COVID-19 and the Long-Term Care system in Denmark

Structural characteristics of the LTC system, impact of the pandemic, measures adopted and new reforms

This country profile contains a section of the LTCcovid International Living Report on COVID-19 Long-Term Care that brings together information on the experience of the long-term care sector (focussing on people who use and provide care) during the COVID-19 pandemic in Denmark, as well as description of the system and of new reforms. The LTCcovid Living report is updated and expanded over time, as experts on long-term care add new contributions. This profile also provides links to research projects on COVID-19 and long-term care, to key reports, and lists key experts on the impacts of COVID-19 on the long-term care sector in Denmark.

Experts on COVID-19 and long-term care in Denmark that have contributed to this report:

Margrieta Langins

Living report: COVID-19 and the Long-Term Care system in Denmark

PART 1 – Long-Term Care System characteristics and preparedness
  • 1.00. Brief overview of the Long-Term Care system
    The Long-Term Care (LTC) system in Denmark is a universal and primarily public system. Access to LTC services is at no cost for home-based care, or with a means-tested co-payment. The LTC system has strong public and political support. It is a highly decentralized system, organised, financed and provided at the municipal level. There is a strong emphasis on community-based care, re-ablement and professionalisation of care staff (WHO, 2019). The main law regulating social service provision and, implicitly, LTC provision is the Social Services Act, which passed in 1998. The Social Services Act emphasizes the users’ right to influence social service provision and enshrines the highly decentralized nature of the system, putting municipalities in a key position to shape long-term care. In recent years there has been a decrease in the number of people who receive home care services, which resulted in more burden placed on unpaid carers (WHO, 2019; Rostgaard, 2020).
    References:
    Rostgaard T. (2020), The COVID-19 Long-Term Care situation in Denmark. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 25 May 2020. WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019.
  • 1.01. Population size and ageing context

    In 2021 Denmark had a population of just under 6 million; 19.4% of the population were over 65,  with 4.1% over 80 and 1.9% over 85 (source: https://www.dst.dk/en/Statistik). These numbers are expected to rise significantly, and according to calculations from Statistics Denmark, by 2053, 10% of the population will be over 80 (source: https://www.sst.dk/da/viden/aeldre).

  • 1.02. Long-Term Care system governance

    Although national legislation sets a broad framework for service provision, municipalities maintain responsibilities for long-term care policies. These include establishing eligibility and entitlement criteria and the level and content of service delivery, regulating services’ delivery and organizing the public provision of services.

    In 2007 the number of municipalities was reduced from 275 to 98, creating larger administrative units. This change was accompanied by municipalities also taking charge of the rehabilitation of people who are being discharged from hospital, with municipalities taking a stronger role in prevention and health-oriented interventions (Rostgaard, 2020).

    In 2015, the responsibility for regulating services and support for older people was transferred from the Ministry of Social Affairs and the Interior to the Ministry of Health. This transfer of responsibilities for regulation and oversight of care for older people was a clear move towards integrating central and strategic decision making for health and social services (WHO, 2019).

    References:

    Rostgaard T. (2020), The COVID-19 Long-Term Care situation in Denmark. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 25 May 2020.

    WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

  • 1.03. Long-term care financing arrangements and coverage
    Public sending on Long-Term Care as % of Gross Domestic Product (GDP):

    In 2016 Denmark spent 2.5% of GDP on publicly funded LTC which was almost twice of the EU average (WHO, 2019).

    Approach to public funding for LTC and eligibility:

    Municipalities are responsible for allocating resources; they obtain funding from the national government, local taxes and equalization money from other municipalities. There are no co-payments for home-based care services  such as cleaning and personal care, although individuals who use private providers can buy additional services. Eligibility for LTC is based purely on needs assessment carried out by the municipalities, principle of free and equal access applies, regardless of income, wealth, age or household situation. There are no thresholds or minimum dependence required for in-kind or cash benefits. Needs assessment is multidimensional and captures a wide range of aspects related to a person’s situation and well-being (WHO, 2019).

    It has been estimated that 16% of the total population provided unpaid care at least once a week in 2016 (WHO, 2019). The availability, or not, of informal care is not considered as a criterion for assessing needs and entitlements. Unpaid carers experience less burden and are less likely to report difficulties in reconciling work and caregiving compared with the rest of the EU (Rodrigues at al., 2013).

    References:

    Rodrigues, R., Schulmann, K., Schmidt, A., Kalavrezou, N. & Matsaganis, M. (2013). The indirect costs of long-term care. European Centre for Social Welfare Policy: Research Note.

    WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

  • 1.04. Approach to care provision, including sector of ownership

    Free choice of provider was introduced in 2003, which banned public monopolies in service provision.  Municipal councils are required by law to ensure private providers exist in each municipality. In 2017, Denmark had 320 private for-profit home care agencies (WHO, 2019).

    Municipalities usually use competition with fixed prices for tendering home care. Competition takes place on quality by, for example, ensuring continuity of workforce. Municipalities are obliged to contract with any private-for-profit provider that meets the requirements on quality standards and the price. Public and for-profit providers co-exist and the latter are not permitted to refuse to provide care for any individual. Legislation allows private home care providers to compete on price in the privately-paid for sector and, although municipalities are no longer obliged to contract with all bidders who meet minimum tender specifications, they must contract with at least two such providers (Marczak and Wistow, 2015).

    References:

    Marczak, J., Wistow, G. (2015). ‘Commissioning long-term care services’, in Gori C, Fernandez JL, Wittenberg R (eds) Long-Term Care Reforms in OECD Countries: Successes and Failures, Policy Press, Bristol. Accessed at Commissioning long-term care services

    WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

  • 1.05. Quality and regulation in Long-term care

    Quality standards for LTC apply to public and private providers. The municipalities are responsible for service and quality assurance, however they need to comply with standards set by national framework legislation.  The municipalities must ensure full transparency and clear separation between their function as providers and as the authority supervising quality. The municipal quality standards describe in detail the services available locally and are intended to be objective and transparent to allow individuals to evaluate the performance of the provider themselves. There are 23 impact and background indicators For general monitoring of providers, most indicators are monitored through administrative data and through user surveys (WHO, 2019).

    References:

    WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

  • 1.06. Care coordination

    Coherence and coordination in service delivery is a stated goal of the Danish Health Act of 2005 and one of the key drivers behind the major reform of local government of 2007. In reducing the number of municipalities and administrative regions, the reform effectively represented a large step towards centralizing health and social services and has actively pursued the coordination between the administrative regions and municipalities in providing care. The Danish Health Authority has also established chronic disease management strategies that bring together efforts by the administrative regions and the municipalities under a single model.

    There is a good level of integration of care across providers, people who need long-term care following hospital discharge, the hospital discharge management team  works closely with the general practitioner and local home services. The administrative regions are responsible for coordinating after-hours care. After-hours clinics tend to be associated with hospital emergency department  (WHO, 2019).

    References:

    WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

  • 1.07. Information and monitoring systems 

    The sundhed.dk portal was launched in 2003 as a partnership between the Ministry of Health, five administrative regions and municipalities. The platform gathers information from 85 sources to enable individuals to access their medical records such as laboratory results, prescription information and scheduled visits, individuals can also enter or complement data on patient-reported outcomes. Hospitals share various information including discharge summaries and outpatient notes, and medical results with other hospitals, general practitioners and other specialists (WHO, 2019).

    References:

    WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

     

  • 1.08. Care home infrastructure

    In Denmark’s 98 municipalities, there are around 930 nursing homes with over 40,000 residents  (source: https://covid19.ssi.dk/overvagningsdata/ugentlige-opgorelser-med-overvaagningsdata).

    The number of people in residential facilities and receiving home care has declined in both absolute and relative numbers in this decade.  In 2018, in absolute numbers there were 65,573 beneficiaries of long-term residential care services aged 65 years or older which equals to 5.8% of the population (source: https://www.dst.dk/en). In particular the proportion of people age 90 and over living in residential care facilities has fallen drastically, as 41.7 percent  lived in LTC facilities and senior housing in 2010 while the number fell to 33.1 percent in 2019 (source: https://www.dst.dk/da/Statistik/nyt/NytHtml?cid=30746#)

    In 1984 it was made illegal to build any multiple bed residential services, therefore currently all nursing homes are private rooms with personal space, kitchenette and living space. Denmark is the only country in the EU in which the construction of traditional old-age and nursing institutions has been legally banned. There are five types of residential care facilities: nursing homes; sheltered housing; housing for older people; general homes for older people;  private care accommodation. The choice of specific type of accommodation depends on individuals’ preferences and needs, those choosing to live with their spouse or partner must be offered a facility suitable for two people (WHO, 2019).

    References:

    WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

  • 1.09. Community-based care infrastructure

    The number of people receiving home care has declined over the last decade. Municipalities provide social services for older people and overall, older people can access a wide range of social services that enable them to remain in their homes even if they are chronically or terminally ill. These services include day care services, extensive home help and nursing care.

    In January 2015, a new legislation came mandated all municipalities to consider first whether a person applying for home support could instead receive reablement services. Reablement is often offered in the form of a 12-week exercise training course, provided by multidisciplinary teams with an involvement of physiotherapists, in which the older person together with the care worker identifies and works towards achieving one or more goals such as, showering alone or cleaning home. Individuals receive home support only after the reablement failed to help. Municipalities offer services in the individual’s home or in rehabilitation centres. Rehabilitation services are included in the mandatory healthcare agreements between the administrative regions and the municipalities, and they ensure cooperation between the various service providers.

    Individuals discharged from hospitals can receive follow-up home visits from general practitioners or nurses, which takes place a week after discharge and may be repeated at three and eight weeks after discharge if additional support is needed (WHO, 2019).

    References: 

    WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at:  https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019

  • 1.10. Workforce conditions: pay, employment conditions, qualification levels, shortages

    Social and health helpers and assistants represent most of the long-term care workforce. Physiotherapists and occupational therapists have increased in numbers during the past decade, particularly after the reablement programme was implemented. While the number of personnel has stagnated or sometimes declined in most residential settings, while there has been an increase by almost 10% of staff in employed in home help. Moreover, between 2005-2015 the number of staff working part time increased. There has also been a greater professionalization of the workforce: in 2016, 46% of the staff in residential care facilities had relevant qualifications that required training of more than two years as compared to 33% in 2005. As care needs of residents have increased, nursing home staff also experienced an increase in health, and nursing-related tasks. LTC workforce also reported higher work intensity (WHO, 2019).

    The Danish Health Authority provides accreditation and licensing services for practitioners, including physicians, nurses, social and health care assistants, physiotherapists (Olejaz, 2012). Social and health helpers can become accredited after 1.5 years of training, including a basic course of 20 weeks and a period of alternating practical and theoretical courses. Social and health helpers can perform tasks related to support with personal care and hygiene as well as household chores. A further module of 32 weeks of theoretical training and 48 weeks of practice leads to the next level as social and health assistants. These can carry out nursing functions, including planning of activities. Social and health assistants may choose the traditional nursing education that encompasses 3.5 years for a university bachelor’s degree (Raholm et al. 2010). Modular training for personal carers is under development  for those seeking to access managerial roles or for nurse aides wanting to become nurses (OECD, 2020).

    References:

    OECD (2020) Who Cares? Attracting and Retaining Care Workers for the Elderly

    Olejaz, M.,  Nielsen, A., Rudkjøbing, A., Okkels Birk, H., Krasnik, A., Hernández-Quevedo, C. (2012) Denmark: Health System Review. WHO European Observatory

    Raholm, M., Birte Larsen HedegaardAnna LofmarkAshild Slettebo (2010).  Nursing education in Denmark, Finland, Norway and Sweden – from Bachelor’s degree to PhDJournal of Advanced Nursing

    WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

  • 1.11. Role of unpaid carers and policies to support them

    It has been estimated that 16% of the total population provided unpaid care at least once a week in 2016. Family members may apply to the municipality to be formally recognised as informal carers. If they are found to be eligible, the carer is employed by the municipality, up to six months with a pre-specified salary based on the national yearly income. Additional services for caregivers include training and education, often focused on improving knowledge and ability to provide support and on improving coping skills (WHO, 2019).

    References: 

    WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

  • 1.12. Personalisation, user voice, choice and satisfaction

    Municipalities partner with voluntary organizations to roll out community programmes to engage and reach out to older people (Olejaz et al. 2012).

    Non-profit actors play mainly a role in advocacy rather than in providing services, although some provide nursing home care (Danish Deaconess Foundation and OK Foundation) while others organize self-support and peer-support activities (DaneAge Association and Danish Alzheimer Association). The DaneAge Association, a voluntary organisation with more than 825 000 members, has the most prominent role among civil society organizations and is involved in advocating the rights and well-being of older people, whilst many volunteers are themselves 65 years or older. The Elders Help Elders network, a partnership among six organizations, is one of the most visible initiatives organizing volunteers with a focus on visiting services, mobility support, shopping, practical assistance in the home, sharing meals and exercise. Non-profit organizations also play an important role in organizing volunteers in nursing homes, hospices and hospitals (WHO, 2019).

    Individuals can complain to their municipality if they are not satisfied with the quality of local LTC offer and the services they receive. When a complaint is made,  the municipality must review the decision and if the decision is not changed, their complaint must be sent by municipality to a National Board of Complaints (European Commission, 2021).

    References:

    European Commission (2021)  2021 Long-Term Care Report Trends, challenges and opportunities in an ageing society. Luxembourg: Publications Office of the European Union,

    Olejaz, M.,  Nielsen, A., Rudkjøbing, A., Okkels Birk, H., Krasnik, A., Hernández-Quevedo, C. (2012) Denmark: Health System Review. WHO European Observatory

    WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

     

  • 1.13. Equity and Long-Term Care

    Denmark is one of the European countries with the lowest income inequality and high coverage of social and health services. The rate of poverty or social exclusion for older people  was 8.7% in 2015, about half the EU average (WHO, 2019).

    References:

    WHO (2019), ‘Denmark: Country case study on the integrated delivery of long-term care’. Accessed at: https://www.euro.who.int/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

  • 1.14. Pandemic preparedness of the Long-term care sector

    The health sector was prioritized during the first wave of the pandemic, and therefore there were challenges early on with preventing infections and securing resources to protect care homes. Conversely, adequate measures in LTC facilities have been implemented later on (Rostgaard, 2020).

    References: 

    Rostgaard T. (2020), The COVID-19 Long-Term Care situation in Denmark. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 25 May 2020.

PART 2 – Impacts of the COVID-19 pandemic on people who use and provide Long Term Care
  • 2.01. Impact of the COVID-19 pandemic on the country (total population)

    As of February 8, 2021, there have been 202,051 confirmed cases of COVID-19 in Denmark, and 2,216 deaths, according to the Danish Health Authority, corresponding to 38.5 attributed deaths per 100,000 population.

  • 2.02. Deaths attributed to COVID-19 among people using long-term care

    The data on cases and deaths within nursing homes are published weekly every Tuesday by the Statans Serum Insititut under the Danish Department of Health. Deaths among confirmed residents are defined as deaths among residents who died within 30 days of a positive covid-19 PCR test (from the data first tested).

    As of April 19, 2022, there have been 6,019 deaths from COVID-19 in the whole population. There have been 2,204 deaths of care home residents. Therefore, the share of confirmed deaths among nursing home residents was 40% (Source: https://covid19.ssi.dk/overvagningsdata/ugentlige-opgorelser-med-overvaagningsdata).

    There were just over 40,000 nursing home residents in Denmark, which suggests that 4.69% of this population have died from confirmed COVID-19.

     

  • 2.05. Impacts of the pandemic on the health and wellbeing of people who use Long-Term Care

    report on mental health from the nursing home sector indicated that the quality of life actually increased for the majority of residents. Nursing home managers reported that residents slept better, medication was reduced, there were fewer conflicts with residents suffering from dementia, more time for individual residents and the sickness rates among staff was lower. This was attributed to fewer common for all residents, instead members of staff make activities in smaller groups of residents or engage with them one by one. Staff reported a more relaxed atmosphere, one reason being that they did not have to engage with family members who at times are considered overly critical (Rostgaard, 2020).

    However, there were also concerns that the Danish government’s response to the pandemic (e.g. care home visiting ban) was inflexible and not tailored to individuals circumstances (rather, it was based on ‘one size fits all’ rules). Combined with the late ease of restrictions, it had a negative long-term impact on older people’s mental and physical health and concerns were raised that the government should have done more to respect basic individuals’ freedoms (Source: https://www.djoef.dk/presse).

    Reference:

    Rostgaard T (2020) The COVID-19 Long-Term Care situation in Denmark. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 25 May 2020.

  • 2.09. Impact of the pandemic on workforce shortages in the Long-Term Care sector

    According to The Federation of European Social Employers (February 2022 report), Denmark has reported an increase of between 1 – 10% in staff shortages since 2021. The sub-sector most critically affected by staff shortages across the countries surveyed for this report were services for older persons. The job position most affected was nursing, but care assistants and homecare / social care workers also face real shortages. The most common reasons given for staff leaving the social care sector for another include low wages, and mental and physical exhaustion relating to the pandemic.

PART 3 – Measures adopted to minimise the impact of the COVID-19 pandemic on people who use and provide Long-Term Care

PART 4 – Reforms to strengthen Long-Term Care systems and to improve preparedness for future pandemics and other emergencies

Printable version of this country profile:

https://ltccovid.org/country/denmark/

To cite this report:

Langins, M. COVID-19 and the Long-Term Care system in Denmark. In: Comas-Herrera A., Marczak J., Byrd W., Lorenz-Dant K., Pharoah D. (editors) LTCcovid International Living report on COVID-19 and Long-Term Care. LTCcovid, Care Policy and Evaluation Centre, London School of Economics and Political Science. https://doi.org/10.21953/lse.mlre15e0u6s6


Ongoing research projects on COVID-19 and Long-Term Care in Denmark:

https://ltccovid.org/completed-or-ongoing-research-projects-on-covid-19-and-long-term-care/?_country=denmark

Previous LTCcovid report on COVID-19 and Long-Term Care in Denmark (May 2020)

https://ltccovid.org/wp-content/uploads/2020/05/The-COVID-19-Long-Term-Care-situation-in-Denmark-29-May-2020.pdf

Acknowledgement and disclaimer:

This report has built on previous LTCcovid country reports and is supported by the Social Care COVID-19 Resilience and Recovery project, which is funded by the National Institute for Health Research (NIHR) Policy Research Programme (NIHR202333) and by the International Long-Term Care Policy Network and the Care Policy and Evaluation Centre at the London School of Economics and Political Science. The views expressed in this publication are those of the author(s) and not necessarily those of the funders.

Copyright: LTCCovid and Care Policy and Evaluation Centre, LSE