INTERNATIONAL REPORTS

Responses to 1.02. Brief description of the Long-Term Care system


Australia

The Australian government is the primary funder and regulator of the long-term care system. The government subsidises both home care and residential care for people of all ages who have been assessed as needing care and support. There are four main types of services under aged care: the Commonwealth Home Support Programme (CHSP) Home Care Packages (HCP), residential care and flexible care. More than 1.2 million people received aged care services during 2017–2018. 77% received support in their home or other community-based settings. Of Australians over the age of 65, 7% accessed residential aged care, 22% accessed some form of support or care at home, and 71% lived at home without accessing government-subsidised aged care services. (sources: https://agedcare.royalcommission.gov.au/sites/default/files/2021-03/final-report-volume-1.pdf; https://agedcare.royalcommission.gov.au/sites/default/files/2020-12/aged-care-and-covid-19-a-special-report.pdf)

Last updated: August 3rd, 2021


Austria

The LTC system is based on three pillars: cash benefits, care services and measures to support unpaid carers. Cash benefits (“Pflegegeld”) are needs based and not means-tested, they are intended to be used to buy formal care or to reimburse informal care provision (source: https://ec.europa.eu/info/sites/default/files/economy-finance/ip105_en.pdf), since 2007 there is an additional subsidy to facilitate the hiring of 24-hour carers in private households (source: https://apps.who.int/iris/bitstream/handle/10665/330188/HiT-20-3-2018-eng.pdf?sequence=7&isAllowed=y).

A comprehensive, tax-based funding for the long-term care cash-for-care allowance was introduced in 1993 and remains the responsibility of the federal state, while in-kind services fall under the realm of provincial governments. This means that both the federal republic and the nine states are responsible for social care. All states are obliged to provide a minimum standard of long-term care services such as mobile care services, residential care facilities, short-term care services and case and care management.

There is growing reliance on live-in migrant personal carers, mainly from neighbouring Eastern European countries. In 2018 there were about 462,000 Austrians assessed as eligible for the federal care allowance, of which 33,000 relied on migrant live-in carers, 70,000 were in care homes and 153,000 used professional home-based care (source: https://journal.ilpnetwork.org/articles/10.31389/jltc.54/).

LTC services are provided by private and public home care providers. Residential facilities are planned, regulated and funded by state governments and municipalities (source: https://apps.who.int/iris/bitstream/handle/10665/330188/HiT-20-3-2018-eng.pdf?sequence=7&isAllowed=y).

Last updated: August 3rd, 2021


Canada (British Columbia)

Approximately 42,000 people live in BC’s LTC homes. In 2012/2013, 38,810 people received home support services (source: Bedlam_in_BC_Continuing_Care_Sector.pdf (bccare.ca). The average age of residents in LTC facilities is 85 years; 59% are aged 85 or older (source: QuickFacts2018-Summary.pdf (seniorsadvocatebc.ca).

Last updated: August 3rd, 2021


Chile

The majority of people with support needs receive care from their family members, mostly women (source: https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Chile-24-July-2020-3.pdf).

There is some provision of subsidized institutional care. In principle all long-term care facilities should be registered with the Ministry of Health and subject to staffing requirements. However, it has been estimated that half of all care homes are not registered or unregulated (source: https://journal.ilpnetwork.org/articles/10.31389/jltc.72/)

Last updated: August 3rd, 2021


China

Long-term care is mostly provided by family and other unpaid carers, with some provision by paid carers for those who can afford it. The Government covers the costs of care for people who fit the “Three No’s” category: no ability to work, no income and no family. Relying on families as the main source of care is increasingly under question given demographic and social changes resulting in smaller and geographically dispersed families. In response to this, the government has increased its focus on developing a formal long-term care system, initially through encouraging the rapid development of a private institutional care sector, setting targets for numbers of beds. This took place before developing regulation and quality assurance mechanisms and has led to the lack of development of community-based care. There are shortages of trained care professionals. There have been pilots of social long-term care insurance in 16 cities since 2016, with strong policy interest on these as a mechanism for long-term care financing. For a good overview read Feng et al. (2020).

 

 

Last updated: October 1st, 2021


Czech Republic

Informal care constitutes a major part of care provided to older and dependent people. It is estimated that roughly 52% to 75% of care is provided by relatives, at home. The introduction of care allowance in 2007 has been the most significant change in the social services system since the 1990s, and the allowance has been used to compensate informal carers. Formal LTC is based on a two-tiered system of regulation, funding, and services provision—separate for the health sector and for the social services sector and some private provision of LTC services have been developing, including a rise of unregistered LTC services (source: CEQUA – Czech Country Report (filesusr.com).

Last updated: August 3rd, 2021


Denmark

TheLTC system in Denmark has strong public and political support. The main law regulating social service provision and, implicitly, long-term care provision is the Social Services Act, which passed in 1998. The Social Services Act emphasizes the users’ right to influence social service provision and enshrines the highly decentralized nature of the system, putting municipalities in a key position to shape long-term care. It is a highly decentralized system, with a strong emphasis on community-based care, reablement and professionalisation of care staff (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Last updated: August 3rd, 2021


England (UK)

The majority of long-term care in England is provided by unpaid carers. Formal long-term care in England is provided by a complex system involving organisations in charge of health, social care, housing and other services. There is an important distinction between means-tested social care (non-medical services aimed at supporting people with LTC needs with their daily living activities) and health care services, which are free at the point of use and funded from general taxation.

Formal care services include home-based care services, personal assistants, residential/institutional care, day care and professional services such as social work, occupational therapy and aids and adaptations. Most publicly funded services are commissioned at local level, but, as a large share of the population who use long-term care is not covered by the public system, a large share of care is purchased directly from private providers.

There is strong consensus on the urgent need to reform the social care system in England.

For further reading:

CEQUA report on England (2017), LTCcovid report on England (2020), Report on the problems with the social care system in England (2018)

Last updated: September 6th, 2021


Finland

Care for older people in Finland is primarily delivered at home and in the community. Over 90% of the older population (75+) live in their own home, with the majority receiving no formal care (~75%), some receive regular home care, or informal care. Less than 10% of the older population receives some kind of 24-hour sheltered housing or institutional care (source: https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view).

Last updated: August 3rd, 2021


France

Currently, there are 7,502 long-term care facilities welcoming 610,000 residents. Of these, 50% are public, 31% are not-for-profits and 24% are for-profit. There are 256 care homes for autonomous older people and 2,294 supported living settings. Hospitals also offer long-term care units, where there were 32,790 patients recorded in end-2015. There are approximately 886,000 people in receipt of domiciliary care, most of which are older people. Nursing and polyvalent domiciliary care services provide services to 125,7000 service users, and domiciliary care services provide care to 760,000 people (source: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf).

In 2015 there were 1.25M beneficiaries of Long-Term Care Insurance for older people (8% of over-60s) (source: https://halshs.archives-ouvertes.fr/halshs-02058183/document).

The domiciliary care sector is extremely fragmented, with one department (sub-regional authority) having over 100 agencies (source: http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf). Financing is unprofitable, with the difference between pay from LTCI and hourly costs in 2017 of 2.2€/hour (source: http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf).

Organisation largely befalls the regional structures (ARS) around healthcare matters, and departments (sub-regional structures) manage social care matters, but there is a joint responsibility for tariff setting and financing of operations in care homes (source: http://www.senat.fr/rap/r20-199-1/r20-199-11.pdf). ARS do not have oversight of domiciliary care, except where a nursing component is involved (source: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf).

Last updated: August 3rd, 2021


Germany

In 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;jsessionid=D36A8A29106991E309E81E1FD2976D71.live712).

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/gbe/pkg_olap_tables.prc_sort_time?p_uid=gastd&p_aid=11066930&p_sprache=D&p_help=2&p_indnr=397&p_ansnr=12428255&p_version=3&p_sortorder=d).

Last updated: August 3rd, 2021


India

There is no formal or organized public LTC system in India, however a number of schemes cover some aspects of care for older people or people with disabilities and mental health conditions. Families (particularly women) are the main source of care, as well as untrained care workers such as “home attenders”. There are some formal care services available, mostly provided by private and not-for-profit organisations (source: https://ltccovid.org/wp-content/uploads/2020/05/LTC-COVID-situation-in-India-30th-May.pdf).

Last updated: August 3rd, 2021


Ireland

Most LTC in Ireland is provided by unpaid carers supplemented by home care services. There are more public resources available for residential care than for home care services. By December 2018, 581 nursing homes in Ireland registered with the Health Information and Quality Authority offered 31,250 places for people with care needs. More than 460 of the homes are operated by private or voluntary (not-for-profit) providers), supporting 25,000 people. Ireland also has some ‘psychiatry of later life units’. Most of the residents are 65 years and older. Publicly funded support for home care can be obtained following a needs assessment conducted by a healthcare professional. So far financial means are not taken into consideration. Most home care services are provided by private providers, but these providers are contracted by the State. The role of the public sector in the delivery of home care is relatively small (source: https://ltccovid.org/wp-content/uploads/2020/05/Ireland-COVID-LTC-report-updated-13-May-2020.pdf).

Last updated: August 3rd, 2021


Israel

Israel organizes its LTC system in a fragmented manner, with the Ministry of Health, the Ministry of Labor and Social Affairs, and the National Insurance Institute (NII) holding separate yet overlapping responsibilities for publicly funded LTC (source: http://taubcenter.org.il/wp-content/files_mf/longtermcare.pdf).

Last updated: August 3rd, 2021


Italy

The public system of LTC in Italy is underdeveloped and characterised by a high degree of institutional fragmentation, as sources of funding, governance and managerial responsibilities of public services are spread over local (municipal), regional and national authorities, with different methods according to the institutional models of each region (source: https://www.sciencedirect.com/science/article/abs/pii/S0168851014000086). Unpaid carers – together with home care assistants privately hired by households – represent the bulk of LTC provision in Italy (source: Italy Country Report (filesusr.com).

Last updated: August 3rd, 2021


Jamaica

There is relatively little published information on the long-term are system in Jamaica. An article that set out to map long-term care in Jamaica found that care is largely provided by informal carers (both unpaid and paid). There is a high prevalence of unregulated care homes and limited formal home and community-based services. NGOs and places of worship are an important part of the few community-based services available.

Last updated: September 8th, 2021


Japan

Most of Japan’s LTC services are covered by the public long-term care insurance (LTCI) system that was introduced in 2000. The LTCI is administered by municipal governments and operates independently of the medical insurance system. The LTCI subsidizes non-medical services including residential care (long and short-term), day care, care services in people’s own homes and home adaptations. The insurance benefits do not cover room and board, but other than this, the level of re-imbursement is a relatively low level of co-payment (10%) (source: https://ltccovid.org/wp-content/uploads/2021/03/ltccovid-Country-Report-Japan_Final-27-February-2021.pdf).

The Japanese LTC system has a large non-residential care sector: just under 1?million older people (2.6% of adults aged over 65) live in care facilities and 4 million older persons utilize day care facilities (2019) (source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675525/).

In 2017 there were 24.1 LTC beds per 1,000 older adult population (source: https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf). In 2014, 7.8% of those aged 65 or older used day care in Japan. Unlike many European countries, the Japanese LTC system does not offer cash benefits to people who need care or to family carers (source: https://ltccovid.org/wp-content/uploads/2021/03/ltccovid-Country-Report-Japan_Final-27-February-2021.pdf).

Last updated: August 3rd, 2021


Latvia

The key players in the provision of formal LTC are the national government, 119 local governments and 110 municipalities. The number of organizations providing state-funded services decreased from 17 institutions in 2010 to 15 in 2015, the number remaining unchanged since then. The 15-state financed social care institutions provided LTC social services for 5,353 clients; 86 local government and other organization social care centres provided LTC social services for 6,134 clients. Additionally, there were 83 such institutions in the country provided by local government in 2010, and the number increased to 86 institutions by 2015 (source: CEQUA Latvia Country report (filesusr.com).

Last updated: August 3rd, 2021


Netherlands

Since 2015, LTC is governed through three separate legal acts: the Long-term Care Act (WLZ 2014), the Social Support Act (WMO 2015) and the Health Expenses Act (Zvw 2008). As a result, there are different rules and funding streams for care-related (LTC insurance), social support related (municipalities) and health and nursing related (health insurance) services. LTC is needs assessed but not means assessed (source: https://drive.google.com/file/d/1P5J1JQlr-ts65lknBwBFtTkJNXHLDyrL/view).

Last updated: August 3rd, 2021


Poland

By law and by tradition, families are primarily responsible for care provision, with social institutions’ intervening when families are incapable of undertaking adequate care measures and LTC is provided mostly by unpaid carers in Poland. Some home care as well as residential care services are however also available through health and social care sector and more recently day care centres have gained prominence in providing support for people with LTC needs (source: Poland Country Report).

Last updated: August 3rd, 2021


Singapore

Singapore’s approach to LTC focuses on home and  community-based care, aiming to reduce unnecessary utilization of institutional care, Singapore’s LTC policies are based on a principle that calls for individuals, families, communities, civil society, the private sector, and government to all play a role in ensuring the well-being of older people although it emphasises the primacy of the family in aged care (source: https://www.adb.org/sites/default/files/publication/637416/singapore-care-system-population-aging.pdf).

Last updated: August 3rd, 2021


South Korea

In 2008, South Korea introduced a universal, public long-term care insurance to complement the existing national health insurance. The LTCI covers residential, domiciliary and community-based care. By the end of 2018, approximately 9% of the population aged 65 and older were eligible for LCTI coverage (source: https://www.tandfonline.com/doi/full/10.1080/01634372.2020.1797977).

A shortage of qualified home-based care services in South Korea means that most older people have no choice but to depend heavily on residential institutional care. From 2012 to 2017, the number of long-term residential care facility beds per thousand people aged 65 years old and over significantly increased from 51.1 to 60.9, and the number of beds in long-term care hospitals was  36.7 per thousand people, the highest among OECD countries  (source: https://www.tandfonline.com/doi/full/10.1080/01634372.2020.1797977).

Long-term care hospitals (LTCHs) under the national health insurance play a role in long-term care provision; the average length of stay at such hospitals was about 168 days per year in 2016 Lengthy hospitalizations are likely a result of residential institutional care being financially supported by the national health insurance (NHI) and Long-Term Care Insurance (LTCI) (source: https://ltccovid.org/wp-content/uploads/2020/05/The-Long-Term-Care-COVID19-situation-in-South-Korea-7-May-2020.pdf).

Last updated: August 3rd, 2021


Spain

In Spain, the 2006 ‘Dependency Act’ created new public national care coverage as the ‘fourth pillar of the welfare state’, aiming to improve personal autonomy and care for dependent people. The Act established two types of long-term care benefits: 1) in-kind services, and 2) those of an economic nature, and it gave the former a priority. The law lists social services which contribute to long-term care:  services for averting dependency and enabling personal independence; tele-assistance services; home care services (help with home tasks and personal care); day and night care centres; residential services. All benefits and services established in the law are integrated in the social services provided through the autonomous regions (source: CEQUA Spain Country report (filesusr.com).

Last updated: August 3rd, 2021


Sri Lanka

Long-term care provision has remained mainly with families, and formal LTC service provision is considered inadequate to meet even current needs and demand.  Home and community-based care services that support aging in place for elders with limitations in
ADL and IADL are rare; residential care is not appropriate in terms of available services or eligibility. Informal care at home is often provided by family members, usually,  a female relative. Untrained domestic workers are sometimes hired as caregivers.

Last updated: September 6th, 2021


Sweden

In 2019, over 160 000 of older people were provided with services and care in their own home and some 82 000 were provided with institutional care. A wave of closures of municipal institutional beds, resulted in a reduction of nearly 40% of all municipal places since 2000s (source: https://aldrecentrum.se/wp-content/uploads/2021/02/Johansson-L.-Sch%C3%B6n-P.-2021.-Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf).

Last updated: August 3rd, 2021


Thailand

Families provide most of the care given to older persons, at home and without payment. Home-based care provided by trained volunteers or paid caregivers is growing, and helps to support informal care-support systems (source: Country Diagnostic Study on Long-Term Care in Thailand | Asian Development Bank (adb.org).

Last updated: September 6th, 2021


United States

In the United States, there are five major types of LTC services: adult day centre, home health agencies, nursing homes, hospices, and residential living facilities. As of 2016, there were approximately 15,300 nursing homes and 28,900 residential care (‘assisted living’) facilities. Approximately 24 in every 1,000 people aged 65+ use nursing homes, and 15 in every 1,000 people aged 65+ live in residential care. 75 in every 1000 people aged 65+ use home health agencies for at-home services (source: https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-508.pdf).

Last updated: August 3rd, 2021