This is the institution that brought covid to Geneva. The remark provokes in its director, Marie Da Roxa, a forced laugh. But history will remember that it was an employee of the Home Support Institution (Imad) who, on his return from Italy, was the first official patient of SARS-Cov-2 in the canton. “I will remember that evening of February 26 for the rest of my life,” said the director. I was having dinner with friends, it was 9.45 p.m. when the cantonal doctor called me. ” The news he had to tell her will have a lasting impact on the life of the canton. Therefore, it will change everything in Imad as well, this sister of the University Hospitals (HUG), whose mission is to avoid entry into nursing homes or hospitalization for as long as possible, in the age of demographic aging.
We wanted to understand how the Imad takes the shock. In the car with Noémi Fauconnet, a lively meal delivery woman among the institution’s 2,114 employees.
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“Growing old is boring!” This 90-year-old in a bathrobe sets the tone for this tour of Grand-Saconnex. Affable, a little flirty, he waits for the delivery woman every day of the week, at a fixed time. This Tuesday in December, it will be sautéed beef with oyster mushrooms, beet salad. “The food is good, but every day it’s a bit boring,” concedes the customer. It must be said that the cooks at the HUG, where the dishes come from, prepare several thousand a day, taking into account more than 20 diets.
Villas zone and town planning inconsistencies
The laces of the villas zone and urban inconsistencies punctuate the timed passage from one client to another: seven minutes per contact, travel included. Our delivery girl grew up in the town. This profession, which she has been exercising for eight years, is a professional retraining. Human contact, the feeling of being useful, she likes everything. A retired colleague is part of his tour. In her day, she says, having coffee with clients was the rule.
The subsidized institution has started to manage which is intended to be rigorous. Our presence has reduced the size of the tour, which can go up to over 30 addresses. Spring containment has pushed the figure to 55. Imad provided 1,700 meals a day before the pandemic, 2,700 at the height of the crisis compared to 2,300 today. In the spring, reinforcements came from everywhere: the Red Cross, the civil service, Imad office workers. This is the “great pride” of Marie Da Roxa: “Our non-healthcare employees have mobilized to help delivery people. The pandemic has shown that we are all working together. ” No delivery man was infected in the first wave, that’s what delights Noémi Fauconnet, even if the covid has changed the job, she admits, cutting back on the social aspect.
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One delivery man, who has left the institution, speaks of the peak of the summer as a period of “heavy pressure” which made the profession “mechanical”. “There is violence in responding that you don’t have time to someone seeking contact,” he said.
Friday is a complicated deadline. HUG patients are driven home and this is the day to deliver double rations, for the weekend. The trunk of the electric car chosen by the institution – reduction of polluting emissions obliges it – hardly contains the meals to be delivered that day. It is these signs, some argue, that we see that people on the ground are not really being listened to. “We have to be allowed to make mistakes,” replies Marie Da Roxa. The real problem would be keeping something wrong. “
The director defends the logic of “focus groups”: bringing out solutions by listening to the grassroots. It launched Cap 139, a strategy based on this principle. The V2 schedule, introduced in 2019, is one of its achievements. It’s an electronic version of the Daily Organization. The day is defined in sequences. Any modification must be justified to the administrative pool to which each of the 50 multidisciplinary teams is attached. This link, Aurélie Perron does not see it as a constraint. We followed this nurse who has nine years of experience during her tour in Meyrin.
Care immerses relationships with patients in a dimension other than that experienced with meals. You have to be able to fill a weekly medication diary while listening to the requests of this patient who fell in the street the previous week. The care can be heavy, as in this couple who spent Christmas 2019 in hospital and who are delighted to be at home for New Year’s Eve 2020. “If we can,” said the lady in a whisper. “Aurélie saved my life,” slips her husband in a soft voice, confidently. Several weeks ago, while nursing his wife, he went into cardiac arrest. The nurse’s presence was providential. While covid has made it difficult for the nurse, protective measures slowing down work, she believes it has not altered the bond with patients.
For others, this timing is a thing of the past. This field worker, twenty-five years of experience, seems to live in fear of “the time gap”, these delays that must be justified. “This system is a permanent stress, says the one we encountered via the SSP union. Everything that is next to the planned and timed medical act is a plus that I must try to manage on my tour: complicated communication with a client who is hearing impaired or with cognitive disorders, preparing a weekly schedule of 10 drugs in an environment where the hygienic conditions mean that we must first clean the work place, arriving at customers’ premises that must first be encouraged to get out of bed to help them wash. These medical acts are timed in a standard way in computer tools that are supposed to be at the service of the client. The caregiver must adapt to these tools, which have become more important than the patient and which take us outside of our professional ethics. This stress increases the risk of missing a clinical observation. We are moving away from the main thing, which is to take good care of customers. The lack of resources worsens this situation. ”
The union denounces, him, a management of control which drowns the personnel under the directives. “With 1.5 million visits per year, the pace is tight all the time, regrets Sabine Furrer, union secretary. Absorbing the surplus is proving impossible. ”
Geneva, victim of its pioneering role
“I do not dispute the feelings of the field teams, answers Marie Da Roxa. Planning V2 is popular with some, less with others. It makes it possible to have effective travel management whereas previously they were taken into account theoretically. Documenting activities also allows us to justify positions. However, the timing to which the teams are subject is not due to management, but to the LAMal, which introduced this principle in 2011. Coordination times between professionals, for example, are not recognized. Ditto for travel times. They are therefore financed by the canton. We are fighting in Bern to correct these flaws. Geneva is a victim of its pioneering role in the development of home care. However, if the canton has the lowest rate of institutionalization in EMS, it is not due to chance. “
Another reform: experienced nurses join the coordination teams. Some believe that hands and skills are needed in the field, not in the office. “A nurse who knows the field will be all the more receptive to the arguments of those who are there, when it comes to explaining a time gap”, replies the director, who affirms that each of these movements is replaced by link with the team’s workload. “By 2016,” she said, “our organization’s efforts to optimize and optimize had reached their limits. We had to transform. ” Travel time, computerization: everything must contribute to making the 50 teams autonomous in the management of their tours, “in an inter-professional and intra-community logic”.
A leap since 2015
The number of Imad benefits has jumped 10% in five years. If patients meet the criteria of the Federal Law on Health Insurance, the institution has an obligation to accept them. In 2011, a hip replacement operation required two weeks of hospitalization at the HUG, compared to three days today, as much extra work for the institution. Subject to this double constraint, the Imad found support among the Genevans.
On September 27, they enshrined in the constitution automatic deficit coverage by the state. The result known, the director sent two SMS. One went to Mauro Poggia, state health adviser who is said to have an ear. The other was for Guy-Olivier Segond, who had the political intuition that led to the creation of the Imad. “This intuition is still valid,” assures Marie Da Roxa. Hospitals are moving towards ever more acute care. We are doing work to strengthen home care. We cultivate the genius of proximity by making the teams autonomous, in charge of the management committee to find solutions that serve everyone. For example, the training courses we offer are a lever that would not be accessible without a minimum of centralization. ” In the event of a third wave, “a probability that borders on certainty”, according to the director, this vital tension between autonomy and centralization could experience new peaks in this institution which works 24 hours a day, 7 days a week.