LTCcovid Country Profiles

Responses to 1.08. Care home infrastructure

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.

There are approximately 845 residential care providers in Australia, operating across more than 2,720 sites. In terms of ownership (ACFA, 2021, table 6.1):

  • – 56% of providers and 55% places are in for not-for profit residential homes (ACFA, 2021)
  • – 10 % government operated
  • – 34% are for profit/private

The number  of residential aged care providers has been decreasing due to industry consolidation while the number of government-funded places (beds) in aged care has gradually been increasing.

Industry consolidation has seen a reduction of one owner/one-site facilities and a corresponding increase in large for-profit providers building large facilities across multiple sites.

Other contextual data:
  • – 245,000 people lived in aged care facilities at some point in 2019/2020
  • – 65% of residents in aged care are women.
  • – Average age of residents is 85
  • – NB: 4,900 aged care residents are aged under 65.

Data from: Aged care snapshot 2021  (AIHW, 2021, accessed 25 Oct 2021).

References:

Aged Care Financing Authority, ACFA (2021) Report on the Funding and Financing of the Aged Care Sector. https://www.health.gov.au/sites/default/files/documents/2021/08/ninth-report-on-the-funding-and-financing-of-the-aged-care-industry-july-2021.pdf

Australian Institute of Health and Welfare, AIHW (2021) Australia’s welfare 2021, Aged care. Australian Government. https://www.aihw.gov.au/reports/australias-welfare/aged-care

Last updated: January 17th, 2022   Contributors: Sara Charlesworth  |  Wendy Taylor  |  Lee-Fay Low  |  


In 2015, about 850 nursing homes or residential care facilities provided 75 632 inpatient care places while 12 019 persons lived in alternative housing forms. Since 2000, the number of places in nursing homes or residential care facilities increased by more than 30%, as a result of population ageing and increasing demand for long-term care (BMGF, 2017k). Also, the number of hospitals and beds in rehabilitative care increased by around 40% between 2007 and 2016. In 2020 about 90,000 people are cared for in about 870 care homes (about 50% public, 25% private for-profit, 25% non-profit) (source: https://ltccovid.org/wp-content/uploads/2020/07/The-COVID-19-Long-Term-Care-situation-in-Austria-13-July-1.pdf).

Last updated: January 6th, 2022


Researchers from the ‘Frente Nacional de Fortalecimento à ILPI’ have published a study estimating the number of Long-Term Care Facilities (LTCFs) in the country in 7,029 facilities, noting that 64% of the 5 570 Brazilian municipalities do not have any LTCFs for older adults. (Lacerda TTB et al., 2021 https://doi.org/10.53886/gga.e0210060)

Last updated: January 6th, 2022   Contributors: Patrick Alexander Wachholz  |  


There are longstanding problems in the LTC homes in Canada, which have been the subject of many reports, commissions and enquiries. A review carried out for the Royal Society of Canada Working Group on LTC found that, between 1998 and 2020, there were 80 reports making recommendations on the Long-Term Care system and LTC homes. The most common recommendations were for increased funding (66.7% of reports), standards/regulation/audits of LTC quality of care (58.3%), and regulation/reform/standardisation of education and training for staff (https://f1000research.com/articles/10-87).

Last updated: January 6th, 2022


89% of the rooms in long-term care are single-occupancy rooms, 7% are double-occupancy, and 4% are multi-bed rooms (3 or more beds). 76% of residents reside in single-occupancy rooms. In health authority owned facilities, 57% of residents reside in single-occupancy rooms compared to 85% in contracted facilities (source: QuickFacts2020-Summary.pdf (seniorsadvocatebc.ca).

Last updated: January 6th, 2022


There an estimated 25,000 older people living in registered care homes (1.4% of the population aged 65 or older). Of the 994 registered care homes, 16 are public, 181 are not-for-profit (with public subsidies) and the rest are for-profit (operating under supervision of the Ministry of Health) (Browne et al., 2020).

There are many unregulated care homes operating in an informal manner, probably as many as there are in the regulated sector. Prior to the COVID-19 pandemic there were no regulations or mechanisms to survey the Infection Prevention and Control capabilities of care homes (Browne et al., 2021).

References

Browne J, Fasce G, Pineda I, Villalobos P (2020) Policy responses to COVID-19 in Long-Term Care facilities in Chile. LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 24 July 2020.

Browne, J., Palacios, J., Madero-Cabib, I., Dintrans, P.V., Quilodrán, R., Ceriani, A. and Meza, D., 2021. Enablers and Barriers to Implement COVID-19 Measures in Long-Term Care Facilities: A Mixed Methods Implementation Science Assessment in Chile. Journal of Long-Term Care, (2021), pp.114–123. DOI: http://doi.org/10.31389/jltc.72

 

Last updated: January 6th, 2022


In Denmark’s 98 municipalities, there are around 930 nursing homes with over 40,000 residents  (source: https://covid19.ssi.dk/overvagningsdata/ugentlige-opgorelser-med-overvaagningsdata).

The number of people in residential facilities and receiving home care has declined in both absolute and relative numbers in this decade.  In 2018, in absolute numbers there were 65,573 beneficiaries of long-term residential care services aged 65 years or older which equals to 5.8% of the population (source: https://www.dst.dk/en). In particular the proportion of people age 90 and over living in residential care facilities has fallen drastically, as 41.7 percent  lived in LTC facilities and senior housing in 2010 while the number fell to 33.1 percent in 2019 (source: https://www.dst.dk/da/Statistik/nyt/NytHtml?cid=30746#)

Social care act made it illegal for the government to build any multiple bed residential services, hence currently all nursing homes are private rooms with personal space, kitchenette and living space. Denmark is the only country in the EU in which the construction of traditional old-age and nursing institutions has been legally banned. Early in the 1980s, the government phased out large institutions with multiple beds in each room and infrastructure for long-term care that resemble hospital environments, replacing them with nursing homes to ensure that users have individual living spaces. By 2011, the vast majority of older individuals living in residential care were housed in modern nursing home facilities. There are five types of residential care facilities: nursing homes, which are institutions with permanent staff and service areas; sheltered housing, which are connected to nursing homes with associated staff and service areas; housing for older people, which are dwellings for older people with associated staff and service areas; general homes for older people, which are suitable for older people and people with disabilities but without permanent staff or service areas;  private care accommodation, which provides rental facilities for people with extensive disabilities, including personal staff and service areas outside the municipal sector. The choice of specific type of accommodation depends on individuals’ preferences and needs. Beneficiaries choosing to live with their spouse or partner must be offered a facility suitable for two people (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Last updated: January 6th, 2022


In Denmark’s 98 municipalities, there are around 930 nursing homes with over 40,000 residents  (source: https://covid19.ssi.dk/overvagningsdata/ugentlige-opgorelser-med-overvaagningsdata).

The number of people in residential facilities and receiving home care has declined in both absolute and relative numbers in this decade.  In 2018, in absolute numbers there were 65,573 beneficiaries of long-term residential care services aged 65 years or older which equals to 5.8% of the population (source: https://www.dst.dk/en). In particular the proportion of people age 90 and over living in residential care facilities has fallen drastically, as 41.7 percent  lived in LTC facilities and senior housing in 2010 while the number fell to 33.1 percent in 2019 (source: https://www.dst.dk/da/Statistik/nyt/NytHtml?cid=30746#)

Social care act made it illegal for the government to build any multiple bed residential services, hence currently all nursing homes are private rooms with personal space, kitchenette and living space. Denmark is the only country in the EU in which the construction of traditional old-age and nursing institutions has been legally banned. Early in the 1980s, the government phased out large institutions with multiple beds in each room and infrastructure for long-term care that resemble hospital environments, replacing them with nursing homes to ensure that users have individual living spaces. By 2011, the vast majority of older individuals living in residential care were housed in modern nursing home facilities. There are five types of residential care facilities: nursing homes, which are institutions with permanent staff and service areas; sheltered housing, which are connected to nursing homes with associated staff and service areas; housing for older people, which are dwellings for older people with associated staff and service areas; general homes for older people, which are suitable for older people and people with disabilities but without permanent staff or service areas;  private care accommodation, which provides rental facilities for people with extensive disabilities, including personal staff and service areas outside the municipal sector. The choice of specific type of accommodation depends on individuals’ preferences and needs. Beneficiaries choosing to live with their spouse or partner must be offered a facility suitable for two people (source: https://www.euro.who.int/en/health-topics/Life-stages/healthy-ageing/publications/2019/denmark-country-case-study-on-the-integrated-delivery-of-long-term-care-2019).

Last updated: January 6th, 2022


Of the 7,502 LTCFs for older people, 50% are public, 31% are not-for-profits, and 24 are for-profit. In 2020, the National Assembly noted that the home care infrastructure is largely outdated, often with shared rooms (source: https://www2.assemblee-nationale.fr/static/15/pdf/rapport/i3633.pdf).

Last updated: January 6th, 2022


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).

Last updated: January 6th, 2022


There has been an important effort to upgrade care homes. Whereas in 2005 just half of people in care homes were in single rooms, and 29% had a private bathroom, by 2013 83% were in single rooms. The emphasis, since a new policy approved in 2008 is to build smaller units (for 6 to 10 people) with private rooms and and a common area for residents and staff. Minimum standards for the construction and running of care homes were issued in 2013.

(Source: Sigurveig H. Sigurdardottir, Omar H. Kristmundsson & Steinunn Hrafnsdottir (2016) Care of Older Adults in Iceland: Policy Objectives and Reality,Journal of Social Service Research,42:2, 233-245, DOI: 10.1080/01488376.2015.1137535)

Last updated: January 6th, 2022


As of 2017, amongst OECD countries, Israel had one of the lowest numbers of LTC beds available in its hospitals at 23.6 beds per 1000 people aged 65+ (the OECD average is 47.2 beds) (source: OECD). Notably, The proportion of people aged 65+ who receive LTC in institutions in Israel is the lowest among OECD countries (under 2%), while the number of recipients of care in the community is among the highest in these countries (source: Muir, 2017).

Last updated: January 6th, 2022


The actual number of nursing homes in Italy is unknown: different institutional sources indicate distinct values. In particular, the Interior Ministry counted 4,629 nursing homes for dependent older people (data confirmed also by the National Committee for the guarantee of people deprived of their freedom – Garante Nazionale dei diritti delle persone private della libertà personale). The National Health Institute provides data on 3,417 nursing homes for people living with dementia. The Ministry of Health considers 3.475 residential centers, which include nursing homes, care homes, hospice and a blurry “other type”. Such inconsistency between numbers makes it difficult to build up a comprehensive picture of the service supply.

Also the number of service providers is uncertain, estimates talk about 1.927 companies. As concerns nursing homes’ features, the Observatory on nursing homes from one of Italy’s largest trade unions pointed out that:

  • 10,3% NHs count less that 20 beds;
  • 33,1% NHs have 21 to 50 beds;
  • 38,9% NHs have between 52 and 100 beds
  • only 17.7% of NHs dispose of over 100 beds.

The average nursing home counts 67,5 beds. Moreover, the large majority (70%) of NHs is managed by private providers – generally in accreditation regime -, 38,2% are for profit companies, 6% are public owned foundations, 15% are NGOs. 14% of NHs are directly managed by municipalities or Local Health Authorities. On average, each provider manages 2,07 nursing homes and 140 beds. Hence, the typical nursing home is quite small and managed by a private provider which received an accreditation from the public sector.

The distribution of nursing homes is diversified and heterogeneous throughout the national territory, with strong consequences for equity in access. The table below shows the take up rate of care home beds with respect to the number of people with functional dependency aged 75 and over in each region, representing the population most likely to consider nursing home care.  the most vulnerable and likely target for such service

The distribution of the rate follows the Italian geography: Southern regions have the lowest rates; regions from the Centre reach middle values and the Northern regions have the highest take-up values. For example in Trento, there are 25 beds for each person aged 75 with dependency, compared to 0.65 in Basilicata, signalling the almost total absence of care home services in some areas of the country.

Region Take up rate of nursing homes’ beds with respect to dependent over75 residents in the region (2016)
Molise 0,26%
Basilicata 0,65%
Sicily 0,69%
Puglia 2,57%
Calabria 2,78%
Abruzzo 2,73%
Campania 0,73%
Marche 5,89%
Valle d’Aosta 0,25%
Tuscany 6,28%
Umbria 5,12%
Friuli – Venezia Giulia 15,36%
Liguria 9,73%
Emilia – Romagna 9,61%
Veneto 17,88%
Trento 25,66%
Lazio 2,85%
Sardinia 1,03%
Bolzano/Bozen 24,21%
Piedmont 18,15%
Lombardy 18,97%

Sources:

Berloto, S., Fosti, G., Longo, F., Notarnicola, E., Perobelli, E., Rotolo, A. (2019). La rete dei servizi di LTC e le connessioni con l’ospedale: quali soluzioni per la presa in carico degli anziani non autosufficienti? In Cergas (Eds.), Rapporto OASI 2019.

Fosti, G., Notarnicola, E. (Eds). Primo Rapporto OLTC.

Garante Nazionale dei diritti delle persone private della libertà personale (2020). Atto di sindacato ispettivo n° 3-01482.

Istituto Superiore di Sanità (2020). Mappa dei servizi.

Ministero della Salute (2021). Annuario Statistico del SSN. Anno 2019.

Ministero dell’Interno (2019). Le statistiche ufficiali del Ministero dell’Interno. Strutture per anziani. Ed. 2019.

Last updated: January 6th, 2022   Contributors: Eleonora Perobelli  |  Elisabetta Notarnicola  |  


The majority of nursing care facilities are run by non-profit social welfare or medical institutions (for profit organisations are restricted from entering the care market for the individuals with high needs). The rest of the market operates with a mixed market of provision, ownership types and sizes. For-profit assisted living facilities tend to cater to the more independent and hence less vulnerable population. They cannot provide LTC services unless they are specially licensed by the respective prefectural governments to do so, even if they have a licence, such facilities have to contract external licensed LTC service providers if the residents need nursing care. Providers are paid according to a national fee schedule, so they compete on quality and convenience, not price.  All providers must be licenced by the prefectural government (source: https://programs.wcfia.harvard.edu/files/us-japan/files/margarita_estevez-abe_covid19_and_japanese_ltcfs.pdf; https://ltccovid.org/wp-content/uploads/2021/03/ltccovid-Country-Report-Japan_Final-27-February-2021.pdf).

Last updated: January 6th, 2022


Care homes are distinguished by whether they have an WLZ (Wet langdurige zorg, LTC) accreditation. These mostly include nursing homes and residential care homes with a nursing department. Care homes without a WLZ accreditation do not provide nursing care or medical treatments, but are residential homes that provide small-scale elderly housing and apartments linked to nursing homes, in which additional care can be provided as needs increase. In addition, there are private care homes for more affluent residents who contribute more to the costs of housing and facilities (such as entertainment). There is also small-scale housing where people pool their WLZ cash (provided as a personal budget) and which are self-organised or provided by entrepreneurs. Nearly 114,000 people aged 65 and over live-in residential care and nursing homes (source: https://drive.google.com/file/d/1P5J1JQlr-ts65lknBwBFtTkJNXHLDyrL/view).

Last updated: January 6th, 2022


Providers of institutional care facilities are mostly private; the majority are individual-owned, small-size homes, and their numbers have rapidly increased, resulting in fierce competition (source: https://www.sciencedirect.com/science/article/pii/S016885102030275X). Services comprise residential care homes, long term care hospitals, and community services. There has historically been a reliance on institutional care, and in 2018 the Government announced a “Community Care” policy, to shift care to home and the community.

The recent outbreak revealed that care institutions are particularly vulnerable to COVID-19 for the following reasons: (a) the high population density of long-term care hospitals: the number of beds in one room is 5.12 on average in long-term care hospitals compared to 3.61 in general hospitals, (b) difficulties in requiring people with dementia or respiratory disease to observe needed hygiene and/or to wear masks; (c) the pre-existing health conditions of most residents in care institutions that make them more susceptible to infection (source: https://www.tandfonline.com/doi/full/10.1080/01634372.2020.1797977).

Last updated: January 6th, 2022


Singapore relies heavily on community-based care, however older adults who cannot receive care appropriate for their needs at home are able to seek accommodation in a LTCF. Singapore has over 16,000 LTCF places as of 2019 of which 40% are run by the government, 37% by non-profit organisations and 23% by the private sector (source: ageingasia.org).

Public and NFP run long term care facilities in Singapore are particularly vulnerable to infectious diseases due to their infrastructure: most resemble dormitory-style residential conditions shared between roughly 6 – 12 residents, with communal facilities. There is more variation in the layout of private nursing homes: some have dormitory-style living conditions that have as many as 30 residents; others have single or double private rooms (Udod et al., 2021).

Last updated: January 11th, 2022


In 2020 three in every four LTCFs in Spain were privately run and many residents had some of their costs publicly funded. The fees received by the institutions had not changed for a long time, a result of years of austerity in Spain, and many private facilities had to make cuts to make a profit, whilst some lacked equipment even before the pandemic, many operated with minimum staff (source: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0241030).

Last updated: January 6th, 2022


LTC institutions are similar to regular apartment houses, namely three quarter of residents have an apartment with 1 or 1½ room, with cooking facilities, a WC and a shower. Many units have balconies attached at each floor.  A garden or outdoor space at ground floor is also frequently available. The main problem relates to shortages of facilities (which are municipal with eligibility criteria for admission) since a wave of closures of municipal institutional beds, which began in the 2000s, resulted in a reduction of nearly 40% of all institutional places (source: Governmental-response-to-the-COVID-19-pandemic-in-Long-Term-Care-residences.pdf). Consequently, the older people moving into institutional care are more frail and more dependent both in terms of functional and cognitive capacity than before (source: Sweden Country Report).

Last updated: January 6th, 2022


Residential nursing care and specialist care are less available than community care, but they are  growing as well. Most residential care services for dependent older persons are found in private nursing homes and private hospitals, although some residential homes and homes for poor older persons are financed by the government and charitable organizations. The Ministry of Social Development and Human Security manages public homes called “Social  Welfare Development Centers for Older Persons,” which aim to provide shelter, but also a degree of care for residents if they develop care support needs.  Services at residential care facilities range from basic to complex care, including accommodations, help with personal hygiene, assistance with ADL and moving about, care that requires nursing skills, rehabilitation, day care, respite care, and hospice care (source: Country Diagnostic Study on Long-Term Care in Thailand (adb.org).

A survey of care home residents  living at two government long-term care centres during August 2020 to October 2020 found that most residents (82.5%) lived in shared rooms (government financed rooms) and the median length of stay was 5 years (Srifuengfung et al., 2021).

References:

Srifuengfung, M., Thana-Udom, K., Ratta-Apha, W., Chulakadabba, S., Sanguanpanich, N., & Viravan, N. (2021). Impact of the COVID-19 pandemic on older adults living in long-term care centers in Thailand, and risk factors for post-traumatic stress, depression, and anxiety. Journal of Affective Disorders, 295, 353–365. https://dx.doi.org/10.1016/j.jad.2021.08.044

Last updated: January 14th, 2022


The Center for Disease Control (CDC) studies LTCFs vis-a-vis the following categories: adult day services centres, nursing homes, residential care communities, hospices and home-health agencies. State-by-state information on the number of each kind of LTCF, the number of people they serve, ownership (i.e. for-profit or governmental), certification, staffing, and services provided can be found in the CDC’s National Post-Acute and LTC Study (source: https://www.cdc.gov/nchs/data/nsltcp/2016_CombinedNSLTCPStateTables_opt.pdf).

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.