Provision of Health Services: Long-Term Care
This chapter examines the financing, organization and regulation of long-term care in OECD countries. Historically, long-term care services and supports constitute a blending of social welfare benefits and health care provision. Depending on the complexity and severity of care recipients’ needs, delivery is characterized by both specialized nursing and medical care and personal and home-help services such as assistance with meals, grooming and household chores. The delivery of long-term care is accomplished via institutional (residential) care, formal home care services, as well as through informal care provided by family members or hired care givers. In line with the preferences of older people to remain in their own homes, the past decade has seen a substantial shift in most OECD countries towards more home and community based care. This trend has regulatory and cost implications for monitoring the quality of care, which in the past has focused predominantly on institutions. Moreover, increased demand for formal services, in both residential and home care settings, due to ageing population pressures, also has implications for the long-term care workforce, with shortages anticipated over the next 20–40 years.
While funding of long-term care services comes mainly from public sources, there are very large variations between OECD countries in the resources dedicated to this sector. Eligibility for coverage also varies between countries, ranging from universal systems - based solely on need and not on income - to long-term care systems that apply means testing and safety-net principles to determine who qualifies for publicly-provided long-term care services and benefits. However, irrespective of financing model, all countries use some form of needs assessment to judge an applicant’s level of functional impairment and care needs. Financial support is provided via in-kind services or through cash benefits to recipients to purchase the services they need (with varying degrees of restrictions). Cost-sharing, in the form of user charges, play a role in all countries, to different degrees, with service users, unless they are destitute, having to meet a proportion of the cost of their care from their own private resources.
The chapter also looks at the regulatory mechanisms used across a selection of countries to monitor the quality of long-term care, particularly in residential facilities, identifying three broad quality assurance approaches. The chapter ends with a discussion of key challenges in quality monitoring and its role in enhancing user choice and stimulating improvements in providers’ performance.
- Alakeson V. International development in self-directed care. Issue Brief (Commonw Fund). 2010;78:1–11.Google Scholar
- Bettio F, Solinas G. Which European model for elderly are? Equity and cost-effectiveness in home based care in three European countries. Econ Lavoro. 2009;43(1):53–71.Google Scholar
- Carpenter I, Hirdes J. A good life in old age: monitoring and improving quality in long term care. OECD Health Policy Studies, OECD Publishing; 2013. https://doi.org/10.1787/9789264194564-en
- Duyvendak JW, Grootegoed E, Savernije MT, Tonkens E. Day 1: long-term care in Europe, the state of the art. Presentation given at does Europe care? European Conference on Long-Term Care and Diversity, Amsterdam; 2009. http://www.careconference.eu/site/sites/default/files/Part201.pdf.
- European Commission. Long-term care in the European Union. Brussels: Commission of the European Communities, DG Employment, Social Affairs and Equal Opportunities; 2008.Google Scholar
- Fernandez JL, Forder J, Trukeschitz B, Rokosová M, McDaid D. How can European States design efficient, equitable and sustainable funding systems for long-term care for older people? Copenhagen: World Health Organization and World Health Organization on behalf of the European Observatory on Health Systems and Policies; 2009.Google Scholar
- Ikegami N, Ishibashi T, Amano T. Japan’s long-term care regulations focused on structure – rationale and future prospects. In: Mor V, Leone T, Maresso A, editors. Regulating long-term care quality: an international comparison. Cambridge: Cambridge University Press; 2014.Google Scholar
- Jung H-Y, Jang S-N, Seok J-E, Kwon S. Quality monitoring of long-term care in the Republic of Korea. In: Mor V, Leone T, Maresso A, editors. Regulating long-term care quality: an international comparison. Cambridge: Cambridge University Press; 2014.Google Scholar
- Kane RA, Kane RL, Ladd RC. The heart of long-term care. New York: Oxford University Press; 1998.Google Scholar
- Katz MB. In the shadow of the Poorhouse: a social history of welfare in America. Tenth anniversary edition. New York: Basic Books; 1996.Google Scholar
- Kellogg DO. The pauper question. Atl Mon. 1883;51(307):638–652.Google Scholar
- Larson Allen L. Mapping the future: estimating Florida aging service needs 2008–2030. Tallahassie: Agency for Health Care Administration; 2008.Google Scholar
- Mor V, Leone T, Maresso A, editors. Regulating long-term care quality: an international comparison. Cambridge: Cambridge University Press; 2014.Google Scholar
- Mot E, Willemé P, editors. Assessing needs of care in European nations, ENEPRI policy brief no. 14, vol. 2012. Centre for European Policy Studies: Brussels; 2012.Google Scholar
- OECD. Ensuring quality long-term care for older people. Paris: OECD Publishing; 2010. Policy Brief.Google Scholar
- OECD. Recipients of long-term care. In: Health at a glance 2013: OECD indicators. Paris: OECD Publishing; 2013a. https://doi.org/10.1787/health_glance-2013-75-en
- OECD. OECD health data: long-term care resources and utilisation. Paris: OECD; 2013b.Google Scholar
- OECD/European Commission. A good life in old age? Monitoring and improving quality in long-term care, OECD health policy studies. Paris: OECD Publishing; 2013. https://doi.org/10.1787/9789264194564-en
- Rothgang H. Long-term care for older people in Germany. In: Comas-Herrera A, Wittenberg R, editors. European study of long-term care expenditure. Investigating the sensitivity of projections of future long-term care expenditure in Germany, Spain, Italy and the United Kingdom to changes in assumptions about demography, dependency, informal care, formal care and unit costs. Report to the European Commission, Employment and Social Affairs DG: 24–42. 2003. http://ec.europa.eu/employment_social/soc-prot/healthcare/ltc_study_en.pdf
- RWJF – Robert Wood Johnson Foundation. Executive summary: cash and counseling program. Princeton: Robert Wood Johnson Foundation; 2013. Available at: http://www.rwjf.org/content/dam/farm/reports/program_results_reports/2013/rwjf406468/subassets/rwjf406468_1
- Simmonazzi A. Home care and cash transfers. Effects on the elderly care-female employment trade-off. Cost Conference. Rome; 2009.Google Scholar
- Sloane PD, Zimmerman S, Gruber-Baldini AL, Hebel JR, Magaziner J, Konrad TR. Health and functional outcomes and health care utilization of persons with dementia in residential care and assisted living facilities: comparison with nursing homes. Gerontologist. 2005;45 Spec No 1(1):124–32.CrossRefGoogle Scholar
- Tarricone R, Touros AD, editors. The solid facts: home care in Europe. Copenhagen: World Health Organization Regional Office for Europe and Universita' Commerciale Luigi Bocconi; 2008.Google Scholar
- Ungerson C, Yeandle S. Cash for care in developed welfare states. Houndmills: Palgrave Macmillan; 2007.Google Scholar
- van Hooren F. Bringing policies back in: How social and migration policies affect the employment of immigrants in domestic care for the elderly in the EU-15. Paper presented at Transforming elderly care at local, national and transnational level, International Conference at the Danish National Centre for Social Research (SFI), Copenhagen; 2008.Google Scholar
- Werner RM, Konetzka RT. What drives nursing home quality improvement under public reporting? An examination of post-acute care. Chicago: AcademyHealth; 2009.Google Scholar
- Wirrmann Gadsby E. Personal budgets and health: a review of the evidence. London: PruComm. Policy Research Unit in Commissioning and the Health Care System, Department of Health; 2013.Google Scholar