LTCcovid Country Profiles
Responses to 1.09. Community-based care 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, Patel D, 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.
Many countries have attempted to invest more resources in homecare and
community-based care, away from residential care. Despite the overall shift towards care at home, such services are limited in several Eastern and Southern European countries as well as Canada, Korea and US. Conversely, care in the community is more prevalent in several Nordic countries, Japan or New Zealand. However, even if on average community care is available in a country, access to such care is often hampered in rural and remote areas (Marczak et al. 2015; 2021 Long-term care in the EU).
Marczak J, Wistow G. (2015) Commissioning long –term care in OECD, in Gori C, Fernandez JL, Wittenberg R (eds) Long-Term Care Reforms in OECD Countries: Successes and Failures, Policy Press, Bristol
International reports and sources
Gori C, Fernandez JL, Wittenberg R (2015) Long-Term Care Reforms in OECD Countries: Successes and Failures, Policy Press, Bristol
Some information on care in the community in EU countries can be found in the following reports:
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)
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).
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
Duckett, S. and Swerissen, H. (2021). Unfinished business: Practical policies for better care at home. Grattan Institute. https://grattan.edu.au/wp-content/uploads/2021/12/Unfinished-business-Practical-policies-for-better-care-at-home-Grattan-Report.pdf
Last updated: February 15th, 2022
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).
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 |
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).
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
The number of people receiving home care has declined over the last decade. Municipalities provide social services for older people and overall, older people can access a wide range of social 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.
In January 2015, a new legislation came mandated all municipalities to consider first whether a person applying for home support could instead receive reablement services. Reablement is often offered in the form of a 12-week exercise training course, provided by multidisciplinary teams with an involvement of physiotherapists, 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 receive home support only after the reablement failed to help. Municipalities offer services in the individual’s home or in rehabilitation centres. Rehabilitation 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).
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: February 1st, 2022
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
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).
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%.
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).
Golinowska, S., Sowa-Kofta, A. (2017) ‘The Polish policy landscape. Retrieved from CEQUA: Poland Country Report
Last updated: February 10th, 2022 Contributors: Joanna Marczak |
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
Long-term care in Sweden is heavily focused on the provision of community services. The deinstitutionalisation of old age care started with the ‘ageing in place’ reform policy in 1992, after which municipalities started to downsize the number of institutional beds they provided for elderly members of the population 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 institutional care. It should be noted that some people – such as the disabled or those with dementia – are more likely to need institutional 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).
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
Last updated: February 10th, 2022
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
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).
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: February 10th, 2022 Contributors: William Byrd |
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
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
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 email@example.com
Elisa Aguzzoli, Liat Ayalon, David Bell, Shuli Brammli-Greenberg, Erica Breuer, Jorge Browne Salas, Jenni Burton, William Byrd, Sara Charlesworth, Adelina Comas-Herrera, Natasha Curry, Gemma Drou, Stefanie Ettelt, Maria-Aurora Fenech, Thomas Fischer, Nerina Girasol, Chris Hatton, Kerstin Hämel, Nina Hemmings, David Henderson, Kathryn Hinsliff-Smith, Iva Holmerova, Stefania Ilinca, Hongsoo Kim, Margrieta Langins, Shoshana Lauter, Kai Leichsenring, Elizabeth Lemmon, Klara Lorenz-Dant, Lee-Fay Low, Joanna Marczak, Elisabetta Notarnicola, Cian O’Donovan, Camille Oung, Disha Patel, Martina Paulikova, Eleonora Perobelli, Daisy Pharoah, Stacey Rand, Tine Rostgaard, Olafur H. Samuelsson, Maximilien Salcher-Konrad, Benjamin Schlaepfer, Cheng Shi, Cassandra Simmons, Andrea E. Schmidt, Agnieszka Sowa-Kofta, Wendy Taylor, Thordis Hulda Tomasdottir, Sharona Tsadok-Rosenbluth, Sara Ulla Diez, Lisa van Tol, Patrick Alexander Wachholz, Jae Yoon Yi, 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.