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
  • 1.01. Population size and ageing context
    Denmark has a population of just under 6 million (5 840 045 in 2021). In 2021, 19.4% of the population were over 65 (1, 134, 564) with 4.1% over 80 (240, 398) and 1.9% (110, 396) 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. Brief description of the Long-Term Care system

    The Long-Term Care (LTC) system in Denmark can characterised as 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.

    The main law regulating social service provision and, implicitly, long-term care 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, and these are increasingly focusing on personal care. This has resulted in families needing to take on more. Recent reforms have also included the introduction of for-profit providers.

    Sources:

    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.

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

     

  • 1.03. Long-term care financing arrangements and coverage

    Public sending on Long-Term Care as % of Gross Domestic Product (GDP):

    Denmark spent 2.5% of GDP on publicly funded LTC in 2016, almost twice the EU average (source: https://ec.europa.eu/info/sites/info/files/economy-finance/ip079_en.pdf).

    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. No co-payments are applied for using long-term home-based care services (cleaning and personal care), although users who choose private providers can purchase additional optional services. Access is based on the principle of free and equal access, regardless of income, wealth, age or household situation. Eligibility for long-term care is based entirely on needs assessment carried out by the municipalities. There are no thresholds or minimum dependence required for in-kind or cash benefits. Needs assessment for long-term care is multidimensional in nature and generally captures a wide range of aspects related to a person’s situation and well-being.  (source: 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).

    It has been estimated that 16% of the total population provides unpaid care for a relative, neighbour or friend at least once a week (source: 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). The availability, or not, of informal care is not considered as a criterion for assessing needs and entitlements. Unpaid caregivers experience less burden and are less likely to report difficulties in reconciling work and caregiving compared with the rest of the European Union countries (source: https://www.euro.centre.org/publications/detail/415).

    Family members may apply to be formally recognised as informal carers by applying to the municipality. If eligible, and after consultation with the person with care needs, the caregiver is employed by the municipality, up to six months, with a pre-specified salary calculated based on the national yearly income. Alternatively, municipalities can compensate for lost earnings individuals caring for close relatives with a terminal illness. Additional services for caregivers include training and education programmes, often focused on improving knowledge and ability to provide the needed support and on attaining coping skills, such as self-help and peer groups (source: 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).

  • 1.04. 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.

    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 represents a step towards integrating central and strategic decision making for health and social services. In 2016, a position of Minister for Senior Citizens was created within the Ministry of Health, transferring to it a portfolio that was previously under the control of the Minister for Health.

    Sources:

    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

  • 1.05. Quality and regulation in Long-term care

    While the municipalities are responsible for service and quality assurance they need to comply with standards set by national framework legislation. Quality standards for long-term care apply to public and private providers. 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 at the local level and are intended to be sufficiently objective and transparent to allow users to evaluate the performance of the provider themselves. For general monitoring of providers, municipal governments and the Ministry for Social Affairs and the Interior have developed 23 impact and background indicators as part of the agreement on care for older people. Most indicators are monitored through administrative data and, every two years, user surveys (source: 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).

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

    Since 2003, free choice of provider was introduced, banning public monopolies in service provision.  Municipal councils have been required by law to ensure private offers in each municipality, based on contracts with accredited companies. In 2017, Denmark had 320 private for-profit home care agencies. (sources: 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).

    Municipalities typically use competition with fixed prices for tendering home care and 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. Recent 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 (source: Commissioning long-term care services – Policy Press Scholarship (universitypressscholarship.com).

  • 1.07. Care coordination and personalization

    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 fair level of integration of care across providers. For beneficiaries who need long-term care on discharge, the hospital discharge management team communicates and works closely with the general practitioner and local home services. The administrative regions are responsible for coordinating after-hours care. The first contact with beneficiaries after hours is via a devoted phone line staffed by a physician or a nurse. Based on algorithms, the practitioner decides whether to refer the patient to a home visit or an after-hours clinic. After-hours clinics are usually nested within or next to a hospital emergency department (source: https://www.euro.who.int/healthy-ageing/publications/2019/denmark).

  • 1.08. Information and monitoring systems 

    The sundhed.dk portal was launched in 2003 as a partnership between the Ministry of Health, the five administrative regions and municipalities, this platform integrates information from 85 different sources and aims to improve communication between patients and the health systems enabling beneficiaries to access their medical records. Beneficiaries can consult laboratory results, prescription information and scheduled visits and enter or complement data on patient-reported outcomes. Hospitals share discharge summaries and outpatient notes, laboratory work, and medical imaging results with other hospitals, general practitioners and other medical specialists. A national medication database includes data on dispensed products in public and private (non-hospital) pharmacies (source: 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).

  • 1.09. 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#)

    Social care act made it illegal for the government to build any multiple bed residential services, hence 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. Early in the 1980s, the government phased out large institutions with multiple beds in each room and infrastructure for long-term care that resemble hospital environments, replacing them with nursing homes to ensure that users have individual living spaces. By 2011, the vast majority of older individuals living in residential care were housed in modern nursing home facilities. There are five types of residential care facilities: nursing homes, which are institutions with permanent staff and service areas; sheltered housing, which are connected to nursing homes with associated staff and service areas; housing for older people, which are dwellings for older people with associated staff and service areas; general homes for older people, which are suitable for older people and people with disabilities but without permanent staff or service areas;  private care accommodation, which provides rental facilities for people with extensive disabilities, including personal staff and service areas outside the municipal sector. The choice of specific type of accommodation depends on individuals’ preferences and needs. Beneficiaries choosing to live with their spouse or partner must be offered a facility suitable for two people (source: 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).

  • 1.09. 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#)

    Social care act made it illegal for the government to build any multiple bed residential services, hence 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. Early in the 1980s, the government phased out large institutions with multiple beds in each room and infrastructure for long-term care that resemble hospital environments, replacing them with nursing homes to ensure that users have individual living spaces. By 2011, the vast majority of older individuals living in residential care were housed in modern nursing home facilities. There are five types of residential care facilities: nursing homes, which are institutions with permanent staff and service areas; sheltered housing, which are connected to nursing homes with associated staff and service areas; housing for older people, which are dwellings for older people with associated staff and service areas; general homes for older people, which are suitable for older people and people with disabilities but without permanent staff or service areas;  private care accommodation, which provides rental facilities for people with extensive disabilities, including personal staff and service areas outside the municipal sector. The choice of specific type of accommodation depends on individuals’ preferences and needs. Beneficiaries choosing to live with their spouse or partner must be offered a facility suitable for two people (source: 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. Community-based care infrastructure

    The number of people receiving home care has declined in both absolute and relative numbers in this decade. Older people can access a wide array 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. Home help is available for those who need support for activities of daily living. Municipalities provide social services for older people.

    In January 2015, a new legislation came into force mandating that all municipalities 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 specific goals such as, showering alone or carrying out basic home cleaning activities. Users receive home support only after the reablement failed to help them regain the capacity to function independently.

    Municipalities offer services in the beneficiary’s home or in rehabilitation centres. Rehabilitation services are included in the mandatory healthcare agreements between the administrative regions and the municipalities, thus ensuring cooperation between the various actors providing services.

    Beneficiaries discharged from hospitals can receive follow-up home visits from general practitioners or nurses. These visits take place one week from discharge and may be repeated at three and eight weeks after discharge if additional support is considered necessary (source: 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).

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

    In addition to GPs, Nurses, Physiotherapists, Occupational Therapists there are two kinds of professionalized social care helpers. Social and health helpers and assistants represent most of the long-term care workforce. Physiotherapists and occupational therapists have grown in numbers and in influence during the past decade, especially after the reablement programme was implemented. In most residential settings, the number of personnel has stagnated or even declined while personnel employed in home help has increased by almost 10%. Between 2005-2015 there has been an increase in part-time working: 49% of practitioners employed in home care worked 30–35 hours per month in 2016 versus 21% in 2005. Greater professionalization of the workforce has also been observed, 46% of the practitioners in residential care facilities held relevant qualifications that require training of more than two years in 2016 versus 33% in 2005. As care needs of residents have increased, nursing home personnel also experienced an increase in health- and nursing-related tasks. Personnel also reported higher work intensity in both home and residential care, especially related to administrative workload. Although more than 75% of those interviewed perceived their work in long-term care as highly meaningful, about 40% have considered switching jobs because of deteriorating working conditions, especially less autonomy, less support from superiors and insufficient training (source: 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).

    The Danish Health Authority provides accreditation and licensing services for practitioners, including physicians, nurses, dentists, clinical dental technicians, dental auxiliaries, social and health care assistants, physiotherapists, chiropractors, midwives and optometrists (source: https://www.euro.who.int/__data/assets/pdf_file/0004/160519/e96442.pdf).

    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 (source: https://pubmed.ncbi.nlm.nih.gov/20626496/). Modular training for personal carers is under development  for those seeking to access managerial roles or for nurse aides wanting to become nurses (source: https://www.oecd.org/fr/publications/who-cares-attracting-and-retaining-elderly-care-workers-92c0ef68-en.htm).

  • 1.12. User voice, choice and satisfaction

    All municipalities partner with voluntary organizations to roll out community programmes to engage and reach out to older people (source: https://www.euro.who.int/__data/assets/pdf_file/0004/160519/e96442.pdf) .

    Non-profit actors play mainly a role in advocacy (rather than in providing services), although some are active in nursing home care (Danish Deaconess Foundation and OK Foundation) while others are taking a lead role in organizing self-support and peer-support activities in the community (DaneAge Association and Danish Alzheimer Association). The DaneAge Association, a voluntary association with more than 825 000 members, has the most prominent role among civil society organizations. The DaneAge Association is heavily involved in advocating the rights and well-being of older people and is recognized as a stable partner in the political dialogue, whilst many volunteers are themselves 65 years or older. The Elders Help Elders network, a partnership among six older people organizations, is one of the most visible initiatives organizing older people volunteers for supporting other older people throughout Denmark. Most volunteering activities through the network focus on visiting services, mobility support, shopping, practical assistance in the home, sharing meals, exercise, walking, biking and telephone security services. Non-profit organizations also play a crucial role in organizing volunteers in nursing home, hospices and hospitals (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).

    Citizens can complain to their municipality if they are not satisfied with the quality of their LTC offer and the package of services they receive. If a citizen complains about a decision the municipality must review the decision and if the municipality does not change the decision their complaint must be sent to a National Board of Complaints  (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).

  • 1.13. Equity

    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 the entire population is 14.8%, significantly lower than the EU average. Among older people, this rate was 8.7%, about half the EU average (source: 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).

  • 1.14 Pandemic preparedness of the Long-term care sector

    The health sector was prioritized first and therefore there were challenges early on with preventing infections and securing resources to protect care homes, however, the characteristics of the care system seem to have supported the implementations of measures later on (source: https://ltccovid.org/2020/05/28/new-country-report-the-covid-19-long-term-care-situation-in-denmark/).

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 who use and provide Long-Term Care

    As of April 6, 2021, there have been confirmed COVID-19 infections in 42.6% of Danish nursing homes (405 out of 937). There have been 3,690 residents in nursing homes which have tested positive for COVID-19 and 924 of these have died. In the total population, 2,432 COVID-19 related deaths were confirmed. Therefore, the share of confirmed deaths among nursing home residents was 38% (Source: https://covid19.ssi.dk/overvagningsdata/ugentlige-opgorelser-med-overvaagningsdata).

    There were just over 40,000 nursing home residents in Denmark, which suggests that 2.30% of this population have died from confirmed COVID-19.

  • 2.03. Impact of long COVID among people who use and provide Long-Term Care

    On September 15, 2020, the Danish Health Authorities announced that they have established a special committee responsible for developing national guidelines to health services and health professionals regarding the handling of long-term COVID-19 complications. There is no data yet on long-term COVID-19 in the LTC sector.

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

    The latest report on mental health from the nursing home sector indicates that the quality of life is increasing for the majority of residents. Nursing home managers’ report that residents sleep better, medication is reduced, there are fewer conflicts with residents suffering from dementia, more time for the individual resident and the sickness rates among staff is now lower. The factors which have contributed to this seems to be that there are no longer any common activities for all residents, instead members of staff make activities in smaller groups of residents or engage with them one by one. Staff report a more relaxed atmosphere, one reason being that they do not have to engage with family members who at times are considered overly critical.

    However, concerns were expressed 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).

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