LTCcovid Country Profiles

Responses to 1.06. Care coordination and personalization

The LTCcovid International Living report is a “wiki-style” report addressing 68 questions on characteristics of Long-Term Care (LTC) systems, impacts of COVID-19 on LTC, measures adopted to mitigate these impacts and new reforms countries are adopting to address structural problems in LTC systems and to improved preparedness for future events. It is compiled and updated voluntarily by experts on LTC all over the world. Members of the Social Care COVID-19 Resilience and Recovery project are moderating the entries and editing as needed.

The report can be read by question/topic (below) or by country: COVID-19 and Long-Term Care country profiles.

To cite this report (please note the date in which it was consulted as the contents changes over time):

Comas-Herrera A, Marczak J, Byrd W, Lorenz-Dant K, Pharoah D (eds.) and LTCcovid contributors. LTCcovid International living report on COVID-19 and Long-Term Care. LTCcovid, Care Policy & Evaluation Centre, London School of Economics and Political Science. https://doi.org/10.21953/lse.mlre15e0u6s6

Copyright is with the LTCCovid and Care Policy and Evaluation Centre, LSE.

Overview

Most countries have made an active effort to facilitate coordinated care, at least at policy level. Despite the policy efforts, shortcomings have been identified in health and social care coordination/integration across countries at both national and local level undermining the performance of care provision.  E.g.: Analyses of integrated care policies in European countries indicate that although at governmental level integration documents tend to be produced involving health and social care sectors, at regional and local level integration between health and social care services often involves separate coordination institutions for each of the sectors (source: https://www.cequa.org/copy-of-all-publications).

Overall, LTC services are often separate from health services and countries frequently distribute responsibility for LTC across national, regional and local actors. In many countries, an absence of coordination between health and social care often translates to parallel but not aligned systems for oversight, financing, staffing, and collection/management of data (source: https://apps.who.int/Eurohealth-26-2-77-82-eng.pdf).  Other more intangible factors pertaining to the health and social care divide include values and social standing of professionals (hierarchies) that impact the joint working of staff (source: https://www.euro.centre.org/downloads/detail/1537).

International reports and sources

The CEQUA project provides an overview of policies on integration in 11 European countries including England, France, Germany, Spain, Sweden, Finland, Austria, Poland, Latvia, Bulgaria, Czech Republic and Italy. There are also two case studies on integrated care, from Sweden and from France (https://www.cequa.org/).

WHO has developed a framework for LTC integrated care and has published detailed country reports online.

The Australian government’s Ministry of Health oversees both the health and aged care sector. States and territories are responsible for the actual delivery of care. The aged care sector has been found to have less access to services, including allied health services. The Royal Commission into Aged Care Quality and Safety recommends the Australian Government to increase coordination by creating Medicare Benefits Schedule items to specifically increase the provision of allied health services, including mental health services, to people in aged care.

The aged care system is difficult to access and navigate. The Royal Commission into Aged Care Quality and Safety found that people needing care found the experience to be time-consuming, overwhelming, and intimidating. The Royal Commission also expressed concern regarding the ability for people to make informed decisions due to the lack of information available.

Last updated: January 6th, 2022


There is a lack of integration between health and social care both at a national and provincial level. Healthcare is broadly regulated by the Canada Health Act but provinces have jurisdiction over the operational aspects, funding, and services offered. Social care, including home and continuing care, are not covered under the Canada Health Act. Although the health and social care sectors are not governed under the same regulations, it is the same five regional health authorities providing both social and health care. The system is fragmented and power dynamics are difficult to understand (source: https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-care-system/canada.html).

Last updated: January 6th, 2022


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

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

Last updated: January 6th, 2022


Integration of health and social care services for older people has taken place particularly in home care services. Integration of home care has been viewed as an instrument to increase the possibilities for independent living of older people. The most common practice aiming to increase care coordination is structural integration where municipal home care units are organizationally merged with health and welfare departments. The care coordination has led to more integrated management processes with some impact on actual care-taking practices or quality of care among home-dwelling and institutionalized patients (source: CEQUA Finland Policy Brief (filesusr.com). However, despite attempts at standardization of care services across the nation, there are major differences between municipalities due to their demographics; this appears to affect individuals ability to navigate the system (source: https://drive.google.com/file/d/19z_e5j7bcPxUYh2qLBa6VwrVDVnWilv7/view).

Last updated: January 6th, 2022


Coordination in the care sector is a longstanding preoccupation of the state and a response to the highly fragmented organization and funding of health, social and the need for ‘medico-social’  interventions in the care field.

Some level of integration at a local authority level has also been achieved through pathways and networks generally around gerontology and independence loss, as well as regional support networks and local information centres (source: https://halshs.archives-ouvertes.fr/halshs-02058183/document).

Various schemes have been developed since 2010– the PTA, the MAIA, and PAERPA schemes – having in common the creation of specific functions or professionals to support the social, medico-social and health professionals in their coordination tasks. Since, other arrangements have been developed in including the DAC (schemes to promote coordination) which should merge all other schemes excepting for CLICs which are organised by local authorities.

From a public policy perspective, the analysis of these developments shows that despite their initial objective of improving coordination between the health, social and medico-social interventions and facilities, the creation of three dedicated coordination schemes has also contributed to the complexity of elderly care professional and organizational landscape. Research also highlights limited accountability with poor transparency for users, prospective users and carers  (source: CEQUA France Country report (filesusr.com).

Last updated: January 6th, 2022   Contributors: Camille Oung  |  Alis Sopadzhiyan  |  


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).

Last updated: January 6th, 2022


There is a blurred line separating medical and functional assistance. Generally, the tendency is to leave patients in their homes (community-based care), with the primary task of LTC defined as practical, mental and social assistance in functioning, with limited medical intervention.  The Israeli healthcare system is a national health insurance plan that provides universal coverage to all Israeli citizens or residents. All residents register with one of four competing non-profit health plans (HP’s).  The HP’s are reponsible for geriatric and complex care and has dominated the discourse regarding services for the vulnerable during the pandemic (source: Traub Centre). Community long-term care is a branche of social insurance while institutional LTC is under the supervision of the Ministry of Health (MoH) and the Ministry of Welfare and Social Affairs (MoWSA) . The large percentage of privately funded LTC services and the widespread culture of unpaid, family caregiving suggest a lack of ease that social care users have with understanding, navigating, and accessing the full extent of LTC services.

Last updated: January 6th, 2022   Contributors: Sharona Tsadok-Rosenbluth  |  


The Italian care system remains fragmented. Italy’s LTC fragmentation is related to the fact that the essential functions (such as health and social care as well as basic care training) are decentralized and managed at regional level. An increasing trend to reorganize the LTC system via a ‘decentralisation’ of the health and social care functions from the national to the regional and local level can be observed in Italy. In the social care sector, this development has made local administrations the core governance centres of the system, as they are able to develop their own LTC policies. The only body in charge of ensuring inter-institutional coordination in this context is the State-Regions Conference (source: Italy Country Report (filesusr.com).

Last updated: January 6th, 2022


LTC services include some nursing, so much of what we would count as healthcare comes under LTC. Individuals are assigned a care manager on becoming eligible for care and, if the person is in hospital, they facilitate discharge. At a national level, the LTC and health systems are reviewed together every 6 years – this is where provider rates and regulations are reviewed (source: https://www.nuffieldtrust.org.uk/research/what-can-england-learn-from-the-long-term-care-system-in-japan). Japan has an ambition to create integrated care communities but these are wider than health and care and include community services and voluntary organisations too (source: https://www.researchgate.net/Towards_community-based_integrated_care_in_Japan’s_LTC). Individuals assessed and deemed to have care needs are assigned a care manager who helps people to navigate the system (source: https://pubmed.ncbi.nlm.nih.gov/21885099/).

Last updated: January 6th, 2022


The Netherlands has been experimenting with various integrated care initiatives over the past years (source: WHO | World Health Organization).

Last updated: January 6th, 2022


LTC in Poland is organised by national health care and local social services. The coordination of activities between sectors has been hampered by different governance priorities. The health sector concentrates on the long-term goals formulated in the National Health Programme. In the social services sector, ‘senior policy’ was formulated, aimed at the social activation (e.g. day care facilities) and social integration of older people (source: Poland Country Report).

Last updated: January 6th, 2022   Contributors: Joanna Marczak  |  Agnieszka Sowa-Kofta  |  


Care integration is high on the policy agenda in Singapore. For example, to facilitate integrated delivery of support and services, Singapore has consolidated aging, health, and LTC under the Ministry of Health (MOH) with inter-ministerial remits, where relevant.

The Agency for Integrated Care has taken on the role of a National Care Integrator since 2009. It is the agency’s role to match people with LTC needs with available services. The agency further is ‘responsible for supporting community care service partners in manpower development, quality improvement, programme development, and crisis management’.

In 2012, a Regional Health System model was introduced by the Ministry of Health to support the provision of ‘seamless integrated care based on geographic location’. This model facilitates local collaboration and transitions between care settings and has been reported to strengthen management capabilities and continuity of care. Key actors are designated anchor public acute hospitals as well as ‘primary, chronic health and social care’ services in the different geographic areas.

Last updated: January 6th, 2022


The provision of LTC in Spain is fragmented, due to the intervention of many agents and the differences between the autonomic regions. There have been several initiatives to improve care coordination through: the creation of social and healthcare coordination structures, the implementation of shared information systems, improving the comprehensive assistance in social centres and promoting the creation of hospital assistance units of continuity (Guillen et al., 2017).

A published study aimed to analyse the residential care crisis in Spain in the context of the COVID-19 pandemic and its impact on high mortality and abandonment of the user population. The theoretical focus of the analysis was the comprehensive and person-centred care (CPCC) model based on the autonomy of people and the centrality of their rights. The study concludes by proposing a comprehensive reform of long-term care that includes both a change in residential care in the form of small cohabitation units and reinforcement of care in the home and the community as a growing preference for the elderly population. An optimal combination of residential and home care is the basic proposal of this work (Gallego et al., 2021).

References:

Gallego, V. M., Codorniu, J. M., & Cabrero, G. R. (2021, January 1). The impact of COVID-19 on the elderly dependent population in spain with special reference to the residential care sector. Ciencia e Saude Coletiva. Associacao Brasileira de Pos – Graduacao em Saude Coletiva. https://doi.org/10.1590/1413-81232020261.33872020

Guillen M. et al. (2017) Country Report – Spain. Quality and cost-effectiveness in long-term care and dependency prevention. CEQUA LTC Network.

Last updated: January 6th, 2022   Contributors: William Byrd  |  


In Sweden, integrated care is an explicit policy goal, both within the care systems and between health and social care. The obligation on municipalities and county councils to cooperate is enshrined in legislation, regulations and agreements. The law also stipulates that an individual care plan should be established when a person requires services from both municipal social services and the health sector within the county council to ensure coordinated care with continuity.  However, challenges of care coordination and in particular coordination between health and social care services for older people exist e.g. shortening of hospital stays translated into increasing burden placed on community care. Moreover, local autonomy means that the national government has no power to enforce these kinds of structures for care coordination at a local government level (sources: CEQUA Sweden report; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6659761/).

Last updated: January 6th, 2022


There is a clear policy drive towards integrated care in England. Health care has traditionally been coordinated through local National Health Service (NHS) planning and provider organisations, which are accountable to the national government. In contrast, social care contrast is under the responsibility of local authorities, which have their own governance structures and are accountable to elected local governments. Local authorities can make their own decisions about implementation and funding allocation. Since the late 1990s to 2010 the government focused on the structural elements of partnership through multiple policy reforms. A review of progress in that period concluded that there was insufficient attention to supporting joint working through building relationships and trust (Glasby et al, 2011).

Since 2010, England introduced initiatives to encourage better integration between health and social care, building on previous efforts to improve partnerships between the two sectors. A study reviewing progress on integrated health and social care in England from 2010 to 2020 has concluded that a focus on locally relevant and specific tasks or issues has resulted in the greatest progress. Broader ill-defined goals and constant policy changes are not helpful (Miller et al, 2020).

A review of the findings from three key integration pilot programmes (Integrated Care Pilots, Integrated Care and Support Pioneers, and New Care Model ‘Vanguards’ highlights the challenges of identifying the objectives of integrated care). All three programmes shared the aim of improving coordination between hospital and community-based health services and between health and social care. However, over time, the NHS narrowed the lens used to evaluate their success to impact on reducing unplanned hospital admissions, which led to a diminished role for local authorities and voluntary sector partners. The evaluations of the pilots show that integration is a long-term project and that reductions in unplanned hospital admissions are not necessarily the best way to measure success (Lewis et al, 2021).

The NHS Long Term Plan published in 2019 announced Integrated Care Systems (ICS) everywhere by April 2021, bringing together local organisations to deliver a ‘triple integration’ of primary and specialist care, physical and mental health services, and heath and social care. These ICSs are rooted in the NHS, with the expectation that local authorities, the voluntary sector and others will partner with them.

The plan also includes the expansion of the Enhanced Health in Care Homes model to the whole country by 2023/4 to strengthen links between primary care networks and care homes.

The Plan announces support for local approaches to blending health and social care budgets and that a forthcoming green paper on adult social care will set out further proposals for social care and health integration.

References:

Glasby J, Dickinson H, Miller R. Partnership working in England – where we are now and where we’ve come from. International Journal of Integrated Care. 7 March 2011; 11: 1–8. DOI: https://doi.org/10.5334/ijic.545.

Lewis, R. Q., Checkland, K., Durand, M. A., Ling, T., Mays, N., Roland, M., & Smith, J. A. (2021). Integrated Care in England – what can we Learn from a Decade of National Pilot Programmes?. International Journal of Integrated Care, 21(S2), 5. DOI: http://doi.org/10.5334/ijic.5631

Miller, R., Glasby, J., & Dickinson, H. (2021). Integrated Health and Social Care in England: Ten Years On. International Journal of Integrated Care, 21(S2), 6. DOI: http://doi.org/10.5334/ijic.5666

Last updated: January 6th, 2022   Contributors: Adelina Comas-Herrera  |  Chris Hatton  |  


Anyone who is eligible to receive social care services in Scotland has the option of choosing Self-Directed Support for their care. Self-Directed Support was introduced in Scotland in April 2014.      This option gives individuals greater control over how they receive their care and allows them to personalise their care in a way that suits them. A Public Health Scotland report on social care estimated that in 2018/19, around 79.4% people used self-directed support to make choices about their care. However, an Audit Scotland report suggested that the accuracy of data regarding self-directed support required improvement.

Last updated: January 6th, 2022   Contributors: Jenni Burton  |  David Bell  |  Elizabeth Lemmon  |  David Henderson  |  


Despite Medicaid and Medicare’s central role in the funding of long-term care services, the long-term care and health care sectors are not integrated at the governmental and health systems levels. Differences in how medical care and long-term care are paid for and prioritized in each state, as well as the ownership of healthcare organizations (i.e. hospitals) compared to the LTC sector, disallows coordination of services and impedes opportunities for a seamless care delivery system (source: https://onlinelibrary-wiley-com.gate3.library.lse.ac.uk/doi/full/10.1111/1468-0009.12500).

Last updated: January 6th, 2022


Contributors to the LTCcovid Living International Report, so far:

this list is regularly updated to reflect contributions to the report, if you’d like to contribute please email a.comas@lse.ac.uk

Elisa Aguzzoli, Liat Ayalon, David Bell, Shuli Brammli-Greenberg, Jorge Browne Salas, Jenni Burton, William Byrd, Sara CharlesworthAdelina Comas-Herrera, Natasha Curry, Gemma Drou, Stefanie Ettelt, Maria-Aurora Fenech, Thomas Fischer, Nerina Girasol, Chris Hatton, Kerstin HämelNina Hemmings, David Henderson, Stefania Ilinca, Margrieta Langins, Shoshana Lauter, Kai Leichsenring, Elizabeth Lemmon, Klara Lorenz-Dant, Lee-Fay Low, Joanna Marczak, Elisabetta Notarnicola, Cian O’DonovanCamille Oung, Disha Patel, Eleonora Perobelli, Daisy Pharoah, Stacey Rand, Tine Rostgaard, Olafur H. Samuelsson, Maximilien Salcher-Konrad, Benjamin Schlaepfer, Cheng Shi, Cassandra Simmons, Andrea E. SchmidtAgnieszka Sowa-Kofta, Wendy Taylor, Thordis Hulda Tomasdottir, Sharona Tsadok-Rosenbluth, Sara Ulla Diez, Lisa van Tol, Patrick Alexander Wachholz, Jessica J. Yu

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.