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 Germany, 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 Germany.
Experts on COVID-19 and long-term care in Germany that have contributed to this report:
Living report: COVID-19 and the Long-Term Care system in Germany
PART 1 – Long-Term Care System characteristics and preparedness
- 1.00. Brief overview of the Long-Term Care systemIn 2019, there were about 4.13 million people with LTC needs that have been allocated into care levels 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%). Of those living in their own homes, more than 60% were supported by informal carers only while almost 30% use care and support from both unpaid and domiciliary carers or domiciliary carers only. Approximately 80% of people with LTC needs living at home have a level 2 and 3 care need. (source: https://www.destatis.de/DE/Themen/Gesellschaft-Umwelt/Gesundheit/Pflege/Tabellen/pflegebeduerftige-pflegestufe.html). Care needs are classified into five categories. Level 1 reflects lower needs, while level 5 represents severe needs. The assignment for the overall levels is based on 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 degree of support provided varies between the different levels of care need (source: https://academic.oup.com/gerontologist/article/58/3/588/3100532). In 2019, out of the 15,380 residential care homes, 43% were operated by private for-profit provider, 53% by private not-for-profit providers and 5% were owned and operated by public providers (source: https://www.gbe-bund.de).
- 1.01. Population size and ageing context
Germany has a population of 83.1 million. In 2018, 17.9 million people were aged 65 years and older (22% of the population). According to the German Federal Statistical Office (Destatis), in 2019 there were 4.1 million people with long-term care needs, 62% women (source: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf). Furthermore, population age is not distributed evenly across the country. A larger share of population with care needs have been identified in Federal States in the East of Germany, which may in part be due to higher average age and a larger share of women, who more frequently experience care needs compared to men of the same age (source: https://www.iwkoeln.de/fileadmin/publikationen/2015/244405/IW-Trends_2015-03-04_Kochskaemper_Pimpertz.pdf).
- 1.02. Long-Term Care system governance
The government has laid out the legal framework, providing an overview of the different actors, their roles and the list of benefits in the Social Code Book XI (source: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view). The German Federal Government has a dedicated person responsible for care. This role was created in 2014 and the responsible person was appointed in 2018. 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. (source: https://www.pflegebevollmaechtigter.de/amt-und-person.html).
By law, 50% of residential care workers are required to be trained as skilled workers. This requirement, however, is not always met. From March to October 2020 quality controls were suspended during the pandemic to relieve the burden on domiciliary and residential care (source: https://www.bundesgesundheitsministerium.de/presse/pressemitteilungen/2020/1-quartal/corona-gesetzespaket-im-bundesrat.html; https://www.mdk.de/aktuelles-presse/meldungen/artikel/ab-oktober-persoenliche-pflegebegutachtungen-und-qualitaetspruefungen/).
The medical service of the health insurances (Medizinischer Dienst der Krankenversicherung (MDK)) 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 MDK evaluates quality of services on an annual basis. The Social bill ensures that members of the MDK are independent.
TheLTC insurances funds are required to publish the quality reporting of the MDK. 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 (source: https://www.mdk.de/mdk/mdk-gemeinschaft-gesundheitssystem/; https://link.springer.com/content/pdf/10.1007%2F978-3-662-56822-4.pdf).
- 1.03. Long-term care financing arrangements and coverage
In 2018, Germany’s expenditures for LTC amounted to 2.1% of GDP, including voluntary insurance and out-of-pocket-spending. Expenditures for compulsory government schemes amounted to 1.5% of the GDP, which is below the OECD average of 1.7% Germany has a LTC insurance system, which is the dominant financing scheme for LTC and is mandatory for enrolees in the statutory or private health insurance (source: Germany_draft.pdf (who.int). The LTC insurance is financed through equal contribution between employer and employees. Childless people pay a slightly higher contribution rate than those with children (3.30% of gross wages versus 3.05%) (source: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view). Financial situation of LTC funds in 2020 can be found online.
In 2019, 4.25 million inhabitants received benefits from the LTCI. Of them, 3.34 million received home care and 0.91 million received residential care, and 4 million were covered by social LTCI and 0.25 million by private compulsory LTCI (source: Germany_draft.pdf (who.int). 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. Where individuals/families cannot shoulder these costs, this will be provided through social security mechanisms. Costs vary substantially between the different Lander. 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 (source: http://www.sozialpolitik-aktuell.de/files/sozialpolitik%20aktuell/_Politikfelder/Gesundheitswesen/Datensammlung/PDF-Dateien/abbVI49_Thema_Monat_02_2020.pdf).
LTCI grants access to services on the basis of LTC needs and it is not means-tested. Everyone with LTC needs is entitled to receive the services they require regardless of age, income, wealth, personal circumstances (such as living with a carer) and medical diagnosis (whether physical or cognitive). A needs assessment recognizes whether an individual should receive benefits and the amount. Individuals have to take a needs-based, uniform assessment test, which assigns them to one out of five potential “care degrees” ranging from 1 – “little impairment of independence” to 5 – “hardship”. The “care degrees” define the amount of benefits that the individual receives (source: Germany_draft.pdf (who.int).
- 1.04. Approach to care provision, including sector of ownership
Over the past three decades, Germany has seen an overall increase in home care and residential care providers. However, the increase in beneficiaries has been even steeper, leading to a higher number of beneficiaries per provider. Both homecare and residential care recorded a change in the market structure from private non-profit to private for-profit providers. The change is however more pronounced in home care than in residential care (source: Germany_draft.pdf (who.int).
Between 1999 and 2019, the share of private care providers in residential care increased from 35% to almost 43%, while the share of third sector organisations declined from 57% to 53% and that of public institutions from 8.5% to 4.5%.
Among domiciliary care providers, the share of private providers increased from 51% to 67%, while the proportion of third sector decreased from 47% to 32% and that of public providers from 19% to 1% between 1999 and 2019.
- 1.05. Quality and regulation in Long-term care
Quality of LTC has been a government focus, and addressed through different laws, including new procedures for quality assurance and reporting in residential care settings, financing of 13,000 additional posts, LTC pay rates required to be set according to collective wage agreements and the development of a test to calculate adequate staffing levels (Personalbemessungsverfahren) in LTC settings (source: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view; https://www.gs-qsa-pflege.de/wp-content/uploads/2020/09/Abschlussbericht_PeBeM.pdf).
Responsibility for quality of services sits with the providers, however they operate in close collaboration with LTC funds and municipalities. Länder and local authorities are responsible for an efficient infrastructure, including that facilities are available and accessible (source: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view).
- 1.06. Care coordination and personalization
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 (source: https://www.awmf.org/Haeusliche-Versorgung-soziale-Teilhabe-Lebensqualitaet-bei-Menschen-mit-Pflegebedarf-COVID19-Pandemie_2020-12.pdf).
- 1.07. Information and monitoring systems
Reports show that the health and long-term care insurance funds collect data on clients’ service use. Some of the information can be accessed (anonymised) for research purposes.
- 1.08. Care home infrastructure
A report by the University of Cologne suggests that the increasing demand for residential care requires establishing additional as well as maintaining existing resources (source: https://www.iwkoeln.de/fileadmin/publikationen/2015/244405/IW-Trends_2015-03-04_Kochskaemper_Pimpertz.pdf). 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). (Source: https://www.gbe-bund.de/gbe/pkg_isgbe5.prc_menu_olap?p_uid=gastd&p_aid=15610743&p_sprache=D&p_help=2&p_indnr=570&p_indsp=&p_ityp=H&p_fid=)
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 federal states 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-Wurttemberg, 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 (source: https://www.deutschlandfunk.de/einzelzimmerquote-in-der-pflege-mehr-privatsphaere-weniger.769.de.html?dram:article_id=466416; https://www.aerzteblatt.de/nachrichten/105668/Baden-Wuerttemberg-lockert-Einzelzimmervorgabe-fuer-Pflegeeinrichtungen; https://www.swp.de/suedwesten/landespolitik/umbau-oder-schliessung_-neue-vorschriften-29392427.html).
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 (source: https://www.tz.de/muenchen/stadt/neue-standards-pflegeheimen-mehr-platz-aber-weniger-plaetze-zr-6706663.html).
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 (source: https://www.bertelsmann-stiftung.de/fileadmin/files/BSt/Publikationen/GrauePublikationen/Studie_VV_FCG_Pflegeinfrastruktur.pdf).
- 1.10. Workforce conditions: pay, employment conditions, qualification levels, shortages
In 2019, the rate of LTC workers per 100 inhabitants 65 years and above in Germany was slightly above the OECD average, at 5.1 compared to 4.9. Of all LTC workers, about one third full-time equivalents was employed in home care and the remaining two thirds were employed in residential care. The workforce is predominantly female and works part-time (source: Germany_draft.pdf (who.int).
In 2019, approximately 976,500 (mostly qualified) people worked in residential care settings. Almost two thirds (more than 85% women) were employed part-time (source: https://www.gbe-bund.de/gbe/!pkg_olap_tables.prc_set_page?p_uid=gastd&p_aid=3932778&p_sprache=D&p_help=2&p_indnr=406&p_ansnr=61388070&p_version=3&D.499=1000529&D.993=1000518&D.991=23746).
The creation of an additional 13,000 additional care workers in residential care settings has been criticised as too low and efforts to make jobs more attractive through pay increase have been insufficient to attract people. This law came was prepared in 2018 and came into effect in large parts in 2019 (source: Gesundheitspolitik – Gesetze und Verordnungen 19. Wahlperiode: seit 2017 (vdek.com). LTC workforce shortage is one of the main concerns. Projections estimated that Germany will have a shortage of 263,000 full time care workers by 2030. (source: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view).
Working conditions are considered poor, especially given the wages and social standing are low, while working hours are unfavourable and physical and psychological strain is high (source: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view).
A 2020 report on care (Barmer Pflegebericht) found that, due to insufficient staffing levels, care workers had to work more overtime, duty rosters couldn’t be adhered to and care workers were called in when they were on leave. This can lead to reduced working ethic and lower quality of care. A comparison of psychological burden of LTC workers in comparison with other jobs showed that burden was higher in a number of the aspects compared. The report also showed that while the majority of care workers felt their job was important, 53% of care workers reported that they felt their work was socially recognised.
In 2019, LTC workers earned a median gross salary of €2146- 3032 per month (FTE-adjusted) depending on their level of qualification, although salaries in residential care tend to be higher than in homecare. Salaries in LTC sector have increased by about 28% from 2012 to 2019, however the salaries are considerably below the median salary of nurses working in hospitals, and Germany might see a drift of the LTC workforce from the LTC sector to the inpatient sector (source: Germany_draft.pdf (who.int). The share of LTC workers who are unhappy with their incomes (almost half) is higher than among employees in other jobs (less than 30%). Among people working care 53% report having difficulty to live off their income. Among LTC workers, 52% think that their retirement pay will not be sufficient (source: https://www.barmer.de/blob/278006/6b0313d72f48b2bf136d92113ee56374/data/barmer-pflegereport-2020.pdf).
A report by the Bertelsmann Stiftung found that future availability of workforce is likely to differ across the country. In most local authority areas and districts in Eastern Germany an increasing number of people with care needs is unlikely to be met by decreasing number of care workers. Challenges were also identified for Bavaria and Schleswig-Holstein, while parts of Westphalia, Hessen and Baden-Wuerttemberg do not expect to experience the same challenges.
On 2 June 2021 the German government has passed a new care reform (Pflegereform 2021) that sets out that all LTC workers in care homes need to pay their staff according to tariff. It is also planned that care homes will be able to recruit more staff. This should be enabled through national guidelines. The reform also plans to provide LTC workers with more responsibility to make independent decision as part of domiciliary care. These changes are scheduled to come to effect in September 2022 (source: Pflegereform – Altenpflege wird besser bezahlt und der Beruf attraktiver – Bundesgesundheitsministerium).
- 1.11. User voice, choice and satisfaction
LTC users living at home have choice in a sense that once their care needs are assessed they can choose whether they prefer financial or in-kind support. This is embedded in the principles of the LTC insurance, which aims to support people in living a self-determined and independent life. The Care Charta emphasises people’s choice regarding where to live, care and support and their daily routine as well as financial and legal aspects (source: https://www.der-paritaetische.de/fileadmin/user_upload/Schwerpunkte/Mensch-du-hast-recht/doc/VT2018_WS-Selbstbestimmung-Pflege_ThorstenMittag.pdf; https://www.pkv.de/wissen/pflegeversicherung/so-funktioniert-die-pflegeversicherung/). The task force on LTC recognises the importance of self-determination among people with LTC needs during COVID-19 (source: https://sozialministerium.baden-wuerttemberg.de/fileadmin/redaktion/m-sm/intern/downloads/Downloads_Gesundheitsschutz/Corona_Positionspapier-TF-Langzeitpflege-EGH_Selbstbestimmung-Teilhabe_20201204.pdf).
- 1.13 Pandemic preparedness of the Long-term care sector
Each of the 16 Federal States carries responsibility for the pandemic in their area. On a national level, the Robert Koch-Institute (RKI) takes a key role in infectious disease monitoring and prevention. The Institute also provides pandemic 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 PPE stockpiling, vaccination and training of staff. This plan has been amended to respond to the COVID-19 pandemic in March 2020. A second federal authority with the task to reduce health related risks is the Federal Office for Civil Protection and Disaster Assistance. As early as in 2013, it already warned of the risk of a pandemic through a virus of the ‘virus family Coronaviridae’. Despite this systemic preparedness, in practice there has been divergence in handling and applying hygiene plans, the experience that not all LTC settings had developed specific plans or not developed them in sufficient detail and that not all care workers, especially assistants, had not been sufficiently trained as well as a shortage of protective equipment. The existing shortage in the care workforce posed additional challenge to the response during the pandemic. While the government has taken some measures to increase the attractiveness of working in the LTC sector and the quality of care provided, more needs to be done (source: https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view).
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 (source: https://www.springermedizin.de/gesundheitsversorgung-und-pflege-fuer-aeltere-menschen-in-der-zu/18584958).
A survey conducted among care providers in April/May 2020 found that almost two thirds of care home 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 institutions that did not have training the proportion of those that have been more severely affected by outbreaks was higher. 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 (source: https://media.suub.uni-bremen.de/bitstream/elib/4331/4/Ergebnisbericht%20Coronabefragung%20Uni-Bremen.pdf).
- 1.09. Community-based care infrastructure
The municipalities/ local authorities are primarily responsible for the care infrastructure in their area. 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).
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%.
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 24, 2021, there have been 2,402,818 confirmed COVID-19 infections in Germany, and 68,740 deaths attributed to COVID-19, according to the RKI.
The first wave has been relatively mild, however, the second wave, experienced mostly during December 2020 and January 2021, has been a lot more severe (Source: https://www.zdf.de/nachrichten/heute/coronavirus-ausbreitung-infografiken-102.html). It is anticipated that Germany is going into a third wave as mutations are becoming more widespread (Source: https://www.spiegel.de/politik/ausland/coronavirus-angela-merkel-sieht-deutschland-in-dritter-welle-a-2e8dc0f6-88db-44aa-8432-1cc8c687dbfa).
- 2.02. Deaths attributed to COVID-19 among people using long-term care
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%).
According to a survey conducted in April/May 2020, 50% of COVID-19 related deaths occurred in residential care settings and 12% among people receiving domiciliary care services, while the overall share of people infected in care homes only amounted to 8.5%. It also showed that long-term care workers (particularly those working in residential settings) had a higher risk of infection. Additionally, the survey showed that long-term care providers reported in April/May 2020 that almost every third client who tested positive for COVID-19 died (Sources: https://www.socium.uni-bremen.de/uploads/Ergebnisbericht_Coronabefragung_Uni-Bremen_24062020.pdf).
Based on Robert Koch Institute data, as of March 24, 2021, 120,763 people living in communal settings and 58,736 people working in these settings (as defined by §36 IfSG) had been infected with COVID-19. Out of these, 21,372 residents as well as 163 staff have died. The total number of COVID-19 related deaths in Germany on the same date was 75,212. Therefore, deaths in communal settings represent 28% of all deaths. 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 had been care home residents, 2.61% of all care home residents would have died due to COVID-19 (Source: https://de.statista.com/statistik/daten/studie/36438/umfrage/anzahl-der-zu-hause-sowie-in-heimen-versorgten-pflegebeduerftigen-seit-1999/).
- 2.04. Impacts of the pandemic on access to care for people who use Long-Term Care
Access to care for people living in the community
In Germany many people with care needs living in their own homes receive support from Eastern European migrant workers. The border closure around Easter 2020 left many people without their usual support (https://drive.google.com/file/d/1-RDnqErydbuGGNXlM8WaFB2oSTRKStTc/view).
A survey among family carers of older people 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.
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.
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)
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
- 2.05. Impacts of the pandemic on the health and wellbeing of people who use Long-Term Care
There is no information available that systematically measures the impact of COVID-19 on the health and wellbeing of people with LTC needs. 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.
A study in Berlin investigated the impact of the COVID-19 pandemic on mental health and perceived psychosocial support for elderly 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).
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
- 2.07. Impacts of the pandemic on unpaid carers
A survey among family carers of older people 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).
PART 3 -Measures adopted to minimise the impact of the COVID-19 pandemic on people who use and provide Long-Term Care
- 3.01. Brief summary of the overall pandemic response (not specific to Long-Term Care)
The first wave was relatively mild. However, the second wave experienced mostly during December 2020 and January 2021, was a lot more severe (Source: https://www.zdf.de/nachrichten/heute/coronavirus-ausbreitung-infografiken-102.html). Since March 2021, a third wave is developing with currently high incidence rates and mounting pressure on the health system and critical care resources (Source: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Situationsberichte/Apr_2021/2021-04-09-de.pdf?__blob=publicationFile), caused by a more infectious variant of SARS-CoV-2 (VOC B.1.1.7) becoming the dominant strain (Source: https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/DESH/Bericht_VOC_2021-03-31.pdf?__blob=publicationFile) and relaxation of measures to curb transmission at the beginning of March 2021 (Source: https://www.bundesregierung.de/breg-de/themen/coronavirus/fuenf-oeffnungsschritte-1872120).
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) (Sources: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf; https://www.bundesregierung.de/breg-de/themen/coronavirus/corona-diese-regeln-und-einschraenkung-gelten-1734724).
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 (Source: https://www.bundesgesundheitsministerium.de/service/gesetze-und-verordnungen/guv-19-lp/4-bevschg-faq.html).
- 3.02. Governance of the Long-Term Care sector's pandemic response
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.
- 3.02.01. National or equivalent Covid-19 Long-Term Care taskforce
No national COVID-19 LTC taskforce was established, as health and social care largely falls under Länder [State] authority. However, the State Secretary at the Federal Ministry of Health has in some cases sought a moderating role highlighting topics of importance (Source: https://www.pflegebevollmaechtigter.de/nws-zum-Coronavirus.html). Federal agencies like the Robert Koch Institute have not established LTC-specific taskforces.
Some Länder (e.g. Bavaria, Baden-Württemberg) have established LTC-task forces within their respective Ministries of Health. How these task forces are constituted, and work remains largely unclear.
- 3.02.02. Measures to improve coordination between Health and Social Care in response to the pandemic
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 in the community) and the long-term care system, operate independently of each other. No formal coordination 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 (Source: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf).
- 3.02.03. Measures to support, facilitate and compensate for disruptions to access to care
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).
- 3.03. Monitoring Covid-19 impacts in the Long-Term Care sector: data and information systems
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.
- 3.04. Financial measures to support users and providers of Long-Term Care
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 (Sources: https://www.bundesgesundheitsministerium.de/presse/pressemitteilungen/2020/1-quartal/corona-gesetzespaket-im-bundesrat.html; https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf) .
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 (Source: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf).
The Federal Government has improved access to basic security provision (including costs for accommodation and heating) but also for lunch provision for children with relevant needs (Source: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf). 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 (Source: https://link.springer.com/article/10.1007/s00391-020-01801-7 ).
In addition, there has been criticism regarding the limited focus of COVID-19 social protection packages on people with disabilities (Source: https://www.vdk.de/deutschland/pages/presse/presse-statement/79041/behinderung_corona).
- 3.05. Long-Term Care oversight and regulation functions during the pandemic
LTC quality checks and necessary patient to staff ratios were temporarily suspended. Regular quality checks will not be undertaken until at least until February 28, 2021. Quality checks were only undertaken if there was reason to suspect that quality of care was not maintained (Source: https://www.pflegeberatung.de/corona).
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).
- 3.06. Support for care sector staff and measures to ensure workforce availability
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.
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 (Source: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf). 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).
While children of staff working in system relevant jobs (including health and LTC) can access emergency childcare, there have been demands to expand available childcare services to reflect the demands on care workers (Source: https://www.presseportal.de/pm/17920/4816116; https://km-bw.de/,Lde/Startseite/Service/2020+04+20+Notbetreuung+wird+vom+27_+April+2020+an+erweitert).
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 (Source: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf).
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 (Source: https://www.biva.de/besuchseinschraenkungen-in-alten-und-pflegeheimen-wegen-corona/#bw).
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) (Source: https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf).
Germany relaxed some staffing rules and operational frameworks to relieve pressure on the workforce (Source: https://apps.who.int/iris/bitstream/handle/10665/336303/Eurohealth-26-2-77-82-eng.pdf).
- 3.07. Infection Prevention and Control measures in the Long-Term Care sector: guidance, training and implementation support
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/Alten_Pflegeeinrichtung_Empfehlung.pdf?__blob=publicationFile ; https://www.rki.de/DE/Content/InfAZ/N/Neuartiges_Coronavirus/Altenpflegeheime.html).
For domiciliary care only a short notice has been issued.
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.
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.
- 3.07.01. Measures in relation to transfers to and from hospital, from community to care homes and between settings
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. ().
- 3.07.02. Approach to isolation of people with confirmed or suspected Covid-19 infections in care homes
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).
- 3.07.03. Visiting and unpaid carer policies in care homes
On 10 February 2020 the Federal Government noted that in some care and nursing homes staff and residents have already received the second vaccine. In addition, there has been a joint effort to undertake rapid tests in residential care settings. The Government asks federal states to develop concepts to expanded visiting rules following full vaccination. The armed forces can support rapid testing (https://www.bundesregierung.de/resource/blob/975226/1852514/508d851535b4a599c27cf320d8ab69e0/2021-02-10-mpk-data.pdf?download=1).
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).
- 3.06.01. Surge staffing and other measures to support care homes with outbreaks or critical staff shortages
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).
- 3.08. Access to testing and contact tracing for people who use and provide Long-Term Care
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).
- 3.09. Access to Personal Protection Equipment (PPE) in the Long-Term Care sector
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 (https://ltccovid.org/wp-content/uploads/2020/05/Germany_LTC_COVID-19-26-May-2020.pdf).
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).
- 3.10. Use of technology to compensate for difficulties accessing in-person care and support
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).
- 3.11. Vaccination policies for people using and providing Long-Term Care
COVID-19 vaccination rollout:
Germany’s vaccination strategy has been described here. 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.
Progress has been relatively slow, but most people living in residential care setting had received the first dose by mid-February 2021. Ongoing progress is reported through the vaccination dashboard (https://impfdashboard.de/). 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.
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.
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.
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.
- 3.12. Measures to support unpaid carers
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 (https://www.bmfsfj.de/bmfsfj/themen/corona-pandemie/informationen-fuer-pflegende-angehoerige).
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. (https://www.pflegeberatung.de/corona)
PART 4 – Reforms to strengthen Long-Term Care systems and to improve preparedness for future pandemics and other emergencies
- 4.02. Reforms to the Long-term care financing system
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.
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).
Advice on available care and support through the long-term care insurance has been strengthened through an initiative to expand the network of advice centres as part of the third care strengthening law’ (drittes Pflegestärkungsgesetz) (Source: Bundesministerium fuer Gesundheit; Bundesministerium fuer Gesundheit – die Pflegestaerkungsgesetze)
Since 2019, Germany exempts children of people in need of care with an annual gross income of less than EUR 100,000 Euro from the obligation to cover care costs not covered by the care beneficiary, regardless of the care setting. Moreover, numerous reforms, adopted between 2008 and 2019, have extended benefits to facilitate and provide incentives for informal care as a measure targeting affordability (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).
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. (Source: Bundesministerium fuer Gesundheit)
- 4.03. Reforms to develop or improve Long-Term Care data and information systems
The care profession bill (Pflegeberufegesetz) led to a revision of the training curriculum and examination procedures. In addition to apprenticeships a degree in care has been introduced. School fees are no longer allowed, and apprentices are entitled to an appropriate compensation. The bill has been fully enacted since January 2020. (Source: Bundesministerium fuer Gesundheit – Pflegeberufegesetz)
In 2019 comprehensive measures were introduced to increase workforce training; improve working conditions and pay; relieve the administrative burden on professional carers; and promote recruitment of care professionals in third countries. Consequently, up to 13,000 additional posts for qualified long-term care workers were created in nursing homes. The funding of 20,000 additional positions for nursing assistants was secured. Germany also increased salaries in the long-term care sector, The Care Wages Improvement Act in 2019 created a legal basis to improve wage conditions for care workers. As a result, minimum wages for qualified care workers have been introduced and the minimum wages for nursing assistance staff were increased (and previously disparate regional rates were aligned). (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).
In June 2021 a new care reform was passed. From 1 September 2022 care settings will need to pay their care staff according to tariff. (Source: Bundesministerium fuer Gesundheit – Pflegereform)
In addition, homecare providers and residential care facilities can receive partial funding (up to €12,000 ) through the LTC insurance funds for the purchase of digital and technical innovations to improve the working conditions of staff over the period 2019 to 2021 and reduce time care staff is spending on bureaucratic tasks. (Source: Bundesministerium fuer Gesundheitl; Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu)
Another programme makes grants available up to 2024 for measures to improve the work-life balance of professional carers. The country has made efforts to co-operate with third countries to improve vocational training and recruitment of LTC professionals, especially with Mexico, the Philippines, and Kosovo- this will be funded from health insurance funds (source: Publications catalogue – Employment, Social Affairs & Inclusion – European Commission (europa.eu).
- 4.04. Reforms to improve care coordination
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.
- 4.05. Reforms to address Long-Term Care workforce recruitment, training, pay and conditions
From 1 January 2019 residential care settings with up to 40 occupants can apply to receive funding care positions. The amount of additional care resources financing through the sickness funds depends on the number of occupants in the care home (e.g. a 50% position for homes with up to 40 ocuptions, 1 full-time and one 50% position for homes with 81-120 occupants, 2 full time positions for homes with more than 120 occupants). This initiative should finance about 13,000 positions (Source: Bundesministerium fuer Gesundheit).
In June 2021 a new care reform was passed. This reform also seeks to improve staffing levels in residential care settings by implementing a bundeseinheitlichen Personalschlüssel (a formula determining the level of staff needed in care homes across the country). Care workers will also be allowed to prescribe tools to support people with LTC needs and to make more independent decisions when providing domiciliary care. (Source: Bundesministerium fuer Gesundheit – Pflegerefom)
- 4.06. Reforms to improve support for unpaid carers
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) (Source: Bundesministerium fuer Gesundheit – Verhinderungspflege; Bundesministerium fuer Gesundheit – die Pflegestaerkungsgesetze)
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. (Source: Deutsche Rentenversicherung; Bundesministerium fuer Gesundheit – Verhinderungspflege)
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. (Source: (Source: https://www.bundesgesundheitsministerium.de/fileadmin/Dateien/5_Publikationen/Pflege/Broschueren/PSG_Das_Wichtigste_im_Ueberblick.pdf).
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 ((Source: Bundesministerium fuer Gesundheit – die Pflegestaerkungsgesetze).
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 (Source: Bundesministerium fuer Gesundheit – die Pflegestaerkungsgesetze).
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. (Source: Bundesministerium fuer Gesundheit)
- 4.08. Reforms to strengthen community-based care
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. (Source: Bundesministerium fuer Gesundheit – die Pflegestaerkungsgesetze; Bundesministerium fuer Gesundheit – erstes Pflegestaerkungsgesetz)
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 (Source: Bundesministerium fuer Gesundheit – die Pflegestaerkungsgesetze; Bundesministerium fuer Gesundheit – erstes Pflegestaerkungsgesetz)
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. (source: Bundesministerium fuer Gesundheit – die Pflegestaerkungsgesetze)
Printable version of this country profile:
To cite this report:
Lorenz-Dant K., Fischer T. and Hämel K. COVID-19 and the Long-Term Care system in Germany. 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 Germany:
Most recent LTCcovid report (May 2020):
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.