. It is also possible to reduce the extensive use of SCU-Bs and the abuse of antipsychotic drugs for cases that can be managed non-pharmacologically” (FG, T).
The distinctive features of social innovation also include considerable dissemination among people. The definition proposed by Howaldt and Schwarz [
46] fits into this context: “an innovation can be defined as social to the extent that it is conveyed by the market or by the non-profit sector, it is socially accepted and widely spread in society or some of its sub-areas, adapts to circumstances, and is institutionalized as a new social practice”. Therefore, from this perspective, it is possible to analyze the characteristics of this new intervention method’s replicability in areas where it is not yet present and future implementation is being considered.
3.5. The SCU-B’s Replicability
The SCU-B’s replicability was discussed during the data collection process in four Italian centers (Gazzaniga, Mantova, Bergamo, and Perugia) and the German center (Mannheim). However, other centers did not address this issue in their country reports because it was not widely debated during the FGs and did not yield any summarized feedback. As a result, the experts and professionals who had no direct experience in SCU-B units stated that they were unable to answer.
“Is the SCU-B replicable, and in what way would it be useful?” was the central question used to elicit responses from experts and professionals.
The Mannheim FG revealed that there is a growing culture in Germany of dementia-friendly hospitals, with an SCU in geriatric clinics and an SCU-B mainly in psychiatric clinics. However, patients often need multidisciplinary care. Therefore, as the best possible solution, the FG suggested a special unit in a psychiatric hospital for PwD, separated from patients with no relevant cognitive impairment, with internal medicine expertise, and easy access to additional medical diagnosis and treatment if needed.
In Italian centers, participants’ discussions provided feedback on the replicability of the SCU-B system, indicating a level of replicability for each element and characteristic composing the SCU-B model.
Table 6 summarizes the perceived level of replicability (low, medium, and high) for each SCU-B element and the average level of agreement between Italian centers.
All centers agreed with the possible implementation of interdisciplinary teams. Additional internal elements (for example, periodic follow-up, informal care support group, personalized care, and psychosocial therapy) were rated with a medium-high level of replicability. Case management at home was considered easy to implement by half of the centers and low by the other half. Promoting an active local network involving different stakeholders was considered to be relevant and gauged a medium level of replicability.
In general, the SCU-B model received positive feedback from experts in the different centers, but doubts emerge about the replicability of the complete SCU-B system in other regions.
“The main reasons are the rigidity of the existing service structure that is not open to new services and units (…). In this regard, some of the participants underline how this unit requires professionals with differentiated profiles, not only for health (…) sometimes it is not easy to find them, also because of the financial restrictions of public health units” (FG, MA).
Interesting suggestions emerged from the debate in Perugia’s FG. Given the difficulties of setting up a special ward, the participants suggested modifying the two existing Alzheimer’s units according to the SCU-B model. These two units already use a person-centered approach [
41], individualized care programs with physical and neuropsychological rehabilitation, and a multidisciplinary team. The lack of resources is the main barrier to implementing the ward unit or complete system, which is deemed to have “low replicability”. Therefore, a financial commitment to putting the SCU-B into practice is essential. However, a redistribution of financial resources risks removing funds from prevention and training programs that are already primarily entrusted to private training bodies, non-governmental organizations (NGOs), or voluntary associations.