LTCcovid Country Profiles

Responses to 1.09. Community-based care infrastructure

Australia

The majority of older people who use government-subsidised community care receive services through two major programs:

• The Commonwealth Home Support Programme (CHSP) which provides entry level services. This is the largest program, and remains block-funded, with the government directly funding providers based on client numbers and services delivered.
• The Home Care Packages Program (HCPP) was introduced in 2017 for individuals at four levels of assessed need.

The CHSP provides entry level care for Australian aged 65 older and indigenous Australian aged 50 or over to live independently at home. Services include some personal care, shopping, help with meals, taking people to appointments and community nursing. In 2018-19 there were:

• 1,452 CHSP providers
• 840,984 clients in the CHSP
• Approx. 209 individuals per 1,000 people in the target population

The HCPP provides support for people who need higher levels of care, especially personal care. It is an individualised cash for care scheme, where the government subsidy is reduced by means-tested contributions from ‘consumers’  which depend on that person’s assessed income. These fees vary between $15.81 to $31.63 per day. People may also be asked to pay a ‘basic daily fee’, the level of which depends on the package level. Where the daily fee is charged, it  is added to the government subsidy.

At 30 June 2021 there were

• 939 approved HCPP providers
• 195,699 people had access to a Home Care Package (HCP)

Accessing services:

Older people must be first assessed by an aged care assessment officer  to determine the package level. There are four levels of packages which range from Level 1 –  to Level 4  per annum. There are price differences between providers for various services (although records of median prices charges are kept (see Duckett et al., 2021, figure 2.3 and the national summary of home care prices) and there are differences in the amount of administration and care management fees charged. Such fees average 25% of the total value of a package and they be up to 50% of the HC package in some instances.

The number and level of packages in the HCPP are effectively capped and there are long waiting lists for both assessment and for access to services when a person has been allocated a package. As at June 2021, there were  53,203 older people waiting for a HCP at their approved level (Department of Health, p.15).

References:

Deloitte Access Economics (2020) Commonwealth Home Support Programme Data Study. Department of Health, Australia. https://www.health.gov.au/sites/default/files/documents/2021/06/commonwealth-home-support-programme-data-study_0.pdf

Department of Health (2021) Home care packages program. Data report 4th Quarter 2020-21. Australian Government. https://gen-agedcaredata.gov.au/www_aihwgen/media/Home_care_report/Home-Care-Data-Report-4th-Qtr-2020-21.pdf

Last updated: February 15th, 2022

Austria

There is a wide range of community-based services available across Austria, both provided in the home of care-users and in community centers, although the availability and type of services available vary drastically across and within federal states. A range of long-term care mobile services are available for supporting personal care (i.e. personal hygiene, eating, etc.) and household maintenance in the home of the care user, carried out and coordinated at the regional and municipality level, including: food delivery (i.e. meals on wheels), driving services, mobile therapeutic services, cleaning services, repair services, and laundry services. Social services also exist, such as peer-to-peer advice provided by those with disabilities and visiting services for older people who are lonely (sources: https://www.oesterreich.gv.at/themen/soziales/soziale_dienste/1/Seite.1210130.html and https://www.oesterreich.gv.at/themen/soziales/soziale_dienste/1/Seite.1210140.html).

Day care centres, which are available from Monday to Friday, are another community-based care option for older people. These centers offer a wide range of services, including social contact, skills training, professional care, therapies, and general support (source: https://www.gesundheit.gv.at/leben/altern/wohnen-im-alter/altersgerecht-wohnen).

24-hour care, in which care is provided around the clock by a live-in carer (typically of migrant origin), is also a large part of the community-based care in Austria and provides a relatively cheaper option for individuals with extensive care needs to stay in their home (Aulenbacher et al., 2020).

References

Aulenbacher, B, Leiblfinger, M, Prieler, V (2020) ‘The promise of decent care and the problem of poor working conditions: Double movements around live-in care in Austria.’ Socialpolicy.ch – Journal of the Division of Sociology, Social Policy, Social Work 2: 2.5.

Last updated: February 2nd, 2022   Contributors: Cassandra Simmons  |  

Chile

There is a home-based care programme for people with severe dependency and also to provide health care to people who cannot access healthcare centres. Since 2016, the Ministry of Social Development has implemented a Local Support and Care Network, as part of a set of programmes towards a National System of Care. There are also initiatives to support family carers through cash benefits and respite care (Browne et al., 2020).

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.

Last updated: February 1st, 2022

Denmark

Municipalities provide social and health care services for older people living at home and overall, older people can access a wide range of services that enable them to remain in their homes even if they are chronically or terminally ill. These services include day care services, extensive home help and nursing care.

The number of people receiving home care has declined over the last decade, as a combined effect of the introduction of reablement and a prioritisation of resources for the most frail. As of 2021, 11% of the population 68+ receive home care. There is documentation of an increase in frail older people who live at home without anyone helping them as well as a decline in ASCOT measured quality of live among home care recipients (Rostgaard and Matthiessen, 2019 and 2020).

The municipalities have been implementing and tested reablement in various scales since 2007. In January 2015, a new legislation mandated all municipalities to consider first whether a person applying for home support could instead receive reablement services. Reablement is typically offered in the form of a 12-week exercise training course, provided by multidisciplinary teams with an involvement of physio- or occupational therapists, in which the older person together with the care worker identifies and works towards achieving one or more goals such as, showering alone or cleaning home. Individuals mainly receive home support only after the reablement failed to help, but in some cases, it can be offered parallel to the reablement intervention. Municipalities offer services in the individual’s home.

Rehabilitation training for instance after discharge from hospital are offered in municipal training centres. Services are included in the mandatory healthcare agreements between the administrative regions and the municipalities, and they ensure cooperation between the various service providers.

Individuals discharged from hospitals can receive follow-up home visits from general practitioners or nurses, which takes place a week after discharge and may be repeated at three and eight weeks after discharge if additional support is needed (WHO, 2019).

References: 

 Rostgaard, T., Tuntland, H. and Parsons, J., (eds.) (2023) Reablement in Long-Term Care for Older People – International Perspectives and Future Directions. Bristol: Policy Press.

Rostgaard T. (2016) Socially investing in older people – reablement as a social care policy response? Res Finnish Soc. 2016;9:19–32.

Rostgaard T. (2015) Failing ageing? Risk management in the active ageing society. In:  Torbenfeldt Bengtsson T, Frederiksen M, Elm Larsen J, editors. The Danish welfare state. New York: Palgrave Macmillan; 2015:153–68.

Rostgaard, T. og Matthiessen, Mads. (2020) Hjemmehjælp og omsorgsrelateret livskvalitet. VIVE rapport. København: VIVE

Rostgaard, T. og Matthiessen, Mads. (2019) Hjælp til svage ældre. VIVE rapport. København: VIVE.

WHO (2019), Denmark: Country case study on the integrated delivery of long-term care. Accessed at:  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: May 24th, 2023

Finland

The Finnish government is currently proposing reforms to the Social Welfare Act that aim to strengthen and expand home-based care, including widening the services on offer and adopting measures to secure sufficient staff.

Last updated: February 1st, 2022

France

Community based case in France is mostly provided by domiciliary care services: 

• Personal assistance services (Services à la personne, SAP) either directly employed by the person drawing on care or via an agency 

• Domiciliary care services (Services d’aide et d’accompagnement à domicile, SAAD) who give care and support at home 

• Domiciliary nursing services (Services de soins infirmiers à domicile, SSIAD) to deliver medical/nursing care to prevent admission or readmission to acute services and delay a person’s need for residential care  

• Multidisciplinary domiciliary services (Services polyvalents d’aides et de soins à domicile, SPASAD) set up in 2005 to bring together domiciliary care and nursing services to provide a more coordinated approach to care.     

However, a new strategy in 2023 (see 4.08 Reforms to strengthen community based care) has committed to Streamlining existing domiciliary care services to create a single category of domiciliary care provision and move towards a more integrated delivery of care. The reforms will create two main categories of home care: home care with medical/nursing care, and home care with no nursing, but integrated care models will be prioritised through mergers between home care services and home nursing services. New financing from the regional health agencies for the medical component is intended to increase this integration and improve visibility of domiciliary care to health actors. The move towards adopting more integrated domiciliary care services has been informed by an evaluation of existing models which has found more joined up services for people, greater integration with care homes and health actors, and greater prevention (source). 

The domiciliary care sector is extremely fragmented, with one department (local authority) having over 100 agencies. Financing is unprofitable. 

Estimates of the size of provision in domiciliary care are limited due to the varied ways in which it can be purchased: direct service provision commissioned by the local authority (prestataire), partial management of administration by service user (mandataire), direct employment of home care staff by the service user (see Le Bihan and Sopadzhiyan 2018, download here).  The number of people who draw from home care is estimated between 0.4 and 1.5 million. There were over 110,000 places for home nursing care in 2017 (see Le Bihan, 2018, download here).   

The average fee paid to home care agencies who cater to state-supported individuals (around 75% of provision) is €21.7 per hour – below the estimated 24€ needed to cover costs (source).  

People over 60 can access state support for home based care through the cash-for-care scheme (APA). However, the amount people receive is based on low estimates of the cost of care, valued at 60€ per month. This is based only on services included in a person’s care plan, and excludes costs of living, variations on price, and the level of unpaid care from which a person might draw (source).  

There were 3.9 million carers providing care to the over 60 according to a 2019 government report (source). Carers provide on average twice as much care time with users compared to staff (see Le Bihan and Sopadzhiyan 2018, download here). Support for unpaid carers is limited to a right to a break and a right to unpaid leave, although uptake has been low due to limited awareness of the available support (see Le Bihan, 2018, download here). Unpaid carers can receive 500€ as an annual lump sum to fund day care or temporary accommodation. Studies (see Le Bihan, 2018, download here) ) have estimated that almost half (48%) of people who draw on care depend solely on an un paid carer, and another 32% have both formal and informal support. A high proportion of unpaid carers are female, especially in situations of high need. 

Last updated: October 22nd, 2024   Contributors: Alis Sopadzhiyan  |  Camille Oung  |  

Germany

Differences in care infrastructure

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

Future feasibility

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

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

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

Last updated: February 12th, 2022   Contributors: Klara Lorenz-Dant  |  Thomas Fischer  |  Kerstin Hämel  |  

Japan

Japanese formal LTC relies heavily on day care and homecare services. In 2014, 7.8% of those 65 or older used day care in Japan. In 2019, in absolute numbers there were 1,077,609 users of day care services and 971,432 users of home care services. Many day care service providers also accommodate overnight stays.

With the revision on Japan’s long-term care insurance law, current ageing health policies have shifted to a more population centric approach. Group activities called “Kayoi-no-ba” have been valued in Japan as a disability prevention initiative. The Kihon Checklist – a 25-item questionnaire – has been broadly used by health experts and researchers to assess frailty in Japan. However, a new 15-item questionnaire has been newly developed to identify frailty and other health-related problems in older people of 75 years and above. This will enable the provision of necessary support to frail individuals at any healthcare facility in local communities (Estevez-Abe, 2021; Kojima et al. 2021).

References:

Estévez-Abe, M., Hiroo Ide. (2021). “COVID-19 and Japan’s Long-Term Care System.” LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, February 27, 2021. Retrieved from: ltccovid.org

Kojima, M., Satake, S., Osawa, A., & Arai, H. (2021). Management of frailty under COVID-19 pandemic in Japan. Global health & medicine, 3(4), 196–202. https://doi.org/10.35772/ghm.2020.01118

Last updated: August 4th, 2023   Contributors: William Byrd  |  

Poland

Community services include home-based care comprised of nursing services provided through the health sector and services provided through the social sector. Home care services cover assistance with everyday activities, personal hygiene, tasks related to housework, nursing (if prescribed by a physician), and support in social networking. Specialist home care is adjusted to the specific medical and rehabilitation needs of the recipients, and services are provided by qualified personnel, such as physiotherapists. An important and recently developing type of care is day care centres offering leisure time activities for older people and people with disabilities. Activities ranging from education, culture, to excursions are provided for persons living at home, whose family members are not able to provide care because of work responsibilities, during working hours (Golinowska et al. 2017).

References:

Golinowska, S., Sowa-Kofta, A. (2017) ‘The Polish policy landscape. Retrieved from CEQUA: Poland Country Report

Last updated: March 3rd, 2023   Contributors: Joanna Marczak  |  

Singapore

Singaporean LTC relies heavily on home-based and community care services and aims to reduce unnecessary utilization of institutional care (source: https://www.adb.org/sites/default/files/publication/637416/singapore-care-system-population-aging.pdf). In 2019, there were 7,600 day care places, 10,300 home care places and 1,986 community hospital beds in Singapore (source: Analysis of variable COVID-19 mortality among older people in Asia Pacific, by forms of long-term care (ageingasia.org).

There are different types of day care services in Singapore. These include: ‘senior care centres, day rehabilitation centres, general and enhanced dementia day care and day hospices’. Home care services for bed-bound older people living in their own homes include ‘medical, nursing, therapy, personal care and hospice’ are. In addition, there are meals-on-wheels services and Medical Escort and Transport Services available. Community hospitals offer short-term (2-4 weeks) rehabilitative inpatient care for people who experienced acute medical care needs. It is their role to facilitate transition back into the community (source: https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Last updated: February 1st, 2022

Sweden

Long-term care in Sweden is heavily focused on the provision of community services. The ‘ageing in place’ reform in 1992 promoted the deinstitutionalisation of old age care. After that, municipalities started to downsize the number of institutional beds they provided for older people in need of care (source: European Commisssion / ESPN report). In 2019, over 160,000 older people received care at home; almost double the 82,000 individuals who were provided residential care. It should be noted that some people – such as those with disabilies and those with dementia – are more likely to need residential care, and that an over-reliance on home-based care tends to place more burden on informal carers, most of whom are women (Johansson and Schon, 2020).

Municipalities fund home care for people who are eligible based on a a needs assessment. Local municipality assessors make decisions on the support that a person needs, the services can involve personal care (such as help with dressing and bathing), household support (such as shopping and cooking) and emotional support, for example in the form of social activities. Once services have been granted by the assessor, the persons can choose an agency to deliver the services and the agency home care staff, in consultation with the clients, develop a care plan describing how and when services should be provided (Sandberg et al., 2018, Meyer et al., 2022). Home care may be complemented by nursing care at home provided by primary care (Meinow et al., 2020)

Analysis of the Swedish Social Service Register shows that, of all people aged 70 and over, 9.1% receive home care services, compared to 4.1% living in care homes. Among those receiving services through municipalities (also 70 and over), 75.6% live in a private residence and 24.2% live in a care home, and 69.5% receive home care. Among those receive home care, 62.5% receive support with household activities, 63.2% receive personal care, 7.4% receive support with social participation and 1.2% received services to provide relief to family carers. They receive on average 41.2 hours per month, although there is high variability between municipalities (Meyer et al., 2022).

A study of use of home care services by older people with and without cognitive impairment found that, among those receiving personal care, help with showering was the most common activity. Among those receiving support for household activities, cleaning was the most common activity for which help was provided. The study also found that people with cognitive impairment were had help with more personal care activities and received higher hours of care per month compared to those without cognitive impairment (Sandberg et al., 2018).

Between 2002-03 and 2009-10 there was an important reduction in the coverage of residential care, although in principle this would have been compensated by increases in publicly funded home care, however, in practice it resulted in substantial increases in care provided by family members (mostly women), with those living alone being more likely to receive public home care. There was also a small increase in privately purchased care services amongst the most highly educated (Ulmanen and Szebehely, 2015 and Dahlberg et al., 2017).

References:

Johansson L. and Schön, P. (2020), ‘Governmental response to the COVID-19 pandemic in Long-Term Care residences for older people: preparedness, responses and challenges for the future: Sweden’, MC COVID-19 working paper 14/2021. http://dx.doi.org/10.20350/digitalCSIC/13701

Meinow B, Wastesson JW, Karehold I and Kelfve S (2020) Long-Term Care use during the last 2 year of life in Sweden: Implications for policy to address increased population aging. JAMDA 21:6, 799-805. https://www.jamda.com/article/S1525-8610(20)30028-1/fulltext

Meyer AC, Sandström G and Modig K (2022) Nationwide data on home care and care home residence: presentation of the Swedish Social Service Register, its contents and coverage. Scandinavian Journal of Public Health, 50:946-958. https://journals.sagepub.com/doi/pdf/10.1177/14034948211061016 

Sandberg, L, Nilsson, I, Rosenberg, L, Borell, L, Boström, A-M, (2019) Home care services for older clients with and without cognitive impairment in Sweden. Health Soc Care Community. 2019; 27: 139– 150. https://doi.org/10.1111/hsc.12631

Ulmanen, P. and Szebehely, M. (2015), From the state to the family. International Journal of Social Welfare, 24: 81-92. https://doi.org/10.1111/ijsw.12108

Last updated: March 6th, 2023   Contributors: Adelina Comas-Herrera  |  

Taiwan, RoC

The 2017 Long-Term Care 2.0 reform introduced a Community-Integrated Care system. This was to be organised as a so-called ABC network, governed by local governments, where “A” is a community integration service centre (compared to an LTC flagship store), which is responsible for developing services in their area and for linking other services within a 30 minutes transportation window, “A” centres are also tasked with education, information and education. “B” are “composited service centres” (compared to an LTC speical care store) which provide major community-based services and are tasked with increasing quantiy and utilisation of services as well as helping “C” develop services. “C” are “Alley LTC stop” (compared to LTC grocery stores), with the remit of providing convenient care and temporary respite care, deliver preventative activities adn provide lunch clubs or meals on wheels. All “C” centres whould be within walking distance of users. There have been some ammendments to his original plan and reported tensions between the different types of centres (with B centres being allowed to set up with A centres) (Hsu and Chen, 2019).

The Health and Community-Based Services (HCBS) included in LTC 2.0 are home care serivces (including personal hygiene, transfers and housework), respite care, assistive devices and home modifications, tranportation and community-based services (such as day care and meals).

Another important aspect of the 2017 LTC 2.0 reform was a focus on reablement, giving care recipients who can benefit from reablement goal-oriented care plans to enhance the participation of care recipients in meaningful daily activities. A study found that care recipients with low care nees had greater potential to improve their physical function in Activities of Daily Living using reablement services and that both individuals with low and high care needs, home-based personal care supported improvement in Activities of Daily Living and Instrumental Activities of Daily Living (Yu et al., 2022).

References:

Hsu HC and Chen CF (2019) LTC 2.0: The 2017 reform of home- and community-based long-term care in Taiwan. Health Policy 123:10, 912-916. https://doi.org/10.1016/j.healthpol.2019.08.004

Yu, H-W, Wu, S-C, Chen, H-H, Yeh, Y-P & Chen, Y-M (2022). Relationships between reablement-embedded home- and community-based service use patterns and functional improvement among older adults in Taiwan. Health & Social Care in the Community, 30, e4321– e4331. https://doi.org/10.1111/hsc.13825

Last updated: March 2nd, 2023   Contributors: Adelina Comas-Herrera  |  

Thailand

For many years, Thailand has explored models of home- and community-based care, with an emphasis on services provided at home, initiatives over the years including training volunteers to provide care services in the community (e.g. home visits, assistance with meals, assistance with taking medicine etc); and various integrated community-based care projects.  The Community-Based Long-Term Care Program, under the National Health Security Office (NHSO), started in 2016 and had provided care to some 193,000 older persons by 2018; there are plans to expand it throughout the country (source: Country Diagnostic Study on Long-Term Care in Thailand (adb.org).

Last updated: February 1st, 2022

Spain

Spain characterises insufficient community support for people with moderate of sever needs who live in their own homes, moreover there are visible inter-regional disparities regarding the quality, coverage or funding of services, which creates unequal access to services. A high number of people with LTC needs receive cash allowances to family caregivers in lieu of services, which heightened the responsibility of families in providing care. Migrant care workers, often hired with no legal contract, often provide private care at home (source: CEQUA Spain Country report (filesusr.com)

Last updated: January 6th, 2022

sub-Saharan Africa

Because organized systems of LTC are generally lacking, families constitute the major source of care for older people who are no longer able to live independently. Numerous concerns about quality of care have been documented. These range from general neglect of older people to exclusion, marginalization, and abuse. Care inadequacies may result in older people being unable to maintain their functional ability or lead to depression or early death. Inadequacies in family care arise particularly in contexts of poverty and vulnerable employment. In these cases, the family members who provide long-term care lack the resources to give better care and are faced with a choice between neglecting their work, training or other economic activities or neglecting their dependent older relative (source: https://www.who.int/publications/i/item/9789241513388).

Last updated: January 6th, 2022