**1. Introduction**

The demand for home-based care rises with an ageing population, with elderly people suffering from multiple comorbidities that require long-term management at home [1]. Moreover, due to the advances in modern medicine, efficient medication and high-technology interventions, many children with chronic illnesses reach adulthood, requiring long-term care at home coordinated by family doctors and community nurses. The number of people aged 60 and older is expected to grow from 962 million in 2017 to 21 billion in 2050 in Europe [2].

The proportion of people aged 65years and older is expected to grow to an average of 28% in the Organisation for Economic Co-operation and Development (OECD) countries in 2050, while in some countries (e.g. Japan, Spain, Portugal, Greece and Korea), a share of 40% is forecasted. China's proportion of older people will triple between 2015 and 2050, and also in the USA, Mexico and Israel, these

growing trends will be influenced by higher rates of fertility and migration. Higher age is associated with higher morbidity, which in turn affects care dependency [3, 4]. Prognosis regarding the number of people in need of care shows an increase of 115% in the European Union between 2007 and 2060, and the number of people in need of care in the USA is expected to double from 13 million in 2000 to 27 million in 2050 [5]. Experts anticipate that older adults will comprise 13% of the total population one in eight people will be 65 or older by 2030 [6].

The healthcare system is changeable and unsteady; the period of hospital admission is limited by the high costs, and the trend is to continue the long-term management by the formal and informal home care providers. The chronically ill patients feel rushed from the hospital and worried because they do not have adequate care in the community, especially in rural areas. Patients are discharged with drainage tubes, urinary wells, nasogastric tubes, open wounds and insufficient pain control, and family members are unprepared for the needed care in these complex contexts. In addition, they face limited money and consequences related to their work and childcare. To meet the current challenges in the home care of the frail elderly and children with disabilities, it is a requirement to strengthen the role of informal caregivers [7].

#### **1.1 Family as a recipient of home care**

The family as a recipient of home care has a lot of worries with possible unrealistic expectations. Sometimes, patient's family members are upset, unresponsive or hostile to the home care team. The family is the hidden patient, sometimes acting as a dysfunctional, unsupportive family, with a high perception of the burden of care. Primary care professionals should identify these families that require evaluation and specific interventions to become effective while maintaining their full health status and functionality. Family physicians and community nurses are called upon to build trust, making it clear to the family that they are available to them, explaining the plans of care after discharge, resolving any miscommunication and diminishing concerns about caring for their loved ones at home. These are the persons who they trust, with whom they had the continuity and the relationship. Primary care professionals have an ongoing history with patients, building an agreed relationship over time even in difficult times of an advanced chronic disease or end-of-life care. They need to verify the recipients and his/her family feelings, let them know that they will be listened to and their concerns understood and try to identify an informal home caregiver to work with.

#### **1.2 Family as provider of informal home care**

Family caregivers as informal home care providers have an essential role in ensuring the care of the frail recipients at home [7]. Informal caregivers are defined as individuals who are actively and directly involved in the recipient's home care and who repeatedly support and assist with care, without being paid. They provide ongoing assistance with activities of daily living (e.g. toileting, feeding, bathing, walking, clothing) or instrumental activities of daily living (e.g. meal preparation, housecleaning and managing finances), for individuals with a chronic illness or disability [8, 9].

The primary caregivers, most often the family members, are usually people who are not trained in the process of care and are unprepared for facing difficult situations, making the negative impact stronger in the family evolution. The majority of the general population wishes to stay at home in old age and would prefer to receive informal care from their adult children or formal care from home assistance services [10]. However, the decision of family members to take care of a dependent person, and thus fulfilling his/her wish to age in a domestic environment, is influenced by the

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*The Family as Recipient and Provider of Home Care: A Primary Care Perspective*

degree of family relationship and the willingness of family members to be involved in home care [11]. Although, traditionally, in Romania, the primary caregiver was a family member, in recent decades due to migration of active people working abroad, their elderly parents are cared for by friends or neighbours at home. In addition, there is great need to develop home assistance services and community care units for longterm care recipients with multi-morbid chronic diseases. The caregiving experience varies by the diversity of caregiving activities, time commitments and distance. The proximal caregiver provides assistance with personal care, while long-distance caregivers are involved in offering emotional and social support and financial assistance. The family as provider of informal home care is recognized and valued by the primary healthcare professionals that acknowledge working with family caregivers is the best way to ensure quality outcomes for their recipients. Most physicians (88%) acknowledge seeing better outcomes and higher formal caregiver satisfaction (73%) when they collaborate with families [12]. However, doctors and nurses found that sometimes establishing communication with family caregivers can be challenging. About half of the formal providers (54%) say a recipient having multiple caregivers was a barrier, 44% are not aware who the caregiver is, 44% say there is fluctuation in caregiver involvement, and 39% felt interacting with caregivers was too time-consuming. Among those who felt communication was difficult (20%), most said the inability to reach out to the caregiver was the primary issue [12]. Formal home care providers and informal family caregivers focused on drug administration and meal service, organizing transportation for follow-up visits, discussing the recipient's emotional issues, managing the family caregiver's burden

Delegated interventions provided by family caregivers and coordinated by primary care health professionals contribute to a more proactive, personalized and

**2. International validated tools for the family assessment in primary care**

Home care is the health or social service provided by formal and informal caregivers for the recipient who cannot go to the general practitioner (GP) surgery or to the other levels of health services. Eurostat data from 2016 show that 20% of households needed to use professional home care services. The rate of use of home care services is very different: 88% in Luxembourg, 58% in the Czech Republic and only 6% in Romania [14]. Evaluation of the family as recipient and provider of home care comprises four domains: demographic facts, psycho-emotional domain,

Information about the family's structure, number of members, education, employment status, living place, family network and members with chronic illness or with disabilities are obtained using a self-administrated questionnaire or an interview. Genogram is a brief tool that should be used in the home care consultation, a system helping to identify the vulnerable recipients in the family. This graphic representation includes all family members, alive and deceased, unrelated persons living in the same place, their relationships, hereditary or recurrent illness, drug addiction and issues related to the elderly or child neglect and abuse [15].

The Resident Assessment for Home Care (RAI-HC) was developed following a high demand for a standardized evaluation of the patient's needs through a comprehensive home care system. This instrument addresses frail elderly and patients with chronic

integrated care for recipients with long-term comorbidities [13].

environment aspects and family burden as caregiver.

**2.1 Demographic facts**

*DOI: http://dx.doi.org/10.5772/intechopen.91926*

and encouraging more collaboration.

#### *The Family as Recipient and Provider of Home Care: A Primary Care Perspective DOI: http://dx.doi.org/10.5772/intechopen.91926*

degree of family relationship and the willingness of family members to be involved in home care [11]. Although, traditionally, in Romania, the primary caregiver was a family member, in recent decades due to migration of active people working abroad, their elderly parents are cared for by friends or neighbours at home. In addition, there is great need to develop home assistance services and community care units for longterm care recipients with multi-morbid chronic diseases. The caregiving experience varies by the diversity of caregiving activities, time commitments and distance. The proximal caregiver provides assistance with personal care, while long-distance caregivers are involved in offering emotional and social support and financial assistance.

The family as provider of informal home care is recognized and valued by the primary healthcare professionals that acknowledge working with family caregivers is the best way to ensure quality outcomes for their recipients. Most physicians (88%) acknowledge seeing better outcomes and higher formal caregiver satisfaction (73%) when they collaborate with families [12]. However, doctors and nurses found that sometimes establishing communication with family caregivers can be challenging. About half of the formal providers (54%) say a recipient having multiple caregivers was a barrier, 44% are not aware who the caregiver is, 44% say there is fluctuation in caregiver involvement, and 39% felt interacting with caregivers was too time-consuming. Among those who felt communication was difficult (20%), most said the inability to reach out to the caregiver was the primary issue [12]. Formal home care providers and informal family caregivers focused on drug administration and meal service, organizing transportation for follow-up visits, discussing the recipient's emotional issues, managing the family caregiver's burden and encouraging more collaboration.

Delegated interventions provided by family caregivers and coordinated by primary care health professionals contribute to a more proactive, personalized and integrated care for recipients with long-term comorbidities [13].
