1. LONG TERM CARE “Lessons from Abroad” JUNE 2005 Dr. Rachelle Kaye June, 2007

2. “Facts of Life” Share of older persons continues to grow Life expectancy continues to increase Burden of chronic disease is increasing Degree of disability will continue to increase The need for LTC will continue to grow

3. Organizational and Financial Dilemmas and Tensions LTC is an orphan. Does it belong to health care or social services? Who is responsible for LTC financing and delivery? We all profess to be committed to “aging in place”. Do we put our money where our mouth is?

4. Four Types of LTC “Systems” in OECD Countries Universal and comprehensive coverage for health and LTC (Australia, Austria, Denmark, Finland, Norway, Sweden) Public Social Insurance Programs (Germany, Japan, Luxembourg, Netherlands) Part of Health care coverage (Belgium, Canada, Ireland, New Zealand) Fragmented LTC benefits and services (Greece, Israel, Italy, Portugal, Spain, UK, US)

5. PRACTICES AND INNOVATIONS IN LTC IN EUROPE

6. LTC Coverage Increasing public coverage, special social insurance programs: Netherlands, Germany, Japan Israel: “liberal” but limited social insurance for personal home care “family means-tested” tax-based coverage for institutional LTC: (includes income and assets of the dependent person and spouse and income of all children) Group policies for LTC purchased by HMOs UK: Nursing Home –Medical and Nursing care covered by NHS, domiciliary by family

7. Integration and Community Support Denmark : Integration of health and social services by the municipality Community Centers provide home services geared to community dwelling elderly: health promotion, rehabilitation services, information, referral, day care, meals, transportation, social and cultural activities comprehensive system of assessment and client management for elderly people living in the community very limited user charges from the elderly for personal care and practical assistance in the home

8. Integration and Community Support Germany 4000 “Social Stations” – Community Centers staffed by nurses and social workers coordinate a broad range of non-institutional services including homemaker and other home help services, counseling, shopping assistance, transportation, equipment loan, meals-on-wheels, day care, home nursing, psycho-geriatric nursing services, information and referral. funded by a combination of state and municipal funds, user payments and reimbursement from the sick funds under the medical and long-term care insurance schemes.

9. Primary Caregiver Support In every country informal caregivers provide at least 80% of the care Three major threats:  Economic  Demographic/Social  Personal/Social

10. Financial Support for Informal Caregivers Payments to compensate for loss of income while providing care Carer payment in Australia, the carer's allowance in Ireland, the allowance for families caring for elderly in Japan and the carer's allowance in the UK Recognition of caregiver time for pension points Long term care cash benefits: Personal Budgets Scheme in the Netherlands, Cash Allowance for Care in Germany, Austria and Luxembourg and the Attendance Allowance in the UK may be passed on to the informal caregiver.

11. Support Services for the Primary Caregiver Policies addressing the needs of caregivers including assessment of their needs for services, in addition to services for the dependent person (Australia, UK). Respite Care: short term institutional care of the dependent person, day care or day activity outside of the home or replacement of the informal caregiver at home – in some countries clearly defined legal benefit

12. Additional Kinds of Support Services individual counseling, support groups, training, appointment of a consultant for informal caregivers, contact points or call centers, recreation and holiday trips, health check-ups, provision of information about rights, eligibilities and services available for the dependent people and the procedures for accessing them (Sweden)

13. Summary Clear policy to keep dependent elderly in the community in all countries Infrastructure for community based services is crucial Increase in public spending because or despite policy decision Co-payment: institutional and community care

14. Summary (cont) Informal caregivers continue to be the lynchpin Need for integration among services, service providers, funding sources Concern about long term financial sustainability of health and long term care systems

15. Do we need a Paradigmatic Shift? Dramatic change in allocation of funds from institutional (acute and LTC) to community services Serious focus on support for the primary caregiver LTC as part of a mandatory public catastrophic health insurance scheme – not a welfare benefit Role of private LTC insurance