In 1995/96, a statutory Long-Term Care Insurance (LTCI) Scheme has been established in Germany. LTCI is mandatory to the population. Approximately 88% of the population is insured by the social LTCIs, 11% by private funds (Blümel et al., 2020). LTC benefits based on the LTCI are not means-tested. In 2019, there were about 4.13 million beneficiaries of the LTCI that have been allocated into care grades 1 to 5. Out of these, approximately 0.91 million people were living in residential care homes, while most people receive care and support at home (80%). Those living in their own home may choose between cash and in kind-benefits from LTCI. More than 60% receive cash benefits to be supported by informal carers only while almost 30% choose in kind-benefits, partly mixed with cash-benefits, to use also formal care. Approximately 80% of people with LTC needs living at home have a level 2 and 3 care need (Destatis, 2020).

References

Blümel, M., Spranger, A., Achstetter, K., Maresso, A. & Busse, R. (2020) ‘Germany Health system review‘ Health Systems in Transition, 22(6). Available at: https://apps.who.int/iris/bitstream/handle/10665/341674/HiT-22-6-2020-eng.pdf?sequence=1&isAllowed=y (Accessed 11 February 2022). Destatis (2020) Pflegebedürftige nach Versorgungsart, Geschlecht und Pflegegrade. Available at: https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/Pflege/Tabellen/pflegebeduerftige-pflegestufe.html(Acessed 31 January).

General population

By the end of 2021, Germany had a population of 83.2 million (Destatis, 2022).

Population 65 years and above

In 2018, 22% of the population (17.9 million people) were aged 65 years and older (Lorenz-Dant, 2020). Furthermore, population age is not distributed evenly across the country. In 2017, the share of population in the age of 65 years and older was higher in the Länder of eastern Germany (24%) than western Germany (21%) (Bundesinstitut für Bau-, Stadt- und Raumforschung, 2021).

People with long-term care needs

According to the German Federal Statistical Office (Destatis), in 2019 there were 4.1 million people with long-term care needs, 62% women (Destatis, 2020) . Given the uneven distribution of older people across the country outlined above, a difference can also be observed between the share of people living in residential care. Out of 100,000 residents living in the eastern states, there are 488,2 persons in need of long-term care compared to 394,0 in the western states (Bundesinstitut für Bau-, Stadt- und Raumforschung, 2021).

References

Bundesinstitut für Bau-, Stadt- und Raumforschung (2021) INKAR – Indikatoren und Karten zur Raum- und Stadtentwicklung. Available at: https://www.inkar.de/ (Accessed 31 January 2022).

Destatis (2020) Pflegebedürftige nach Versorgungsart, Geschlecht und Pflegegrade. Available at: https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/Pflege/Tabellen/pflegebeduerftige-pflegestufe.html;jsessionid=ADFD935F5EE5A0113BFA74036FB518B2.live741 (Accessed 11 February 2022).

Destatis (2022) Press – Once again no population growth expected for 2021. Available at: https://www.destatis.de/EN/Press/2022/01/PE22_027_124.html  (Accessed 3 February 2022).

Lorenz-Dant, K. (2020) Germany and the COVID-19 long-term care situation. LTCcovid, International Long Term Care Policy Network, CPEC-LSE, 26 May 2020. Available at: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf (Accessed 3 February 2022)

Decision making powers

In the German health system as well as in the long-term care system decision-making power is shared between the Federal and the State Governments (Blümel et al., 2020). Even more importantly, the state only sets a legal framework for health and social care delivery, while major governance decisions are left to self-regulated provider and payer organisations. For long-term care the main decision-making power rests with the long-term care insurance funds on the one hand and providers of residential or community care services on the other. By law, long-term care insurance funds have to guarantee the provision of services that meet the demand by the population. Municipalities and local authorities have no authority over what services are provided within their region. The legal framework for long-term care, including the different actors, their roles and the list of benefits, is laid out in the Social Code Book XI (Lückenbach et al., 2021).

A Commissioner for Care

The German Federal Government created the role of a ‘Commissioner for Care’ in 2014 . The role of this position is to advocate for the interests of people with care needs in the political arena and to ensure that the health- and care system are centred around them. This office is involved in all matters (legal, orders etc.) to do with care and nursing. (Die Bevollmächtigte der Bundesregierung für Pflege, n.d.) , but is not directly involved in system governance. Germany does not have a Government Chief Nurse. Since 2014 the representative for care held the position of a permanent secretary at the Department of Health, reporting directly to the Minister of Health with a dedicated team of staff. In 2022 the Government transferred the role to a Member of Parliament and scraped the dedicated staff.

The role of the medical service in providing control of provision and quality of services

The medical service (Medizinischer Dienst (MD)) ensures that services provided through health- and long-term care insurance are provided to people based on objective medical criteria and that all people with insurance coverage receive services based on the same conditions. It aims to ensure that people receive necessary services but also are protected from those that are unnecessary or potentially harmful. The MD evaluates quality of services on an annual basis. The Social bill ensures that members of the MD are independent.

Public reporting of provision and quality of care

The LTC insurance funds are required to publish the quality reporting of the MD. The report consists of 59 criteria in the areas ‘care and medical care’, ‘handling of residents living with dementia’, ‘support and everyday life’ as well as ‘living, food, housekeeping and hygiene’. In addition, people living in residential care setting and people receiving support in the community are being ask about their experience (Medizinischer Dienst, n.d.; Jacobs et al., 2018).

References

Blümel M., Spranger A., Achstetter K., Maresso A. & Busse R. (2020) ‘Germany: Health system review’. Health Systems in Transition. 22(6): pp.i–273 Available at: https://apps.who.int/iris/bitstream/handle/10665/341674/HiT-22-6-2020-eng.pdf?sequence=1&isAllowed=y (Accessed 10 February 2022).

Bundesministerium für Gesundheit (2020) Pressemitteilung – Bundesrat stimmt Gesetzespaketen zur Unterstützung des Gesundheitswesens bei der Bewältigung der Corona-Epidemie zu. Available at: https://www.bundesgesundheitsministerium.de/presse/pressemitteilungen/2020/1-quartal/corona-gesetzespaket-im-bundesrat.html (Accessed: 31 January 2022)

Die Bevollmächtigte der Bundesregierung für Pflege (n.d.) Amt und Person. Available at: https://www.pflegebevollmaechtigte.de/amt-und-person.html (Accessed: 31 January 2022)

Jacobs, K., Kuhlmey, A., Gre?, S., Klauber, J. & Schwinger, A. (2018) Pflege-Report 2018:  Qualität in der Pflege. Available at: https://link.springer.com/content/pdf/10.1007%2F978-3-662-56822-4.pdf (Accessed: 31 January 2022).

Lückenbach, C., Klukas, E., Schmidt, P. H. and Gerlinger, T (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Germany’, MC COVID-19 working paper 06/2021. http://dx.doi.org/10.20350/digitalCSIC/13694 Available at: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view (Accessed 31 January 2022)

Medizinischer Dienst (2020) Pressemitteilung – Ab Oktober wieder persönliche Pflegebegutachtungen und Qualitätsprüfungen. Available at: https://www.medizinischerdienst.de/aktuelles-presse/meldungen/artikel/ab-oktober-persoenliche-pflegebegutachtungen-und-qualitaetspruefungen/ (Accessed 31 January 2022).

Medizinischer Dienst (n.d.) Der Medizinische Dienst im Gesundheitssystem. Available at: https://www.medizinischerdienst.de/medizinischerdienst/medizinischer-dienst-gesundheitssystem/ (Accessed 31 January 2022).

Financing

The social LTC insurance is financed through equal contributions between employer and employees. Childless people pay a slightly higher contribution rate than those with children (3.30% of gross wages versus 3.05%) (Lückenbach et al., 2021). Retirees contribute between 3.05% and 3.30% of their pensions (Milstein, Mueller & Lorenzoni, 2021, p.83).

Financing of private compulsory LTC insurance is risk- rather than income-related, with premiums depending on health status and age. However, caps are in place to prohibit that maximum contribution rates exceed those of the social LTC insurance. As with the social LTC insurance, employers co-pay up to half of the insurance premium (Milstein, Mueller & Lorenzoni, 2021, pp. 83-84).

Coverage of the population

The Long-Term Care Insurance in Germany is statutory. It requires enrollees in both statutory sickness funds and private health insurance to also be enrolled in LTCI funds (Milstein, Mueller & Lorenzoni, 2021).

The provision of LTC insurance is needs- but not means-tested (Milstein, Mueller & Lorenzoni, 2021).  People with LTC needs receive an assessment in which their care needs are classified into five grades. Grade 1 reflects lower needs, while grade 5 represents severe needs. The assignment for the overall grades is based on the assessment of six core areas: mobility, cognitive and communicative abilities, behaviour and psychological issues, ability to take care for oneself independently, handling of illness and therapy as well as illness related strain, and therapy and organisation of everyday life and of social contacts. The grade of support provided varies between the different levels of care need (Nadash, Doty & von Schwanenflügel, 2018).

Coverage of costs

The LTC insurance is designed to cover only a share of the LTC-related costs. With regards to residential care, people in need of long-term care have to pay up to €2,400 per month out of pocket. This includes costs for food and the resident’s room. Costs vary substantially between the different Länder. While the private share of costs for care in residential care settings amounts to more than €1,000 in Baden-Württemberg, they are less than €450 in Thuringia (Sozialpolitik-aktuell.de, 2020)

Where individuals/families cannot shoulder these costs, this will be covered through social security mechanisms. In 2019, 302,000 long-term care recipients depended on meats-tested social assistance support; most of them (250,000) were living in care homes (Rothgang & Müller, 2021).

References

Eggert, S., Teubner, C., Budnick, A., Gellert, P. & Kuhlmey, A. (2020) Pflegende Angehörige in der COVID-19-Krise: Ergebnisse einer bundesweiten Befragung. Available at: https://www.zqp.de/wp-content/uploads/ZQP-Analyse-Angeh%C3%B6rigeCOVID19.pdf (Accessed 31 January 2022)

Lückenbach, C., Klukas, E., Schmidt, P. H. and Gerlinger, T (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Germany’, MC COVID-19 working paper 06/2021 http://dx.doi.org/10.20350/digitalCSIC/13694 Available at: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view (Accessed 31 January 2022)

Milstein, R., Mueller, M. & Lorenzoni, L. (2021) Case study – Germany. In WHO Centre for Health Development (?Kobe, Japan)?, Organisation for Economic Co-operation and Development, Barber, Sarah L, van Gool, Kees, Wise, Sarah. et al. (?2021)?. Pricing long-term care for older persons. World Health Organization. https://apps.who.int/iris/handle/10665/344505. License: CC BY-NC-SA 3.0 IGO

Nadash, P., Doty, P. & von Schwanenflügel (2018) ‘The German Long-Term Care Insurance Program: Evolution and Recent Developments’, The Gerontologist, 58(3), pp.588-597. https://doi.org/10.1093/geront/gnx018

Rothgang, H. & Müller, R. (2021) Barmer Pflegereport 2021 – Wirkungen der Pflegereformen und Zukunftstrends. Schriftenreihe zur Gesundheitsanalyse – Band 32. BARMER: Berlin. Available at: https://www.barmer.de/blob/361516/2ad4e5f56c47cb7b7e914190f9fae62f/data/barmer-pflegereport-2021-band-32-bifg.pdf (Accessed 03 February 2022).

Sozialpolitik-aktuell.de (2020) Hohe Eigenanteile bei der Heimpflege – mit erheblichen regionalen Unterschieden. Available at: https://www.sozialpolitik-aktuell.de/files/sozialpolitik-aktuell/_Politikfelder/Gesundheitswesen/Datensammlung/PDF-Dateien/abbVI49_Thema_Monat_02_2020.pdf (Accessed 3 February 2022).

Prioritisation of private and third-sector providers

The Long-Term Care Insurance act stipulates (§ 11 (2)) that private and third sector providers take priority over public providers in the provision of long-term care (Sozialgesetzbuch-sgb.de, n.d.).

Home care

Between 1999 and 2019 the number of home care providers in Germany has grown by 36%, an increase of 3,868 providers. Over the same period the number of people using home care doubled to 982,604 recipients in 2019 (Milstein, Mueller & Lorenzoni, 2021). The press release of another report states that the share of those receiving home care has increased from 20.6% to 25.4%, while the share of those living in residential care remained constant over the same period. This may be indicating a trend towards people’s preference of remaining in the community (RWI, 2021).

The largest share of care providers in 2019 were private for-profit providers (66.52%). Private for-profit providers served over half of home care recipients (52.33%). The second largest group were private non-profit providers (32.14%), providing home care for 46.13% of recipients. The smallest group were public providers (1.35%). This group provided home care for 1.54% of recipients (Gesundheitsberichterstattung des Bundes, 2022b; Milstein, Mueller & Lorenzoni, 2021).

Residential care

In 2019, residential care providers in Germany had a capacity of 969,553 beds. In comparison to other OCED countries Germany had a greater availability of beds in residential long-term care for those aged 65 and older than (53.6 beds per 1000 inhabitants vs. 47 beds per 1000 inhabitants).

Between 1999 and 2019 the increase in the number of residential care providers was larger (74%) than that of home care providers (36%).

Over the same time period, the share of private for profit care providers in residential care increased from 34.90% to almost 43%. In comparison to private-for profit and public providers, the share of full-time places also increased from 25.82% to 40.57%.

At the same time, the share of private non-profit organisations declined from 56.63% to 52.76%. The proportion of full-time places also declined (63.01% in 1999 to 53.81% in 2019).

As with home care, the share of public providers played a declining role in the provision of residential care (8.47% in 1999 declining to 4.52% in 2019). Over the same time period the share of full-time places also declined (11.7% in 1999 to 5.62% in 2019) (Milstein, Mueller & Lorenzoni, 2021).

References

Gesundheitsberichterstattung des Bundes (2022b) Ambulante Pflege- und Betreuungsdienste (Anzahl). Gliederungsmerkmale: Jahre, Deutschland, Art der Pflege- und Betreuungsdienste, Träger. Available at: https://www.gbe-bund.de/gbe/!pkg_olap_tables.prc_set_orientation?p_uid=gastd&p_aid=3932778&p_sprache=D&p_help=2&p_indnr=876&p_ansnr=98223306&p_version=2&D.000=1&D.374=2&D.983=1(Accessed 31 January 2022).

Milstein, R., Mueller, M. & Lorenzoni, L. (2021) Case study – Germany. In WHO Centre for Health Development (?Kobe, Japan)?, Organisation for Economic Co-operation and Development, Barber, Sarah L, van Gool, Kees, Wise, Sarah. et al. (?2021)?. Pricing long-term care for older persons. World Health Organization. https://apps.who.int/iris/handle/10665/344505. License: CC BY-NC-SA 3.0 IGO

RWI (2021) Pflegeheim Rating Report 2022: Wirtschaftliche Lage deutscher Pflegeheime is angespannt, jedes fünfte im “roten Bereich”. Available at: https://www.rwi-essen.de/presse/mitteilung/462/ (Accessed 5 February 2022).

Sozialgesetzbuch-sgb.de (n.d.) Sozialgesetzbuch (SGB XI) Elftes Buch Sozial Pflegeversicherung. Available at: https://www.sozialgesetzbuch-sgb.de/sgbxi/11.html (Accessed 11 February 2022).

Organisational silos pose challenges to care coordination

A report provided by the German Society of Nursing Science focusing on domiciliary care highlights that structural barriers exist through the organisational silos in which service providers work. Data protection causes additional challenges to the effective communication between service providers, such as domiciliary care workers and GPs. Communication and coordination between different service providers are often not part of the services for which the care providers can be reimbursed by the LTC insurance and case conferences across professions are not established, requiring domiciliary care providers and GPs to coordinate services without an established framework (Fischer et al., 2021)

References

Fischer, T., Kopke, K., Sirsch, E., Büker, C., Graffmann-Weschke, K., Horn, A., Junius-Walker, U., Kümpers, S. & Meyer, G. (2021) S1 Leitlinie Häusliche Versorgung, soziale Teilhabe und Lebensqualität bei Menschen mit Pflegebedürftigkeit im Kontext ambulanter Pflege unter den Bedingungen der COVID-19-Pandemie – Living Guideline. Available at: https://www.awmf.org/uploads/tx_szleitlinien/184-002LGl_S1_Haeusliche-Versorgung-soziale-Teilhabe-Lebensqualitaet-bei-Menschen-mit-Pflegebedarf-COVID19-Pandemie_2021-04_1_01.pdf (Accessed 31 January 2022).

Responsibility for care homes

Regulation of the care home infrastructure is under State authority since it was devolved from the Federal level in 2006. Hence, minimal building and operational requirements as well as definitions as to what constitutes as care home (as opposed to more self-directed small-scale living arrangements for example) differ between the 16 Laender.

Demand of care homes

A report by the University of Cologne suggests that the increasing demand for residential care requires establishing additional as well as maintaining existing resources (Kochskämper & Pimpertz, 2015).

Care home providers

According to Federal reporting, the majority of care homes in 2019 (8,115 homes, 521,720 spaces) were owned by not-for-profit organisations, followed by private providers (6,570 homes; 393,308 spaces) and public providers (695 homes, 54,525 spaces) (Gesundheitsberichterstattung des Bundes, 2022).

Types of rooms & requirements

Following the implementation of single room quotas in care homes put in place in many of the Länder over a decade ago (which gave providers 10-15 years to make the necessary changes), care homes in several Laender have to provide a certain percentage of single rooms (e.g. 80% in North-Rhine Westphalia, 100% for new builds; Berlin 60%; Lower Saxony no quota). In Baden-Württemberg, every single room needs to have its own bathroom. Older buildings with shared bedrooms and without individual bathrooms should only be used for short-term stays. While this increases privacy of residents it also reduces the number of spaces. People who choose to live together (e.g. couples) can share double rooms of sufficient size (Deutschlandfunk, 2020; Aerzteblatt.de, 2019;  Wiedemann, 2019)

The requirements in terms of room-size and accessibility vary between the Laender. In Bavaria, for example, according to a newspaper article, single rooms should be at least 14 square meters, double rooms, 20 square meters. In addition, 25% of rooms need to be wheelchair accessible and have wheelchair accessible bathrooms (Wörmann, 2016).

Location of care homes

Research conducted by the Bertelsman group found that residential care across Germany are in good geographical proximity to other care homes: the longest average distance between care setting identified amounted to 8.2km. Within urban areas distances between care settings can be as small as 0.5km, while in rural areas distances may be larger (Hackmann et al., 2016).

References

Aerzteblatt.de (2019) Baden-Württemberg lockert Einzelzimmervorgabe für Pflegeeinrichtungen. Available at: https://www.aerzteblatt.de/nachrichten/105668/Baden-Wuerttemberg-lockert-Einzelzimmervorgabe-fuer-Pflegeeinrichtungen (Accessed 31 January 2022)

Deutschlandfunk (2020) Einzelzimmer in der Pflege/ Mehr Privatsphäre, weniger Plätze? Available at: https://www.deutschlandfunk.de/einzelzimmerquote-in-der-pflege-mehr-privatsphaere-weniger-100.html (Accessed 31 January 2022)

Gesundheitsberichterstattung des Bundes (2022) Pflegeheime und verfügbare Plätze in Pflegeheimen. Gliederungsmerkmale: Jahre, Region, Art der Einrichtungen/Plätze, Träger. Available at: Ad-hoc-Tabelle (gbe-bund.de)(Accessed 31 January 2022)

Kochskämper, S. & Pimpertz, J. (2015) ‘Herausfoderungen an die Pflegeinfrastruktur‘ Institut der deutschen Wirtschaft Köln. Available at: IW-Trends_2015-03-04_Kochskaemper_Pimpertz.pdf (iwkoeln.de) (Accessed 5 February 2022).

Differences in care infrastructure

A study conducted by Bertelsmann found that the care infrastructure differs across Germany. In many areas in East Germany, domiciliary care is more dominant, while in Hessen and in the Rhineland a disproportionate amount of care is provided by family carers. The study further found that in the Federal States located in the South a more balanced provision of services is prevailing, while in Schleswig-Holstein and Mecklenburg Western Pomerania more people receive care in residential care settings. Further analysis provided in the report suggests that the less purchasing power is available in a region, the more unpaid care is being provided. The more unpaid care is being provided, the lower are expected future staffing shortages (source: https://www.bertelsmann-stiftung.de/fileadmin/files/BSt/Publikationen/GrauePublikationen/Studie_VV_FCG_Pflegeinfrastruktur.pdf).

Future feasibility

Another report raises questions regarding the future feasibility of community-based care as it often requires unpaid support in addition to domiciliary and community services. Increasing numbers of people living on their own, increasing number of people without children as well as potential implications of an increasing participation of women in the labour force poses challenges to the availability of unpaid carers.

A second important component of community-based care includes day and night (part-residential) care. These services also include the transport between people’s homes and the day care centres. As with other LTC services in Germany, people with LTC needs can receive financial support for attending these services depending on the assessment of their level of care need (source: https://www.bundesgesundheitsministerium.de/tagespflege-und-nachtpflege.html).

Care statistics for 2019 show that 14.5% of people with (assessed) LTC needs receive day care services. Since 2017, the number of day care places has increased by 24.3%.

In 2019, there were about 4.13 million people with long-term care needs and around 80% of them received care and support at home (80%). Of those, more than 60% were supported by informal carers only, almost 30% use care and support from both unpaid and domiciliary carers or domiciliary carers only  (source: https://www.destatis.de/DE). the German LTC system provides  cash benefits that could be used as payment for informal care arrangements and financial support for unpaid carers through household transfers for beneficiaries remains strong in the German LTC system. Family carers in paid employment are entitled to financial support if they reduce working hours to care for a close family relation: wage compensation can be granted by employers for reduced employment of a minimum of 15 hours for up to 24 months. Moreover,  the Care Leave Act of 2015 introduced a wage compensation for acute care leave of up to ten days, usually 90% of net earnings; a leave of up to three months is also available for those individuals who support family members at the end of life (Frisina-Doetter et al. 2017).

References: 

Frisina-Doetter, L., Rothgang, H. (2017). The German LTC policy landscape. CEQUA LTC Network report 

Roles & responsibilities

Each of the 16 Länder carries responsibility for pandemic preparedness in their area. At the national level, the Robert Koch-Institute (RKI) takes a key role in infectious disease monitoring and prevention. The Institute also provides pandemic plans. A second federal authority with the task to reduce health related risks is the Federal Office for Civil Protection and Disaster Assistance.

Warnings

As early as in 2013, the Federal Office for Civil Protection and Disaster Assistance already warned of the risk of a pandemic through a virus of the ‘virus family Coronaviridae’.

Plans

Tasked by the government, the RKI has maintained a regularly updated National Pandemic Plan for Influenza since the early 2000s. The pandemic plan includes consideration for residential LTC as well as advice on Personal Protection Equipment (PPE) stockpiling, vaccination and training of staff. This plan has been amended to respond to the COVID-19 pandemic in March 2020.

Limitations

Despite this systemic preparedness, in practice there has been divergence in handling and applying infection prevention and control plans, the experience has shown that not all LTC settings had developed specific plans or not developed them in sufficient detail and that not all care workers, especially care assistants, had been sufficiently trained, and there has also been a shortage of PPE. The existing shortage in the care workforce posed additional challenges to the response during the pandemic (Lückenbach et al., 2021).

A paper reviewing the implications of the LTC sector due to COVID-19 established that the LTC sector was not adequately prepared for a crisis. It was highlighted that residential care settings that need to operate under economic principles have been particularly unprepared to manage crisis. Consequently, providers have been imposing strict measures to prevent blame and legal claims. The measures have severe implications on people’s self-determination and quality of life. It was also noted that closer interdisciplinary partnership could help to prepare LTC for crisis situations (Kricheldorff, 2020).

A survey conducted among care providers in April/May 2020 found that almost two thirds of care home staff were not specifically prepared for handling a pandemic during their apprenticeships, university degrees or training. Most surveyed institutions (90.7%) have run training on PPE. Among part-residential care settings almost 60% (n=96) stated that they had not been specifically prepared for a pandemic. More than half of these settings responded by setting up crisis teams. Two-thirds of domiciliary care providers surveyed did not report specific pandemic preparedness prior to COVID-19 (Wolf-Ostermann et al., 2020).

References

Kricheldorff, C. (2020) ‚Gesundheitsversorgung und Pflege für ältere Menschen in der Zukunft – Erkenntnisse aus der Corona-Pandemie’, Zeitschrift fur Gerontologie und Geriatrie, 53(8), 742–748. https://doi.org/10.1007/s00391-020-01809-z

Lückenbach, C., Klukas, E., Schmidt, P. H. and Gerlinger, T (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Germany’, MC COVID-19 working paper 06/2021. http://dx.doi.org/10.20350/digitalCSIC/13694 Available at: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view (Accessed 31 January 2022)

Wolf-Ostermann, K, Rothgang, H., Domhoff, D., Friedrich, A.-C., Heinze, F., Preuß, B., Schmidt, A.,  Seibert, K. & Stolle (2020) Zur Situation der Langzeitpflege in Deutschland während der Corona-Pandemie Ergebnisse einer Online-Befragung in Einrichtungen der (teil)stationären und ambulanten Langzeitpflege. Available at: https://media.suub.uni-bremen.de/bitstream/elib/4331/4/Ergebnisbericht%20Coronabefragung%20Uni-Bremen.pdf (Accessed 5 February 2022).

Latest numbers

As of 4th February 2022, there have been 10,671,602 confirmed COVID-19 infections in Germany, and 118,504 deaths attributed to COVID-19, according to the RKI (Robert Koch Institut, 2022a, 2022b).

Impact of the different waves

The first wave of COVID-19 infections was relatively mild in Germany, however, the second wave (experienced mostly between December 2020 and January 2021) and the third wave (March to April 2021) were much more severe. The fourth wave has had the highest number of infections so far and it gradually eased at the end of 2021. Due to the fast spread of the Omicron variant, the fifth wave is expected to be the strongest in terms of infection figures (ZDF 2022, Schilling et al., 2021, RKI 2022). The death toll was highest in the second wave, followed by the fourth wave (RKI, 2022).

References

Robert Koch Institut (2022) Wöchentlicher Lagebericht des RKI zur Coronavirus-Krankheit-2019 (COVID-19)  – 06.01.2022 – AKTUALISIERTER STAND FÜR DEUTSCHLAND. Available at: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Situationsberichte/Wochenbericht/Wochenbericht_2022-01-06.pdf?__blob=publicationFile

Robert Koch Institut (2022a) Situation reports from Monday to Friday. Available at: https://www.rki.de/EN/Content/infections/epidemiology/outbreaks/COVID-19/Situationsberichte_Tab.html (Accessed 5 February 2022).

Robert Koch Institut (2022b) Coronavirus Disease 2019 (COVID-19) Daily Situation Report by the Robert Koch Institute 04/02/2022- CURRENT STATUS FOR GERMANY. Available at: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Situationsberichte/Feb_2022/2022-02-04-en.pdf?__blob=publicationFile (Accessed 5 February 2022).

Schilling, J., Tolksdorf, K., Marquis, A., Faber, M., Pfoch, T., Buda, S., Haas, W., Schuler, E., Altmann, D., Grote, U., Diercke, M & RKI COVID-19 Study Group (2021) ‘Die verschiedenen Phasen der COVID-19-Pandemie in Deutschland: Eine deskriptive Analyse von Januar 2020 bis Februar 2021’ Bumdesgesundheitsblatt – Gesundheitsforschung – Gesundheitsschutz, 64, pp.1093-1106. Available at: https://link.springer.com/article/10.1007/s00103-021-03394-x

About the data:

Germany’s Robert Koch-Institute published the first official number of infections and deaths in different care settings on April 22, 2020. People in care and nursing homes are covered under §36 of the Protection Against Infection Law (IfSG). §36 also includes people living in facilities for those with disabilities or other care needs, homeless shelters, community facilities for asylum-seekers, repatriates, and refugees, and so the data is not directly comparable with the data on care homes presented for the other countries.

Data recorded here only includes confirmed cases following a laboratory diagnosis independent of clinical assessment. In addition, the Robert Koch Institute advises that information on care setting is missing in 37% of cases, which means that the number of people affected represents the minimum number of cases in specific care settings. A report estimated that, based on a survey of care homes, the share of deaths of care home residents attributed to COVID-19 by May 2020 was 49% of all COVID-19 deaths, which is higher than the rate that would result from the Robert Koch Institute data at the time (36%).

Deaths linked to COVID-19 in residential care

According to Germany’s Robert Koch-Institute, 25,789 residents of residential long-term care facilities (aged 60 and above) died in association with a SARS-CoV-2 infection during the course of the pandemic until week 4 of 2022 (Robert Koch Institut, 2022a). This figure may include a small proportion of staff and visitors in addition to residents, as attribution is not always clear. Thus, out of 118,504 death associated with the Covid pandemic in total, deaths associated with care homes constitute 21.76 % (Robert Koch Institut, 2022b).

The total number of people living in care and nursing homes in Germany in 2017 was 818,000, and assuming that there were a similar number in 2020 and that all the deaths in communal establishment were residents, 3.15% of all care home residents would have died due to COVID-19 (Source: Statista).

Deaths linked to COVID-19 among people who use care in the community

The number of users of community care or persons who are being cared for without the assistance of professional services in the community is unclear. The last data on this group was published on 16 July 2021 when the number of deaths was reported as 195 persons (Robert Koch Institut, 2021). However, the validity of this figure is questionable as data collection does not account for persons in need of care in a standardizes way.

References

Robert Koch Institut (2021) Täglicher Lagebericht des RKI zur Coronavirus-Krankheit-2019 (COVID-19) 16.07.2021 – AKTUALISIERTER STAND FÜR DEUTSCHLAND. Available at: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Situationsberichte/Jul_2021/2021-07-16-de.pdf?__blob=publicationFile (Accessed 5 February).

Robert Koch Institut (2022a) Wöchentlicher Lagebericht des RKI zur Coronavirus-Krankheit-2019 (COVID-19) 03.02.2022 – AKTUALISIERTER STAND FÜR DEUTSCHLAND. Available at: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Situationsberichte/Wochenbericht/Wochenbericht_2022-02-03.pdf?__blob=publicationFile (Accessed 5 February 2022).

Robert Koch Institut (2022b) Coronavirus Disease 2019 (COVID-19) Daily Situation Report by the Robert Koch Institute 04/02/2022- CURRENT STATUS FOR GERMANY. Available at: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Situationsberichte/Feb_2022/2022-02-04-en.pdf?__blob=publicationFile (Accessed 5 February 2022).

 

Access to care for people living in the community

A survey among family carers of older people in April/Mai 2020 found that 39% of unpaid carers agreed that they had greater care responsibility as previous support had disappeared. More than 80% reported that day care had completely stopped, 40% reported that other services (e.g. foot care) had stopped or reduced (26%), 26% reported reduced care from the GP. Over 40% reported reduced support from neighbours and 30% from family members and friends. The same survey also showed that there was a slight reduction in available domiciliary LTC and 24-hour care (domestic care or foreign live in carers), but a considerable reduction in available day care programmes (Eggert et al., 2020).

A survey among care providers in April/May 2020, showed that two-thirds of part-residential care settings stopped accepting new residents or closed completely. Among domiciliary carers, less than 20% had provided care for people with a confirmed infection, and 13.4% had clients with suspected cases. Domiciliary care service providers also recorded a change in take up of services (mostly a reduction) among almost 50% of responding providers. Almost half of all domiciliary care services estimate that the provision of support for people with limited uptake of services is at risk or cannot be ensured (Wolf-Ostermann et al., 2020).

Access to care provided by migrant workers

In Germany, many people with care needs who still live in their own homes receive support from Eastern European migrant workers. The border closure around Easter 2020 left many people without their usual support (Lückenbach et al., 2021).

Access to care for people living in care homes

Lockdowns of nursing homes during the first wave led to physical activity programmes for residents being discontinued, as these were often provided by external providers. There were attempts to promote physical activity in-house although staff were not trained to provide it specifically (Frahsa et al., 2020).

References:

Eggert, S., Teubner, C., Budnick, A., Gellert, P. & Kuhlmey, A. (2020) Pflegende Angehörige in der COVID-19-Krise: Ergebnisse einer bundesweiten Befragung. Available at: https://www.zqp.de/wp-content/uploads/ZQP-Analyse-Angeh%C3%B6rigeCOVID19.pdf (Accessed 31 January 2022)

Frahsa A, Altmeier D, John JM, Gropper H, Granz H, Pomiersky R, Haigis D, Eschweiler GW, Nieß AM, Sudeck G and Thiel A (2020) “I Trust in Staff’s Creativity”—The Impact of COVID-19 Lockdowns on Physical Activity Promotion in Nursing Homes Through the Lenses of Organizational Sociology. Front. Sports Act. Living 2:589214. doi: 10.3389/fspor.2020.589214

Lückenbach, C., Klukas, E., Schmidt, P. H. and Gerlinger, T (2021), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Germany’, MC COVID-19 working paper 06/2021. http://dx.doi.org/10.20350/digitalCSIC/13694 Available at: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view (Accessed 31 January 2022)

Wolf-Ostermann, K, Rothgang, H., Domhoff, D., Friedrich, A.-C., Heinze, F., Preuß, B., Schmidt, A.,  Seibert, K. & Stolle (2020) Zur Situation der Langzeitpflege in Deutschland während der Corona-Pandemie Ergebnisse einer Online-Befragung in Einrichtungen der (teil)stationären und ambulanten Langzeitpflege. Available at: https://media.suub.uni-bremen.de/bitstream/elib/4331/4/Ergebnisbericht%20Coronabefragung%20Uni-Bremen.pdf (Accessed 5 February 2022).

 

There is no information available so far that systematically measures the impact of COVID-19 on the health and wellbeing of people with LTC needs.

Mental health

However, concerns for people’s mental health are being raised, especially for people living in residential care settings whose social life has been severely disrupted. Even before COVID-19, research has estimated that among those 65 and older living in care homes, 25-45% had depression. It has further been estimated that only 40% of those received a diagnosis and only about half of those with a diagnosis received adequate treatment and support (Zeit online, 2021; Aerzteblatt.,de, 2018).

A study by Seethaler et al (2021) investigated the impact of the COVID-19 pandemic on mental health and perceived psychosocial support for older psychiatric patients. This focused on 32 patients with affective or anxiety disorders aged over 60 years. All participants were current or former patients of the Psychiatric University Hospital of Charité at St. Hedwig Hospital, Berlin, Germany. Telephone interviews were conducted in April/May 2020 (T1) and August 2020 (T2). The psychosocial impact (PSI) of the pandemic and psychopathology were measured and the changes between T1 and T2 were examined. There was a significant positive correlation between general PSI and depression as well as severity of illness. However, neither general PSI not psychopathology changed significantly between T1 and T2. Patients reported an increase in psychosocial support between T1 and T2 and high demand for additional support. Elderly psychiatric patients showed a negative PSI of the pandemic (Seethaler et al., 2021).

References:

Aerzteblatt.,de (2018) Wissenschaftler: Depressionen bei Heimbewohner seltener behandelt.Available at: https://www.aerzteblatt.de/nachrichten/98943/Wissenschaftler-Depression-bei-Heimbewohnern-seltener-behandelt(Accessed 6 February 2022).

Seethaler, M., Just, S., Stotzner, P., Bermpohl, F., & Brandl, E. J. (2021). Psychosocial Impact of COVID-19 Pandemic in Elderly Psychiatric Patients: a Longitudinal Study. The Psychiatric Quarterly. https://doi.org/10.1007/s11126-021-09917-8

Zeit online (2021) Treffs gegen Depressionen in Alters- und Pfelgeheimen. Available at: https://www.zeit.de/amp/news/2021-02/26/treffs-gegen-depressionen-in-alters-und-pflegeheimen (Accessed 6 February 2022).

 

Greater responsibility and less support

A survey among family carers of older people in April/May 2020 found that 39% of unpaid carers agreed that they had greater care responsibility as previous support had disappeared. This was linked both to reductions in support from neighbours and family, and to a reduction in formal care (particularly day care) (Eggert et al., 2020).

References

Eggert, S., Teubner, C., Budnick, A., Gellert, P. & Kuhlmey, A. (2020) Pflegende Angehörige in der COVID-19-Krise: Ergebnisse einer bundesweiten Befragung. Available at: https://www.zqp.de/wp-content/uploads/ZQP-Analyse-Angeh%C3%B6rigeCOVID19.pdf (Accessed 31 January 2022).

Similar to other countries, Germany experienced workforce shortages during the pandemic. To address these, Germany supported the recruitment of LTC students through financial help to LTC facilities and increased/ lifted the maximum number of working hours (sources: Germany LTCcovid presentation; COVID-19 in long-term care: impact, policy responses and challenges).

According to a recent report (February 2022) by The Federation of European Social Employers, Germany has experienced a strong increase of over 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.

General measures

General measures agreed between the Federal and the Länder governments include the closure of restaurants, bars, and non-essential retail outlets as well as cultural venues such as cinemas, theatres, and clubs. Wearing of masks in public (shops, transportation, workplace) is mandatory and employers and employees are urged to work from home whenever possible. An evening curfew 8pm – 5am had been in place for a while in some regions and there are restrictions in the number of people that are allowed to gather privately. The measures are being regularly revisited in meetings between the chancellor and the 16 Minister presidents. The Minister presidents have decision making power to alter some of the rules, which is why slight differences in measures can be observed across Germany. The rules also differ depending on the COVID-19 incidence (there are changes in rules even at the local level) (Lorenz-Dant, 2020; Die Bundesregierung, 2022).

Infection prevention bill

On April 23, 2021, a new infection prevention bill was enacted. The aim of the bill is to unify COVID-19 related measures across the country depending on local incidence levels (Bundesministerium für Gesundheit, 2021).

References

Bundesministerium für Gesundheit (2021) Fragen und Antworten zum 4. Bevölkerungsschutzgesetz. Available at: https://www.bundesgesundheitsministerium.de/service/gesetze-und-verordnungen/guv-19-lp/4-bevschg-faq.html(Accessed 6 February 2022).

Die Bundesregierung (2022) Corona-Regelungen: Das haben Bund und Länder vereinbart. Available at: https://www.bundesregierung.de/breg-de/themen/coronavirus/corona-regeln-und-einschrankungen-1734724 (Accessed 3 February 2022).

Die Bundesregierung (2021) Bund-Länder-Beschluss: Öffnungsperspektive in fünf Schritten. Available at: https://www.bundesregierung.de/breg-de/themen/coronavirus/fuenf-oeffnungsschritte-1872120 (Accessed 6 February 2022).

Lorenz-Dant, K. (2020) Germany and the COVID-19 long-term care situation. LTCcovid, International Long Term Care Policy Network, CPEC-LSE, 26 May 2020. Available at: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf (Accessed 3 February 2022)

Robert Koch Institut (2021b) Bericht zu Virusvarianten von SARS-CoV-2 in Deutschland, insbesondere zur Variant of Concern (VOC) B.1.1.7. Available at: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/DESH/Bericht_VOC_2021-03-31.pdf?__blob=publicationFile (Accessed 6 February 2022).

On February 27, 2020, the Federal Minister of Health and the Minister of the Interior established a crisis plan as outlined in Germany’s pandemic plan. It is, however, unclear whether the crisis team specifically focused on LTC (Source: https://www.bundesregierung.de/breg-de/themen/coronavirus/krisenstab-eingerichtet-1726070).

While the Federal Government seeks expert advice on the pandemic response, it is not disclosing names or credentials of the experts involved. It is therefore impossible to know which, if any, expertise on long-term care was sought.

No national COVID-19 LTC taskforce was established, as health and long-term care largely falls under Länder authority. However, the State Secretary at the Federal Ministry of Health has in some cases sought a moderating role highlighting topics of importance (Die Bevollmächtigte der Bundesregierung für Pflege, n.d.). As the new government discontinued the role of the State Secretary for Care and Nursing, these initiatives have ended by the end of the year 2021. Federal agencies like the Robert Koch Institute have not established LTC-specific taskforces and responsibility for different aspects of long-term care is distributed across the agency.

References

Die Bevollmächtigte der Bundesregierung für Pflege (n.d.) Coronavirus. Available at: https://www.pflegebevollmaechtigte.de/nws-zum-Coronavirus.html (Accessed 11 February 2022).

Local health authorities instruct and advise LTC providers within their jurisdiction on infection prevention measures. These measures, as well as the modes of co-operation and collaboration, vary between LTC providers and local health authorities. The health system (particularly the hospital system and the medical care system in the community) and the long-term care system, operate independently of each other. However, community care providers also provide medical care prescribed by family physicians. No formal coordination between the two systems exists on a local, regional, or Länder [State] level. Some states and regions have sought to establish informal modes of coordination during the pandemic. Where care providers are no longer able to provide the services for which they have been contracted, they have to contact the care insurance and work towards solutions with the relevant health and regulatory authorities (Lorenz-Dant, 2020).

References

Lorenz-Dant, K. (2020) Germany and the COVID-19 long-term care situation. LTCcovid, International Long Term Care Policy Network, CPEC-LSE, 26 May 2020. Available at: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf (Accessed 3 February 2022)

From March 17, 2020, until September 30, 2020, people wishing to take up LTC payments or care did not have to attend bi-annual care advisory meetings. Payments continued without these meetings. Since advisory meetings have started again, people with care needs can request for these meetings to take place digitally or over the phone (until March 31, 2021, and perhaps until June 30, 2021). Home visit are still not taking place (until February 28, 2021, and perhaps until June 30, 2021). Similarly, funds for adjustment of accommodation due to care needs have been provided following virtual meetings. In addition, between April 1, 2020, and March 31, 2021, additional funding for consumables to support care had been increased from 40 to 60 Euros per month.

People with limited care needs (Level 1) have been given more flexibility on what they spend the support payment of 125 Euros per month (until 31 March 2021) on (Source: https://www.pflegeberatung.de/corona). The German dementia strategy has recognised the added complexity of COVID-19 related measures to the lives of people with dementia and their carers. The strategy proposes increased remote (telephone) advice and counselling for people with dementia and their relatives, expansion of local (voluntary) networks, strengthening neighbourhood support, increased support for working family carers, support for distance carers, improving dementia training of care workers in different care settings (Source: https://www.nationale-demenzstrategie.de/fileadmin/nds/pdf/2020-07-03__Corona_und_Demenz_.pdf).

Home care providers are given permission to sub-contract services to other providers if their own workforce is currently unable to provide the required care due to the pandemic situation (Source: https://www.awmf.org/leitlinien/detail/ll/184-002.html) and individual Länder [States] may have further support measures in place. Guidelines on the provision of home care recommend a shared-decision making process with consumers to establish which services may be adjusted if the home care provider is unable to fulfil demand due to workforce restrictions or other reasons (Source: https://www.awmf.org/leitlinien/detail/ll/184-002.html).

The Robert Koch-Institute (RKI) is the federal institute responsible for disease detection and health reporting. It collects data on diseases nationwide (Source: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view). Laboratories and medical doctors are required to inform the local health authority about COVID-19 and selected other infections. The local health authorities then transfer the aggregate data to the health authority responsible for the federal state. This main health authority then transfers the information to the RKI. The RKI works closely with the Federal Ministry of Health, other Federal authorities, and public health authorities in each of the 16 Federal states. The RKI also maintains interaction with international bodies, such as the World Health Organisation and European Centre for Disease Prevention and Control. The information routes are outlined by law (Source: https://www.gmkonline.de/documents/pandemieplan_teil-i_1510042222_1585228735.pdf).

RKI publishes a daily Situation Report on the pandemic, which includes limited information on COVID-19 morbidity and mortality in residents of care homes and clients of home care services as well as for staff of these services. Details of how this information is gathered and presented have changed over time. More fine-grained information is not generally available. Information on persons who receive only informal care in their own home is not included. Impacts on the LTC system in general, e.g. availability and usage of services, are not routinely monitored and therefore not easily available.

Support with loss of income for residential care facilities

In March 2020, the government announced that care facilities will be reimbursed through the LTC Insurance system for additional costs (e.g. personal protective equipment) or loss of income due to the pandemic (Lorenz-Dant, 2020; Bundesministerium für Gesundheit, 2020).

Support for people where professional care was unavailable

The National Association of Statutory Health Insurance Funds further outlined possibilities to reimburse other people providing care for up to three months if the usual ambulatory or replacement care cannot be provided (Lorenz-Dant, 2020).

Bonus payment for LTC workers & limitations

Care workers also received a one-off, tax-free COVID-19 payment. A study on LTC workers in different care settings showed that respondents highlighted the need for better pay, which could be achieved through tax exemptions. Respondents were critical of the pandemic bonus, saying they would prefer long-term improvement in pay, and some noted that the bonus should be extended to everyone working in care settings, not just care workers  (Stolle et al., 2020).

Critique of limited focus on support for people with disabilities

In addition, there has been criticism regarding the limited focus of COVID-19 social protection packages on people with disabilities (Sozialverband VDK, 2020).

References

Bundesministerium für Gesundheit (2020) Bundesrat stimmt Gesetzespaketen zur Unterstützung des Gesundheitswesens bei der Bewältigung der Corona-Epidemie zu. Available at: https://www.bundesgesundheitsministerium.de/presse/pressemitteilungen/2020/1-quartal/corona-gesetzespaket-im-bundesrat.html (Accessed 3 February 2022).

Lorenz-Dant, K. (2020) Germany and the COVID-19 long-term care situation. LTCcovid, International Long Term Care Policy Network, CPEC-LSE, 26 May 2020. Available at: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf (Accessed 3 February 2022)

Sozialverband VDK (2020) Menschen mit Behinderung und Corona. Available at: https://www.vdk.de/deutschland/pages/presse/presse-statement/79041/behinderung_corona (Accessed 3 February 2022).

Stolle, C., Schmidt, A., Domhoff, D. et al. Bedarfe der Langzeitpflege in der COVID-19-Pandemie. Z Gerontol Geriat 53, 788–795 (2020). https://doi.org/10.1007/s00391-020-01801-7.

LTC quality checks and necessary patient to staff ratios were temporarily suspended in March 2020 but supposed to resume in October 2020 (source: https://md-bund.de/aktuell/aktuelle-meldungen/corona-qualitaetspruefungen-in-pflegeeinrichtungen-ausgesetzt.html) Due to increased infection risk this date was finally pushed to March 2021 (Source: https://md-bund.de/aktuell/aktuelle-meldungen/regelpruefungen-und-persoenliche-pflegebegutachtungen-starten-im-maerz.html)  Quality checks were only undertaken if there was reason to suspect that quality of care was not maintained.

In March 2020, the German Government allowed care providers to divert from contractual obligations around staffing to avoid gaps. LTC insurance was also given some freedom to avoid gaps in domiciliary care (Source: https://www.bundesgesundheitsministerium.de/presse/pressemitteilungen/2020/1-quartal/corona-gesetzespaket-im-bundesrat.html).

Care strengthening bill

In January 2019, the care strengthening bill was enacted which means that there is active encouragement to increase the care workforce (Source: https://www.bundesgesundheitsministerium.de/sofortprogramm-pflege.html). This bill was developed in 2018 (Source: https://www.vdek.com/politik/gesetze/wahlperiode_19.html#ppsg). This does not solve the problem that there are not enough people available and willing to work in LTC.

Increase of minimum wage for care workers & ‘pandemic-bonus’

In April 2020, the German government announced a stepwise increase of the minimum wage for care workers as well as additional paid leave. In addition, care workers in Germany received a one-off ‘pandemic-bonus’ of up to €1,000 as part of their July 2020 pay. In some states the bonus was topped-up to €1,500 (Lorenz-Dant, 2020). In February 2021 the Federal Minister of Health announced a planned bonus for hospital staff. There are demands to also provide a bonus to LTC workers (Sources: https://www.aerztezeitung.de/Politik/Spahn-plant-weitere-Corona-Praemie-fuer-Klinikmitarbeiter-416931.html; https://www.aerzteblatt.de/nachrichten/121022/Deutscher-Pflegerat-will-Coronapraemie-fuer-alle-Pflegekraefte).

Emergency childcare for essential workers

While children of staff working in system relevant jobs (including health and LTC) could access emergency childcare, there have been demands to expand available childcare services to reflect the demands on care workers (Presseportal, 2021; Ministerium für Kultus, Jugend und Sport Baden-Württemberg, 2020).

Financial support towards catering costs

In Bavaria, the cost of catering for staff in health and LTC settings are financially supported (€6.50 per member of staff per day) as a sign of appreciation (Lorenz-Dant, 2020).

Access to regular testing

Following the national testing strategy, care workers should have access to regular testing. Rules vary between federal states, but LTC staff working in residential or domiciliary care settings should be tested regularly (BIVA Pflegeschutzbund, 2022)

Initiatives to recruit care workers

Earlier in the pandemic, the ‘care reserve’ initiative developed across federal states and separately in some federal states allowed people with a qualification to register. This provided an opportunity to recruit staff if there was a shortage due to infection. There have also been movements in some federal states to prioritise care-related professions when applying for permission to work in Germany and to financially incentivise training to become a care assistant (Pflegeassistenz) (Lorenz-Dant, 2020). In addition, some staffing rules and operational frameworks were relaxed (Langins et al., 2020).

References

BIVA Pflegeschutzbund (2022) Besuchseinschränkungen in Alten- und Pflegeheimen wegen Corona. Available at: https://www.biva.de/corona-im-pflegeheim/besuchseinschraenkungen-in-alten-und-pflegeheimen-wegen-corona/#bw

Langins, M., Curry, N., Lorenz-Dant, K., Comas-Herrera, A. & Rajan, S. (2020) ‘The COVID-19 Pandemic and Long-Term Care: What can we learn from the first wave about how to protect care homes?’ Eurohealth, 26(2). Available at: https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf

Lorenz-Dant, K. (2020) Germany and the COVID-19 long-term care situation. LTCcovid, International Long Term Care Policy Network, CPEC-LSE, 26 May 2020. Available at: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf (Accessed 3 February 2022)

Ministerium für Kultus, Jugend und Sport Baden-Württemberg (2020) Notbetreuung wird vom 27. April 2020 an erweitert. Available at: https://km-bw.de/,Lde/Startseite/Service/2020+04+20+Notbetreuung+wird+vom+27_+April+2020+an+erweitert (Accessed 3 February 2020).

Presseportal (2021) Pflegekräfte stärken bedeutet auch Kinderbetreuung sichern bpa fordert bessere Notbetreuungsangebote für Kinder von Pflegenden in Nordrhein-Westfalen. Available at: https://www.presseportal.de/pm/17920/4816116 (Accessed 3 February 2022)

Measures varied between the States. The Ministry of Health in Bavaria introduced a long-term care group to support residential care settings in responding to COVID-19 cases in December 2020. The group includes experts in care, the authority monitoring quality of care for people with long-term care needs and disabilities and is called out as soon as one confirmed case has been established in a care home. The aim of this group is to prevent, advise and control infections and to support the task force infectious disease. Prior to the long-term care group (since March 2020), the Infectiology task force supported care homes in responding to outbreaks (https://www.stmgp.bayern.de/presse/neue-einsatzgruppe-unterstuetzt-pflege-einrichtungen-im-kampf-gegen-die-corona-pandemie/?output=pdf; https://www.n-tv.de/regionales/bayern/Pflege-Einsatzgruppe-beraet-fast-200-Heime-article22297279.html; https://www.stmgp.bayern.de/presse/huml-pflegeheime-brauchen-besonderen-schutz-vor-covid-19-handlungsanweisungen-des/?output=pdf).

In Lower Saxony care homes experiencing COVID-19 outbreaks could get support from qualified hygienists since May 2020. Health authorities can request support from these mobile teams through the Ministry of Social Affairs, Health and Equality in Lower Saxony (Niedersächisches Ministerium für Soziales, Gesundheit and Gleichstellung) (https://www.ms.niedersachsen.de/startseite/service_kontakt/presseinformationen/mobile-teams-zur-unterstutzung-von-pflegeheimen-bei-covid-19-ausbruchen-eingerichtet-kooperation-mit-medizinischem-dienst-der-krankenversicherung-188513.html).

A report from April/May 2020 showed that among residential care settings experiencing COVID-19 cases, 96.1% (n=749) receive support from a crisis team (https://www.uni-bremen.de/fileadmin/user_upload/fachbereiche/fb11/Aktuelles/Corona/Ergebnisbericht_Coronabefragung_Uni-Bremen_24062020.pdf).

Residential care

The RKI provides guidance on infection prevention and control in residential settings. These guidance documents have been regularly updated throughout the pandemic reflecting improved knowledge around virus transmission  https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Altenpflegeheime.html;https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Pflege/Dokumente.html;jsessionid=7230878758C5CAC3107EBB125EA8FB8B.internet051?nn=13490888; )

A working group of the German Society of Nursing Science have developed a guideline on care in care homes during the pandemic, which also seeks to minimise negative effects of infection control measures. The guideline is currently undergoing a major revision.

Domiciliary care

For domiciliary care, RKI only published a short notice online, last updated in November 2020.

A working group of the German Society of Nursing Science have developed a guideline on domiciliary care during the pandemic which also discusses some of the challenges around infection prevention and control guidance but also making suggestions of how these can be overcome.

Among the barriers identified to effective infection prevention and control in domiciliary care the expert group has identified that home care service providers are not being reimbursed for tasks that are not part of the long-term care insurance scheme. This means that for instance communication and coordination between different service providers or patient, family and carer education are not covered under the reimbursement agreements with the LTC insurance, even though these services could be particularly useful in a pandemic situation.

The document also highlights that domiciliary carers are guests in the home of the person with care needs and that any measures undertaken for infection prevention and control that affect the person with care needs and other people living in the household need to be agreed with them (e.g. isolating a person with COVID-19 in the home). Domiciliary care workers can advise and inform, however, implementing requires the consent of the residents. A domiciliary carer is entitled to protect themselves. The guidance emphasises the importance of consensus between clients and the domiciliary carers.

Suggestions provided in the document include: the development of pandemic plan that centers around the dignity of the person with care needs; the development of a continuity plan should domiciliary care have to stop; domiciliary care workers to receive training on measures for infection prevention; people with care needs to have a say on treatment and care should they develop a COVID-19 infection; infection control measures in the case of a COVID-19 infection; adherence to infection prevention protocols and guidance; adjusting of communication for people with visual, hearing and cognitive impairments; supporting the person with care needs in maintaining social contacts; enabling the person with care needs to maintain and promote mobility; support with nutrition; providing relevant information on pandemic measures to people with care needs and their family carers; in case of a COVID-19 infection there should be regular contact between domiciliary carers and the GP of the person with care needs; domiciliary carers should be able to recognise signs of maltreatment, neglect and abuse and where necessary take steps to protect the person with care needs.

The guideline has been updated once so far and is currently undergoing a major revision.

Day care

Day care and night care services were generally closed during the first phase of the pandemic. The states allowed these services to reopen in autumn in generally, given they had infection control measures in place. Depending on incidence rates, a reduction of the maximum number of users was mandated.

The Robert Koch Institute provides guidelines on infection prevention measures to be taken when transferring a person with a suspected/ confirmed COVID-19 infection between settings. However, actual measures taken has varied across the country.

Guidance:

Guidance to support people living in care homes stress the importance of human dignity and focus on the need to ensure social participation and quality of life of residents (https://www.awmf.org/uploads/tx_szleitlinien/184-001l_S1_Soz_Teilhabe_Lebensqualitaet_stat_Altenhilfe_Covid-19_2020-10_1.pdf). Guidance on approaches to isolation of confirmed/suspected cases in care homes are provided (and regularly updated following the latest evidence) by the Robert Koch Institute.

In some federal states (e.g. Bavaria) relevant ministries can also issue guidelines (https://www.stmgp.bayern.de/wp-content/uploads/2020/08/20200818_handlungsanweisungen.pdf).

In December 2020, the German ethics council issued recommendations on the minimum of social contacts for people receiving long-term care during the COVID-19 pandemic. The council emphasises quality of contacts over quantity, which emphasises the importance of enabling contact with people with whom they have a close and trusting relationship. The document also recognises the important of physical closeness. Where there are no relatives, volunteers should be considered to replace important social contact. Physical contact must be enabled if people with LTC needs express this wish. Programmes supporting social contact should be realised (potentially with help from volunteers) (https://www.ethikrat.org/fileadmin/Publikationen/Ad-hoc-Empfehlungen/deutsch/ad-hoc-empfehlung-langzeitpflege.pdf).

In addition, the authorised representative of the federal government for care has provided concepts to enable safe visiting during the COVID-19 pandemic (https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/3_Downloads/C/Coronavirus/Handreichung-Besuchskonzepte_4.12.20.pdf).

The RKI continues to provide guidance around infection prevention measures around visiting arrangements in residential care settings (https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Alten_Pflegeeinrichtung_Empfehlung.pdf?__blob=publicationFile).

Visiting rules continue to vary somewhat between the federal states. Since the Ministers of Health have agreed on expanding visits in care home again visiting rules have become more similar, but there can be some variation in the number of visitors (in some areas tied to incidence rates), (rapid) testing, hygiene protocols (masks, disinfecting hand), provision of information for contact tracing. In case of an outbreak, care homes can suspect visits in consultation with health authority (https://www.biva.de/besuchseinschraenkungen-in-alten-und-pflegeheimen-wegen-corona/#bw).

On 22 March 2021 the Ministers of Health have agreed that residential care settings are allowed to expand visiting as well as group activities again two weeks after residents received the second vaccination and if there are no active COVID-19 cases in the institutions. There is no differentiation between residents who have received the vaccination and those who have not. New residents, who have not yet been vaccinated should be offered a vaccination appointment in a timely fashion. The federal government will continue to support testing. Länder regulations vary (https://pflegenetzwerk-deutschland.de/fileadmin/files/Corona/210316-Besuchsregelungen-Pflegeheime-Uebersicht.pdf).

The German Federal Ministry of Health has put in place a national testing strategy. Testing is to be provided and paid for by the sickness funds for people with COVID-19 related symptoms, people without symptoms but close contact to a person infected with COVID-19, people in shared social  spaces (e.g. schools, day care centres, refugee centres, prisons) if a positive case has been recorded, staff, patients/residents in residential care settings/hospitals following an outbreak, patients/residents before (re)-entering residential or ambulatory care and staff of health and long-term care setting. Some groups/circumstances are only eligible for rapid tests. (https://www.bundesgesundheitsministerium.de/coronatest.html).

Rules vary between federal states, but LTC staff working in residential or domiciliary care settings have to be tested regularly (https://pflegenetzwerk-deutschland.de/fileadmin/files/Corona/210317-Uebersicht-Testfrequenzen-Laender.pdf).

Health authorities are responsible for contact tracing. Earlier in the pandemic teams were expanded to at least 5 people per 20,000 residents. In addition, affected areas received support from additional teams as well as the armed forces. An app was also been issued to facilitate contact tracing. However, rates have been consistently too high to ensure that contact tracing can be done consistently. It is estimated that all contacts can be traced again when a seven-day incidence of 50 new infections per 100,000 people or below is reached again. The federal government is supporting the individual states (https://www.bundesregierung.de/breg-de/aktuelles/bund-laender-beschluss-1841048; https://www.bundesregierung.de/breg-de/aktuelles/bund-laender-beschluss-1744224 ). A new open-source software was due to be issued to local health authorities, however, so far this software does not offer all promised features and has not been consistently taken up by all health authorities. Other associated costs will be covered by the federal ministry of health (https://www.aerztezeitung.de/Politik/Warum-die-einheitliche-Corona-Kontaktnachverfolgung-holpert-416538.html).

Robert Koch Institute guidelines recommend that contact tracing in residential care settings should be prioritised. The guidelines outline the different levels of contacts and outline responsibilities of the health authority (https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Kontaktperson/Management.htm; https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Alten_Pflegeeinrichtung_Empfehlung.pdf?__blob=publicationFilel).

Two-third of care homes surveyed as part of a study conducted in April/May had implemented clinical monitoring and found that it took on average between 3 and 4 days for care workers and people who use LTC to learn the results of their COVID-19 test (https://www.uni-bremen.de/fileadmin/user_upload/fachbereiche/fb11/Aktuelles/Corona/Ergebnisbericht_Coronabefragung_Uni-Bremen_24062020.pdf).

Across Germany people need to wear surgical or FFP2-masks in public transports and shops since 19 January 2021.

Occupational Health and Safety Regulations stipulate that staff in care homes (https://www.bgw-online.de/SharedDocs/Downloads/DE/Corona/SARS-CoV-2-Arbeitsschutzstandard-Pflege-stationaer_Download.pdf?__blob=publicationFile) and in home care (https://www.bgw-online.de/SharedDocs/Downloads/DE/Corona/SARS-CoV-2-Arbeitsschutzstandard-Pflege-ambulant_Download.pdf?__blob=publicationFile) have to wear FFP-2 masks. In addition, full PPE has to be worn in high risk situations.

At risk groups (people aged 60 and older), people with specific medical risks and people with limited means (recipients of benefits) in Germany receive FFP2 masks for free (https://www.bundesgesundheitsministerium.de/service/gesetze-und-verordnungen/guv-19-lp/schutzmv.html?fbclid=IwAR1ZsHTuu5cNRkbvqnAlRul821iBgJfopUoqu00ygGcODkuAG3ZalNltbXk).

The Federal Government has increased its stock of PPE and increased distribution as infection rates were rising in Winter 2020. The Federal Ministry of Health has also purchased rapid tests to facilitate opening up social life again (https://www.covid19healthsystem.org/countries/germany/livinghit.aspx?Section=2.1%20Physical%20infrastructure&Type=Section). However, rapid tests promised to the German population free by the Federal Minister of Health of charge from 1 March 2021 have been delayed. According to figures for the ECDC Germany is 22nd out of 27 countries in terms of testing (https://www.zdf.de/nachrichten/politik/corona-spahn-schnelltests-verschoben-100.html).

At the beginning of the pandemic federal states have taken different routes to support care providers with protective equipment. A detailed overview can be found here: Lorenz-Dant, 2020).

A study conducted among LTC workers between April and May 2020 showed that respondents found procurement of PPE was quite laborious. Respondents would have preferred a centralised storage and distribution system. Respondents also requested systematic and regular COVID-19 tests as well as rapid tests and improved communication of test results (https://link.springer.com/article/10.1007/s00391-020-01801-7 ).

Already in February 2020, Germany was involved in plans to procure protective equipment for medical staff through a joint European initiative.  In early March 2020, Germany prohibited the export of protective equipment to other countries and the Federal Ministry of Health took responsibility to procure protective equipment for doctors’ surgeries, hospitals and federal authorities (https://www.bundesgesundheitsministerium.de/coronavirus/chronik-coronavirus.html).

References

Lorenz-Dant, K. (2020) Germany and the COVID-19 long-term care situation. LTCcovid, International Long Term Care Policy Network, CPEC-LSE, 26 May 2020. Available at: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf (Accessed 3 February 2022)

A study among unpaid carers in Germany found that a considerable proportion of respondents started using technology for social contacts (https://www.socium.uni-bremen.de/uploads/Schnellbericht_Befragung_pflegender_Angehoriger_-_print.pdf).

COVID-19 vaccination rollout:

Germany’s vaccination strategy has been described here (Lorenz-Dant, 2020). As of 21 December 2021, it is estimated that 70.5% of the general population had received their basic immunisation against COVID-19 and 33.8% had also received a booster (Impfdashboard.de, 2022).

Progress has been relatively slow, but most people living in residential care setting had received the first dose by mid-February 2021 (Lorenz-Dant & Ettelt, 2021). Ongoing progress is reported through the vaccination dashboard (Impfdashboard.de, 2022). However, the dashboard only reports estimates, as a reliable monitoring system is not in place in Germany.

Systematic monitoring of vaccination in residential care facilities was only introduced in October 2021, based on a nationwide sample of care homes and Bavarian monitoring data (n = 1003 facilities). A first report indicates that in October 2021 on average 89.3 % of all residents in care homes and nursing homes had received their basic immunisation and 48.7% had received a booster. However, large variations between different residential care facilities were also reported with individual rates ranging between 28% -100% for the basic immunisation and 0% to 100% for booster vaccinations (Robert Koch Institut, 2021).

According to the same report, on average 81.1% (range: 20% – 100%) of staff in residential care facilities had received their basic immunisation in October and 23.4% (range: 0% – 100%) had received a booster (Robert Koch Institut, 2021).

Unlike in the earlier phases of the vaccination rollout, older persons or residents of residential care facilities are not prioritised to receive booster immunisations. While vaccinations to residential care facilities are still usually organised by the respective state or municipal authorities, persons cared for in their own homes have to rely on their primary care physicians to prioritise them or compete for appointments at vaccination centres in those Länder where they still exist.

Even during the initial rollout, persons cared for in their own homes had to visit a vaccination centre or their personal primary care physician for their immunisation in many Länder, as mobile teams were only deployed to these individuals in some Länder (such as Berlin). This is the case even if a home care service is employed, as Registered Nurses in Germany are not allowed to administer vaccinations independent from a physician. Restricted mobility as well as impaired social, cognitive and financial resources can impede access to the vaccination centres or arrangement of appointments with the individual’s physician. Home care services can be reimbursed for some limited assistance in these cases in some Länder. Support for this user group varies between the Länder.

Many people with disabilities have been isolating since March 2020. The focus of the vaccination on older people, people living in residential care setting and health care workers meant that many people with disabilities living independently had long waiting times for access to vaccines as they fell into Group 2 or lower. There has been criticism that people with disabilities, many of which are at high risk, do not have the same lobby power as older people (Deutschlandfunk.de, 2021).

Mandatory vaccination for Long-Term Care staff

Early in 2021, there was some debate about introducing mandatory vaccination for health and LTC workers, but the Government had then decided against it. With the fourth wave of the COVID-19 pandemic in Autumn 2021 that also led to a resurgence of cases and fatalities in residential care facilities and a growing debate around low vaccination rates among employees in residential care facilities, the debate resurfaced. The newly elected Federal Parliament on 10 December  2021 introduced mandatory COVID-19 vaccinations for all employees at hospitals, residential care facilities and providers of community care services coming into effect on 15 March 2022.

On 10 December 2021 the Federal Parliament also limited access to public transport to persons who are vaccinated or who have recovered from COVID-19 or who can provide a current negative lateral flow test. The same applies to all work places where employers have to provide lateral flow tests to employees. Some states have also limited access to restaurants, retail, gyms and other venues to persons who can provide proof of vaccination or recovery from COVID-19.

References

Deutschlandfunk.de (2021) Coronavirus – Menschen mit Behinderung fühlen sich im Stich gelassen. Available at: https://www.deutschlandfunk.de/coronavirus-menschen-mit-behinderung-fuehlen-sich-im-stich-100.html (Accesse 11 February 2022).

Impfdashboard.de (2022) Wie ist der Fortschritt der COVID-19-Impfung? Aktueller Impfstatus. Available at: https://impfdashboard.de/ (Accessed 11 February 2022).

Lorenz-Dant (2020) A brief overview of the current German Covid-19 vaccination strategy. Available at: https://ltccovid.org/2020/12/18/a-brief-overview-of-the-current-german-covid-19-vaccination-strategy/ (Accessed 11 February 2022).

Lorenz-Dant & Ettelt (2021) Roll-out of Sars-CoV-2 vaccination in Germany: how it started, how it is going. Available at: https://ltccovid.org/2021/02/09/roll-out-of-sars-cov-2-vaccination-in-germany-how-it-started-how-it-is-going/(Accessed: 11 February 2022).

Robert Koch Institut (2021) Monitoring von COVID-19 und der Impfsituation in Langzeitpflegeeinrichtungen STAND DER ERHEBUNG SEPTEMBER BIS OKTOBER 2021 Durchgeführt vom Robert Koch-Institut (RKI) Bericht vom 15.12.2021. Available at: https://www.rki.de/DE/Content/Infekt/Impfen/ImpfungenAZ/COVID-19/Bericht1_Monitoring_COVID-19_Langzeitpflegeeinrichtungen.pdf?__blob=publicationFile (Accessed 11 February 2022)

The Federal Government has issued support measures for unpaid carers during the COVID-19 pandemic (so far valid until 31 March 2021). These include ‘Care Support Payment’, which covers carers pay for up to 20 working days when they need to cover care during the pandemic or if they need to provide care that cannot be replaced by someone else. Working carers can also take ‘family care time’ if they have not used the maximum number of days. Family carers can request an interest free loan or to get loss of income during the pandemic recognised in repayment scheduling (Bundesministerium für Familie, Senioren, Frauen und Jugend, 2021).

The German Society of Nursing Science has developed new guidance on how domiciliary carers can support unpaid carers, this includes offering training on hygiene measures for family carers; informing family carers about available support structures and services; family carers to receive psychosocial support or to be provided with information about psychosocial support (https://www.awmf.org/uploads/tx_szleitlinien/184-002l_S1_Haeusliche-Versorgung-soziale-Teilhabe-Lebensqualitaet-bei-Menschen-mit-Pflegebedarf-COVID19-Pandemie_2020-12.pdf).

In Bavaria unpaid carers receive three FFP2 masks for free through their local government (Pflegeberatung.de, 2022).

References

Bundesministerium für Familie, Senioren, Frauen und Jugend (2021) Informationen für pflegende Angehörige. Available at: https://www.bmfsfj.de/bmfsfj/themen/corona-pandemie/informationen-fuer-pflegende-angehoerige (Accessed 11 February 2022).

Pflegeberatung.de (2022) Aktuelle Regelungen in der Pflege im Kontext von Corona. Available at: https://www.pflegeberatung.de/corona (Accessed 11 February 2022).

Expansion of entitlement to LTC benefits

From 2017 the legal entitlement to LTC benefits and the categories of beneficiaries have been extended (particularly to people with dementia) by recognising cognitive and mental capacity as part of the instrument used to assess people’s care level. The assessment encompasses the six areas: mobility, cognitive and communication abilities, behavioural and mental difficulties, self-care, ability to cope and independently manage health or therapy related needs and burden, organising everyday life and social contacts; in addition, the amount of benefits have increased substantially for most through the reorganisation of support entitlements into five care grades. No person already receiving support should have been worse off following the reform.

Co-payments for people living in residential care settings no longer depend on a person’s care grade. All people in living in a nursing now pay the same care-related co-payment (the amount differs between residential homes). In addition, people in full- or part residential care settings receive a legal entitlement for additional offers of care.

Increasing contributions to LTC insurance

As part of this ‘second care strengthening bill’ (zweites Pflegestärkungsgesetz) contribution rates to the mandatory long-term care insurance increased by 0.2 percentage points (to 2.55 per cent for people with children and 2.8 per cent for people without children).

Income cap on co-payments for children of beneficiaries

Children of people with care needs can be exempt from the obligation to cover the cost of care for their parent that is not provided for as part of the LTC insurance. Since 2019 this exemption has been put in place for children of people with care needs earning less than EUR 100,000 (annual gross income) (European Commission, 2021).

Cap on co-payments for people living in residential care settings over longer time periods

In June 2021 a new care reform was passed. The reform seeks to relieve people living in residential care settings for longer periods of time from some of the co-payments. For example, the reform seeks to reduce co-payments of people living in residential care for more than 12 months by 25 per cent (on average €228 per month based on average contributions of €911). This reduction increases with time spent in residential care. For people living in residential care settings for more than 36 months, the reduction will amount to 70 per cent (on average €638 per month based on average contributions of €911).

The reform is planned to be financed by a federal grant (1 billion per year) and an increase in the long-term care insurance of 0.1 per cent for childless people (Bundesministerium für Gesundheit, 2021).

Reference

Bundesministerium für Gesundheit (2017) Die Pflegestärkungsgesetze – Das Wichtigste im Überblick. Available at: https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/5_Publikationen/Pflege/Broschueren/PSG_Das_Wichtigste_im_Ueberblick.pdf(Accessed 1 February 2022)

European Commission (2021) 2021 Long-term care report – Trends, challenges and opportunities in an ageing society. Country profiles Vol. 2. Available at: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu) (Accessed 4 February 2022).

Funding for digital and technical innovations

The LTC insurance funds can provide home care and residential care providers between 2019 and 2021 with partial funding (up to €12,000) to support the purchasing of technical tools aimed at improving working conditions and reducing bureaucratic load (European Commission; 2021; Bundesministerium für Gesundheit, 2021).

References

Bundesministerium fuer Gesundheit (2021) Sofortprogramm Pflege. Available at: https://www.bundesgesundheitsministerium.de/sofortprogramm-pflege.html (Accessed 4 February 2022).

European Commission (2021) 2021 Long-term care report – Trends, challenges and opportunities in an ageing society. Country profiles Vol. 2. Available at: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu) (Accessed 4 February 2022).

An EU report (2021) notes that care-support bases offering advice and support are being set up in Germany, providing relevant information, application forms, and practical assistance (European Commission, 2021).

References

European Commission (2021) 2021 Long-term care report – Trends, challenges and opportunities in an ageing society. Country profiles Vol. 2. Available at: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu) (Accessed 4 February 2022).

Replacement care

The care strengthening bills ensure that when unpaid carers are temporarily unable to provide care (e.g. holidays, illness) for people with care level 2 or higher, the long-term care insurance covers the costs of up to six weeks replacement (up to €1,612) care per calendar year. This can also support other household members/unpaid carers taking on the replacement care. This replacement care can also be taken up on an hourly basis. (erste pflegestarkungsgesetz). In addition, replacement care can be combined with 50per cent of the support for short-term care (Kurzzeitpflege) (Bundesministerium für Gesundheit, 2017b; Bundesministerium für Gesundheit,2021).

Retirement contribution & unemployment insurance

Following the care strengthening bills, unpaid carers in Germany providing community care for people at care level 2 or higher, providing 10 or more hours per of care and do not work more than 30 hours per week are entitled to retirement contributions through the long-term care insurance. In addition, protection through the unemployment insurance has been expanded for carers. This also remains when unpaid carers take holidays (Deutsche Rentenversicherung. 2022 ;Bundesministerium für Gesundheit, 2021).

Entitlement to qualified advice

The care strengthening bills also provided an entitlement to qualified advice from their care fund. This can help unpaid carers to organise and coordinate care arrangements (Bundesministerium für Gesundheit, 2017b).

Leave and reduced hours for working family carers

A bill to improve the compatibility of family, care and work enables employees to leave their job for up to six months to care for a close relative at home. In addition, employees can reduce their work hours for up to two year to up to 15 hours per week. To mitigate the loss of income, employees taking up this possibility can apply for an interest-free loan from a government agency (Bundesministerium für Gesundheit, 2017b).

In addition, working unpaid carers can take up to 10 days paid leave (paid by long-term care insurance – care support money) if they need to temporarily organise care for a close relative (Bundesministerium für Gesundheit, 2017b).

Improved access to rehabilitation

From 2019 unpaid carers receive improved access to rehabilitation. The changes include that unpaid carers can now access residential rehabilitation even if from a medical perspective ambulatory treatment would be sufficient. Unpaid carers are also entitled to have the person they care for looked after in the same residential setting where they receive medical rehabilitation (Bundesministerium für Gesundheit, 2018).

References

Bundesministerium für Gesundheit (2021) Verhinderungspflege (Urlaubs-/Krankheitsvertretung). Available at: https://www.bundesgesundheitsministerium.de/verhinderungspflege.html (Accessed 1 February 2022).

Bundesministerium für Gesundheit (2018) Neuregelungen im Jahr 2019 in Gesundheit und Pflege. Available at: https://www.bundesgesundheitsministerium.de/presse/pressemitteilungen/2018/4-quartal/neuregelungen-2019.html(Accessed: 1 February 2022)

Bundesministerium für Gesundheit (2017b) Die Pflegestärkungsgesetze – Das Wichtigste im Überblick. Available at: https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/5_Publikationen/Pflege/Broschueren/PSG_Das_Wichtigste_im_Ueberblick.pdf(Accessed 1 February 2022)

Deutsche Rentenversicherung (2022) Pflege von Angehörigen lohnt sich auch für die Rente. Available at: https://www.deutsche-rentenversicherung.de/DRV/DE/Rente/Familie-und-Kinder/Angehoerige-pflegen/angehoerige-pflegen_node.html (Accessed 1 February 2022)

Financial support to adapt homes

People with LTC needs can receive up to €4,000 for changes to their home (for example, to widen doors) to enable people to remain in the community for longer (Bundesministerium für Gesundheit, 2017a, 2017b).

Financial support for shared accommodation for people with care need needs in the community

The care strengthening bills support people wishing to set up shared accommodation for people with LTC needs by providing financial support to set this up. People with care needs living in shared accommodations can also receive monthly financial support (Bundesministerium für Gesundheit, 2017a, 2017b).

Expansion of day and nigh care services

The first care strengthening bill expanded day and night care services. These services can be used without reducing people’s care allowance or entitlement to domiciliary care (Bundesministerium für Gesundheit, 2017b).

References

Bundesministerium für Gesundheit (2017a) Erstes Pflegestärkungsgesetz (PSG I). Available at: https://www.bundesgesundheitsministerium.de/service/begriffe-von-a-z/p/pflegestaerkungsgesetz-erstes-psg-i.html(Accessed 1 February 2022)

Bundesministerium für Gesundheit (2017b) Die Pflegestärkungsgesetze – Das Wichtigste im Überblick. Available at: https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/5_Publikationen/Pflege/Broschueren/PSG_Das_Wichtigste_im_Ueberblick.pdf(Accessed 1 February 2022)