Long-term Care System Research Articles

RE-IMAGINING LTC: QUANTITATIVE AND QUALITATIVE RESULTS OF A NATIONAL MODIFIED DELPHI STUDY, IMPLICATIONS AND NEXT STEPS

In 11/2016 Robert and Rosalie Kane began a 3-round Delphi study to re-imagine long-term care (LTC), , which took as a starting premise that LTSS in the United States fails to comport to the values and preferences of consumers. The Delphi study is “modified” from more typical Delphi designs because of 1) a sample sizes over 100, 2) an unusually broad topic--optimal LTC systems if not constrained by existing programs, financial arrangements and regulations; and 3) incorporation of new sample at each round. Round 1 asked respondents to rate and add to a list of values important to LTC< but largely was an open-ended request for respondents’ ideas, Round 2 was fielded in 6/2018 with all data collection completed by 11/2018 (the delay partly due to Robert Kane’s sudden death on March 6, 2017 and also the time needed to analyze, summarize and present the complex and detailed responses to the first round). Round 3, to be fielded in 4/2019., will provide participants with the ratings of values, principles and programmatic building blocks at Round Two, and the open-ended comment of respondents in explanation of their ratings. Each Round is analyzed cross-sectionally and can be considered a separate “virtual town square.” Ellen McCreedy and Rosalie Kane, respectively, present quantitative and qualitative results from the first two rounds. Discussants will each comment briefly from their perspectives as 1) state LTC policy developer,2) LTC university-based researcher; 3) consumer advocate, followed by audience and presenter discussion of the implications of the findings.

ASSESSING THE EFFECTS OF LONG-TERM CARE INSURANCE ON EQUITY AND EFFICIENCY: A CASE STUDY OF QINGDAO CITY IN CHINA

The demand for equitable and efficient long-term care (LTC) has risen rapidly, and finding a suitable mechanism to finance LTC has become a pressing policy concern for many countries. A number of high income countries have chosen to use a social LTC insurance to fund the LTC system, but empirical assessments on such an insurance in low-and middle-income countries are limited. Using China as an example, this paper empirically assesses the performance of newly-piloted LTCNI by evaluating its impact on equity and efficiency in financing. We draw data from 47 in-depth interviews conducted with local government, care providers and family members of the LTCNI participants in Qingdao in 2016. We found that there remain sizable disparities in financial burden among LTCNI participants, despite of its emphasis on ensuring access to care based on people’s needs; care providers are incentivised to provide care at the least cost even this care is deemed as insufficient or inadequate due to fixed payment for their services. Our paper offers critical insights into the potential and challenges in applying LTC insurance model to a LMIC, where critical lessons can be drawn for public LTC insurance in other LMICs.

CAREGIVER SUPPORT RATIO IN EUROPE

The caregiver support ratio (CSR) has been defined as the number of potential caregivers aged between 45 and 64 (the most common caregiving age range) for each person aged 80 and over (subgroup of older adults most at risk of needing long term services and support). In 2010, for the USA, this number was calculated to be 7 to 1, a ratio that was projected to shrink to 4 to 1 in 2030, and to 3 to 1 in 2015 according to the AARP Public Policy Institute. In this study we used data from CENSUS HUB to calculate the CSR in Europe considering a total of 27 countries. Main results revealed that a group of Mediterranean countries (Italy, Greece, Spain and Portugal), along with France, Belgium and Sweden have the lowest CSR (5 to 1); on the other hand, the countries with the highest CSR are Slovakia (9 to 1), and Ireland, Poland, Cyprus and Malta (8 to 1). In average, for the 27 countries, the estimated number of caregivers per frail older person today is 6 to 1. These findings reveal important differences between countries and may inform EU policy decisions regarding long-term care (LTC). Given that informal care forms a cornerstone of all LTC systems in Europe, and that this continent faces a rapidly increasing number of people in very advanced age with extended years of disability living at home, estimating the CSR for the next decades is of crucial importance.

Comparative analysis of long-term care quality for older adults in China and Western countries.

ObjectiveBased on theoretical and methodological research and the results of a literature review, we evaluated and comparatively analyzed the quality of long-term care for older populations in China and in Western countries.MethodsWe performed a literature review, using the search terms long-term care and care services for older adults, in the databases ProQuest, CNKI, and Wanfang Data.ResultsOur comparative analysis demonstrated that the overall quantity of articles related to long-term care for older populations was relatively large. The literature comprises advanced accumulated experiences in terms of theoretical and methodological perspectives in developed countries. The field of long-term care is relatively young in China and we could retrieve only a few related studies.ConclusionsThe system of long-term care for older populations in China has much room for improvement. In addition, the evaluation criteria for long-term care quality remain controversial. Relevant research focusing on the quality of long-term care services in the country lacks comprehensive, systematic, and scientific validation, comparison, and evaluation. This topic warrants further evidence-based investigation in China.

EU level actions and instruments to support the implementation of integrated care

Abstract Issue/Problem The significance of integrated care as a means for improving health outcomes and the effectiveness and sustainability of health and care systems is acknowledged in several policies at national and EU level, for example: the European Commission’s Communication on effective, accessible and resilient health systems, the 2017 European Semester: Communication on Country Reports, the Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability by the European Commission and the Economic Policy Committee, the Companion Report 2017 of the State of Health in the EU and the most recent Commission Communication on the digital transformation of health and care in the Digital Single Market. As such, there may be no doubt about whether one needs to transform the health and care model and move to integrate care, but the question is how to design and implement integrated care successfully. One pre-condition for this to happen, is for health authorities to have adequate capacity and relevant know-how. Results The European Commission aims at assisting Member State authorities at national, regional and local levels to fulfil this pre-condition and proceed with their health system reforms. There is a number of instruments, initiatives and funding support to raise the capacity of national and regional healthcare authorities to adopt and scale up integrated care. Lessons There is an increasing demand and need to provide support and assistance to Member states to drive the transformation of healthcare systems towards more coordinated, integrated and sustainable healthcare systems.

Participatory approach in developing the long-term care strategy in Slovakia

Abstract Issue/problem In Slovak Republic (SR) old-age dependency will rise rapidly in the near future and will more than double in the next 15 years. This profound demographic changes will require restructuring of health and social care systems with more people working in the long-term care (LTC) sector and most likely a higher level of public spending to cover the growing LTC needs. Description of the problem Providing LTC in Slovakia has many problem areas. It is governed by several acts and regulations, which are not always linked and sometimes do not cover the situation entirely. There is not coordinated and integrated LTC model implemented and the distribution of the roles between the health and social care systems is lacking. Results Since 2017 a policy dialog between the key stakeholders - the Ministry of Health of the SR; the Ministry of Labour, Social Affairs and Family of the SR; and civic societies led by the Association for the Patients’ Rights Protection has been in place with aim to improve the current LTC Strategy Proposal. Online survey was carried out in May - June 2018, which brought deeper insights into the needs regarding demand and supply, and uncovered the main limitations of the current LTC system, e.g. insufficient capacity of LTC beds or a malfunctioning information system. This was followed by six workshops for professional and lay public, organised between February and March 2019 with aim to collect further evidence on regional level. Lessons The LTC Strategy Proposal development is one of 12 pilot projects within the national project - Promoting partnership and dialogue on participatory public policy making in SR. The initiative takes into account the needs and demands of LTC target groups and will serve as a starting point for further action in this area. [Grant Support: APVV-15-0719]. Key messages In Slovakia, a complex solution of long-term care issues is essential. Developing the LTC Strategy Proposal through participatory approach is an important starting point for future action.

The Evolution of Long-term Care Programs Comment on "Financing Long-term Care: Lessons From Japan".

The need for long-term care (LTC) represents a "new social risk," one that overlaps with and complements systems of care that pre-date such programs, complicating LTC program design. This commentary expands on Ikegami’s discussion of how these structural factors must be accommodated, as well as historical and cultural factors that influence public expectations of such a program. The commentary specifically focuses on the role of cash payments, caregiver benefits, and the sometimes indistinct line between LTC and health systems. The experiences of countries operating LTC program in a wide range of contexts can illuminate common challenges, as well as some potential solutions to these vexing design and operational issues.

Political and Cultural Foundations of Long-term Care Reform Comment on "Financing Long-term Care: Lessons From Japan"

This paper comments on Naoki Ikegami’s editorial entitled "Financing long-term care: lessons from Japan." Adding to the editorial, this paper focuses on analyzing the political and cultural foundations of long-term care (LTC) reform. Intergenerational solidarity and inclusive, prudential public deliberation are needed for the establishment or reform of LTC systems. Among various lines of ethical reasoning related to LTC, Confucian ethics and other familist ethics are specifically important in the societies that share these values. The core issue in the debates around LTC reform is how to (re-)define the scope of social entitlements and accordingly to allocate the responsibility for care between states and families, between social groups, and between generations with limited resources.

Private Labor Market Intermediaries in the Europeanized Live-in Care Market between Germany and Poland: A Typology

AbstractThis article looks at the role of private companies involved in organizing so-called live-in care arrangements between two EU member states, Germany and Poland. Due to gaps in the public long-term care system, employing livein migrant care workers in private households has become a widespread individualized solution to rising long-term care needs in Germany. Since eastern EU enlargement, private brokerage agencies placing Polish live-in migrant care workers in German households have grown considerably. Building on approaches conceptualizing the role of intermediaries in formalizing domestic work, we aim to provide a more fine-grained typology of private brokerage agencies, taking into account not only the legal environment and structural features of these private enterprises, but also theirstrategic positioningunder conditions of high legal uncertainty in the EU multi-level governance system. By analyzing corporate as well as political strategies of these intermediaries, we distinguish three different agency types we call pioneers, minimum effort players and followers.

Transitioning of older Australian women into and through the long-term care system: a cohort study using linked data

BackgroundOver two-thirds of older Australians use different types/levels of aged care at some point in later life. Our aims were to estimate transitional probabilities and to identify risk factors influencing the movement between different levels of long-term care.MethodsThe sample consisted of 9007 women from the 1921-26 birth cohort of the Australian Longitudinal Study on Women’s Health. Transitional probabilities between different levels of long-term care were estimated using a continuous-time Markov model.ResultsAn 11-fold transition rates ratio was observed for the movement from non-user to home and community care (HACC) versus non-user to residential aged care (RAC). The predicted probabilities of remaining in the non-user state, HACC, and RAC after 10 years from the baseline were .28, .24, and .11, respectively. While the corresponding probabilities of dying from these states were .36, .65, and .90. The risk of transitioning from the non-user state to either HACC or RAC was greater for participants who were older at baseline, widowed, living outside of major cities, having difficulties in managing income, or having chronic condition, poor/fair self-rated health, or lower SF-36 scores (p < .05).ConclusionWomen spend a substantial period of their later life using long-term care. Typically, this will be in the community setting with a low level of care. The transition to either HACC or RAC was associated with several demographic and health-related factors. Our findings are important for the planning and improvement of long-term care among future generations of older people.Trial registrationNot applicable.

Long-term Care Financing: Inserting Politics and Resource Allocation in the Debate Comment on "Financing Long-term Care: Lessons From Japan"

The ageing of the countries’ populations, and in particular the growing number of the very old, is increasing the need for long-term care (LTC). Not surprisingly, therefore, the financing of LTC systems has become a crucial topic across the Organisation for Economic Co-operation and Development (OECD). In the last three decades, various financing policies have been carried out in different countries and the related international debate has grown. The latter has so far focused mostly on the different alternatives to collect economic resources to pay for care. The international debate needs now to focus also on other issues, so far less discussed. One is the politics of LTC: the degree and nature of the political interest in LTC, that affects the size and profile of public financing. The other is resource allocation: how different services and benefits are distributed among people with different care needs, that determines if resources made available are optimized. If we do not pay more attention to these issues – inextricably connected to policies aimed to collect funds – our understanding of LTC financing will remain inevitably limited.

Notes About Comparing Long-term Care Expenditures Across Countries Comment on "Financing Long-term Care: Lessons From Japan".

The comparison of long-term care (LTC) expenditures is a difficult task. National LTC systems differ widely in terms of eligibility criteria, level of benefits, institutional variety and regional heterogeneity. In this commentary I will first give some general remarks on cross country comparisons. Then I discuss the role of the informal sector which is the most important pillar of all LTC systems. I conclude with some background on current developments in Germany. Different from Japan Germany is extending its LTC insurance instead of containing costs.

Lessons learned from the evolution of long-term care programs in Japan and the implications for Taiwan's long-term care system development

Lessons learned from the evolution of long-term care programs in Japan and the implications for Taiwan's long-term care system development

Mass evacuation and increases in long-term care benefits: Lessons from the Fukushima nuclear disaster.

BackgroundThough mass evacuation may increase the need for long-term care (LTC) services, how the need for LTC services increases and how the public LTC system affects it is not well understood. We evaluated changes in public LTC benefits for the people living in the mandatory evacuation areas established after the 2011 Fukushima nuclear disaster and examined the roles of the universal LTC insurance system in Japan.MethodsIn order to evaluate the effect of the mandatory evacuation on LTC benefits, we examined the trends of LTC benefits in the Fukushima evacuation group and the nationwide non-evacuation group. We first decomposed per-elderly-individual benefits at the municipality level into the LTC certification rate and per-certified-individual benefits, and then implemented difference-in-differences analysis using these variables as outcomes.ResultsPer-elderly-individual benefits significantly increased from 2012 onward in the evacuation group, and this was explained by an increase in the certification rate rather than in per-certified-individual benefits. Increases in per-elderly-individual benefits and the certification rate in the post-disaster period were observed in all but the highest care level, and the corresponding outcomes for the highest care level decreased immediately after the disaster. We also found that the increase in the certification rate had been mostly realized by an increase in the number of certified individuals.ConclusionsThe increase in LTC benefits can be associated with the impact of the increase in the number of people newly certified to receive LTC benefits after the mandatory evacuation. In order to cope with the increase in utilization of long-term care and associated costs after disasters in aging societies, both formal long-term care services and social support for informal care for evacuees should be considered important.

Toward a Fit-for-purpose Policy Architecture on Long-term Care in Sub-Saharan Africa: Impasse and a Research Agenda to Overcome it

Context: Perspectives from sub-Saharan Africa (SSA) have featured little in the expanding global debate on long-term care (LTC) policy thus far – despite SSA countries’ embrace of global commitments on the development of equitable and sustainable LTC systems. Objective: Building on insights derived from ongoing analyses of relevant literature and policy frameworks, stakeholder engagement, as well as personal experience, this commentary examines the lack of a fit-forpurpose policy architecture on LTC in SSA at both regional and national levels. Method: The analysis assesses the nature and drivers of this policy impasse and pinpoints an agenda for research to help overcome it. Findings: LTC in SSA is provided overwhelmingly by families, with available evidence pointing to inequitably distributed deficits in the quality of such care and negative impacts on unpaid family carers. Governments have forged a spectrum of frameworks that speak to questions of LTC. Yet fit-for-purpose provisions that consider a need for expanded organized care and support provision to reduce quality deficits and costs on carers are widely lacking. The impasse may be rooted in a lack of awareness of relevant evidence, as well as in political views that resist organized care provision as an imposed western model that counters African values and as a distraction from priority child-, youth- and gender-focused development agendas. A concerted research effort that examines the compatibility of organized LTC provision with African family norms and its relevance for broader social and economic development in SSA is required to address the policy impasse. Limitations: This overview is an exploration of the agenda, leading to suggestions for ways forward, and not an empirical research report.

Practice variation in long-term care access and use: The role of the ability to pay.

ABSTRACTPractice variation in publicly financed long‐term care (LTC) may be inefficient and inequitable, similarly to practice variation in the health care sector. Although most OECD countries spend an increasing share of their gross domestic product on LTC, it has received comparatively little attention to date compared with the health care sector. This paper contributes to the literature by assessing and comparing regional practice variation in both access to and use of institutional LTC and investigating its relation with income and out‐of‐pocket payment. For this, we have access to unique individual‐level data covering the entire Dutch population. Even though we found practice variation in the use of LTC once access was granted, the variation between regions was still relatively small compared with international standards. In addition, we showed how a co‐payment measure could be used to reduce practice variation across care office regions and income classes making the LTC system not only more efficient but also more equitable.

LTC 2.0: The 2017 reform of home- and community-based long-term care in Taiwan

Taiwan planned to establish a social insurance-based long-term care system in 2016. However, due to the change in political parties that year, it was decided that Taiwan’s long-term care policy would remain a tax-based financing scheme. The new policy focuses on providing home- and community-based service (HCBS); a three-layer HCBS service network within towns and districts was set to provide the 17 types of services in the HCBS spectrum, including preventive care. The reform was criticized as being too restrictive and lacking flexibility. However, the HCBS service spectrum has been widened, the target group has been enlarged, and thus HCBS utilization has increased. A rolling amendment has continued into 2018: the HCBS system requirement has been eased, and a new capitalized fee-for-service payment system has been launched. This paper discusses the analysis of the policy reform.

Evaluating the quality of long-term care services in the city of La Plata, Argentina

AbstractThis paper reports on an innovative survey of long-term care facilities for older people in the Argentine city of La Plata. It applies a range of qualitative methodologies, including a clandestine audit conducted by older people living in the community. The paper pays particular attention to the types and availability of services, perceived quality and the rigour of regulatory processes. It finds that there has been a rapid growth in the availability of formal services, but that there are many gaps in provision, especially for older people with complex care needs. There are strong indications that service quality is uneven and, in some cases, this amounts to the contravention of basic human rights. State regulation is hampered by institutional fragmentation and weak governance. A wider set of expert interviews and the limited available published information indicate that these findings are unlikely to be exceptional, and that similar issues affect rapidly emerging long-term care systems in many low- and middle-income countries.

China's policy experimentation on long-term care insurance: Implications for access.

China's population is aging rapidly, while the traditional long-term care (LTC) system that heavily relies on families is eroding. In response, China has embarked on a journey of policy experimentation for long-term care insurance (LTCI) since 2016, launching LTCI pilots in 15 pioneer cities. These pilots have a great diversity in participation, eligibility, and provision. This paper estimates the prevalence of LTC needs and analyzes the impact of the LTCI pilots on access. Although substantial progress has been achieved, the overall coverage of LTCI is still relatively small, and a large proportion of vulnerable people needing LTC seem to be left behind because of the strict eligibility criteria. This analysis suggests that future policy experimentation on LTCI reform in China needs to address the following pressing policy issues: expanding the coverage of LTCI; narrowing rural-urban disparities in access; improving access for vulnerable subpopulations; and reducing the heavy reliance on institutional care.

Keeping Long-Term Care Patients Out of Hospital During Acute Medical Illness: Proposal for Common Elements of an Integrated Healthcare Delivery System for Long-Term Care.

Integration of acute and palliative care services for long-term care (LTC) residents reduces the morbidity and mortality associated with avoidable hospitalizations while contributing to healthcare system sustainability. This paper explores patient, provider and system factors contributing to potentially avoidable emergency room visits from LTC homes, based on our clinical and quality improvement work in the Greater Toronto Area and Calgary, as well as reviews the existing literature. Commonalities are used to identify key elements for developing an integrated healthcare delivery system to manage acute medical changes in LTC residents and minimize the need for in-patient hospitalization.