International Trends in Aged Care

Anthea Penny, Adv.Dip.Nursing (Distinction), DHM (Massey), MhealthMgt (Hons) FCHSE

1. Introduction

Governments in western countries together with New Zealand are faced with providing health and social care services to an increasing number of older people who are living longer and whose expectations are to access affordable quality health and social services in their old age. Many of these countries are reforming their systems and positioning their policy, resources and services to meet this growing demand. In these countries governments are grappling with the question of how to provide future care to not only the increasing numbers of ageing in their populations but also how to resource and manage the increasing levels of disability and chronic disease.

Internationally demographics are changing, with increasing numbers of elderly particularly those over 85 years of age. There is progression and increase in the amount of chronic disease coupled with increasing longevity and levels of technology leading to large amounts of disability experienced by this age group. Socio-economic factors related to equity of health and disability support services are also a feature. Service delivery issues range across the continuum of health and long-term care with access to preventive primary and secondary services a feature and the financing, type and range of long-term care that public expenditure will be able to afford in the future key issues. All of this is underpinned with the changing expectations of older people, their carers and family about health and disability support services, where it takes place, its effects and the quality of delivery.

Sustainability of health and long-term aged care is a key focus internationally as the number of older people increase along with resource use. In addition health and long-term care is heavily associated with the older frailer population over 85 years of age who are the fastest growing segment of older populations. The trend is for older people to consume large proportions of primary and secondary services as they age and to make use of long-term care services when they become frail and dependent.

Public funding is the most important source of financing for long-term aged care and disability support services but this is still relatively low as a proportion of GDP when compared to health services and economic /pension schemes. Total expenditure on long-term care is reported to range from 0.5 to 1.6 percent of GDP in western countries and comparison reveals that while there are different ways to organize and fund long-term care there are similar expenditure outcomes. A sample of six countries public and private expenditure on long-term care as a percentage of GDP is in the following table

Table 1: Public and Private Expenditure on Long-term Care as a Percentage of GDP in Six Countries

Source: OECD 2005

Over half of public spending in OECD countries is on institutional care. In addition to public expenditure the OECD reported in 2005 that private expenditure is also an important funding source particularly in high care institutions e.g. 30 percent of total spending in long-term care and this can be substantial for individual households However across time a larger share of resources have been devolved to homecare. Publicly funded homecare has been receiving increasing attention and this form of care has been heavily supported by unpaid informal carers. Private households in most of these countries share the burden of care; not only in providing informal unpaid care but also by making substantial co-payments and out-of-pocket spending on care provided under public programmes both at home and in institutions.

Western countries are seeking more cost effective ways of resourcing and responding to older people's specific needs based on the perception that expenditure growth will accelerate mainly as a result of increasing numbers of older people and frail elderly.

While the comparison of spending levels across countries reveals quite different ways of organizing and funding long-term care, empirical evidence from the OECD (2005) suggests that the differences in programme design (e.g. amount of funding and level of cost sharing, where the care takes place, quality of service and the way the services are targeted) play a more important role. In particular the mature long-term care systems remain fairly stable as a share of total public spending relative to acute care spending with the main growth being in development of new social programmes (Japan, Germany and Luxembourg) In addition these future long-term costs are estimated to be highly sensitive to disability levels and trends which in turn are dependent on the level of self care and disease prevention occurring in the population.

In response to these issues internationally there are a number of key trends that are driving and underpinning reform and these encompass new ways of financing aged care services particularly disability support services together with the provision of a continuum of health and social care that brings all services together. Such a continuum is led by primary care which is the first point of contact and focuses on health promotion, information provision and disease prevention. Another key trend is the empowerment of the consumer towards self-determination and choice in their long-term care arrangements, supported by their informal carer and the provision of a qualified /quality aged care workforce. There is a focus on the provision of long-term care home-based services in the person's community coupled with the use of technology to support care and less punitive approaches to monitoring and improving quality of care with a focus on risk management and the development of outcomes of care.

2. New ways of Funding and Financing Aged Care Services Particularly Long-term Care

Financing of public health and long-term social care services in western countries is through taxation or social insurance schemes as well as out-of-pocket payments by the consumer e.g.: General taxation with explicit entitlement; general taxation with eligibility through needs assessment and the use of means testing ; social insurance programmes with explicit entitlements (Aids to Daily Living failures) and large out-of-pocket payment by consumers.

Taxation based systems are allocating public funding for long-term care via assessment processes associated with rationing / prioritization criteria along with means testing and co-payments by the consumer. Means testing has its critics and the National Health Service in the United Kingdom has untaken a survey on public satisfaction with income and asset testing and concluded that it is not popular with the British people due to the lack of reward for saving; the way the decisions regarding the starting point are made; it's failure to provide for “inheritance” money for the family and a feeling that many people have regarding having “paid their taxes” all their lives and therefore entitled to a baseline of social support in their old age.

Most countries are searching for ways in which to fund and provide a continuum of care for long-term care to the older person that is equitable and affordable both for the individual and the government. Various methods at a publicly funded systems level are being used ranging from:

2.1 Overall Systems level

• Co-payment Model – associated with means testing so that anyone assessed as needing long-term care would be income and asset tested prior to receiving government funding. Levels are set in varying ways but include assets thresholds and levels of personal income
• Partnership model – anyone assessed as needing care would be entitled to a basic level of care met from public funds, any care above the minimum is met by state funding matched by private contributions to a specified limit and anything above the limit is funded by the individual or their family. Wanless (2006)
• Savings based models associated with social and private insurance schemes

2.2 Allocation Methods
Home Care / Community Care

• Public funding for personal care and equipment only and the consumer pays for their own house cleaning ( UK and Holland )
• Publicly funded personal budgets and consumer – directed employment of care-givers ( UK , Germany )
• Publicly funded “Voucher” schemes to the person needing the care who can spend it as they like but the outcomes are monitored by government agencies (voucher system – Austria and “Direct Payment” pilots in the UK )
• Publicly funded income support payments to informal carers (policy under consideration in the UK and the “carer payment” in Australia )

Residential Care

• Co – payment model: Associated with asset testing and income criteria
• Accommodation bonds which are capital contributions paid by all entrants to residential care in Australia that are part refunded when the residents exit the facility. There are a number of criteria surrounding this approach.

In some countries health care funding is separate from social care while in others both of these funding streams merge. Primary, secondary /tertiary and community health care together with long-term care are a part of the whole continuum of care which needs to be coordinated to provide cost-effective care for the older person. There is direct evidence of the value of an integrated funding approach which show that direct hospitalization and long-term institutionalization were reduced with improved outcomes and increased consumer satisfaction. Wanless (2006)

While western countries are adapting their funding and resource allocation systems for older people across the continuum of care, there are still significant differences in the reform details. Some common features for long-term care are emerging that focus on consumer choice such as personal budgets, direct payment schemes and income payments to informal carers.

Personal budgets and support as an alternative means of providing formal home care by a single designated agency. Older people or their families are given the budget and can choose from a range of providers or their family to provide direct personal care. Note home cleaning is not provided for in this budget.

Direct payment schemes are available in some countries which allows older people needing care to get cash or finance (part) of their expenditure on long-term care (Voucher systems) The older person, their relatives and the paid workers they employ provide the care and the health and well-being of the person is reviewed very 3 or 6 months by a government agency.

Income payments to informal carers are made in a number of countries in order to compensate for loss of income. It is not anticipated that this will fully compensate the carer rather they are meant to sustain a minimum level of income for persons unable to have a job.

Evaluation outcomes from direct choice and payment schemes internationally report that the quality of care is similar to formal provision, there are high levels of satisfaction as it increases older people's flexibility and level of control that they have over their daily lives, Lundsgaard (2005)

3. Primary Care -led Health and Social Care Services

Internationally primary care is the first point of contact for older people's health and social care needs and is in the forefront of future arrangements for service delivery. It is now recognized that access to primary care services plays a vital role in helping older people keep fit and live longer and healthier lives thus lowering the level of disability. There is growing evidence internationally on the effectiveness of primary care as acute health care costs are not rising so much with age but with the approach to death. Recent research in Canada indicates that approximately one third of health expenditure is incurred in the last year of life MoH (2002).

There are a number of primary care trends from overseas that are being implemented to enable older people to keep as fit as possible and remain in their own homes. The following strategies are examples:

• Development of primary care led health promotion and disease prevention strategies such as:
• Provision of on-line and hard copy information on maintaining wellness, “when to visit the doctor” and disease prevention
• “Life Checks” offering initial assessment and specific advice
• Nutritional advice programmes
• Immunization for Influenza
• Falls prevention
• Evidence based disease prevention programmes e.g. diabetes
• Improving access to primary care via nurse led initiatives e.g. Nurse led walk-in clinics, access to Nurse Practitioners and Medical services including after hours.
• Coordination and positioning of primary care with other members of the multidisciplinary team in the community; e.g. Nursing, Occupational Therapy, Physiotherapy, Podiatry, Vision / Hearing testing and dispensing, Pharmacies etc.
• Increasing the amount of home-care and community based specialist services such as specialist geriatric and rehabilitation services based alongside general practice. Evidence shows that community-based services can be substituted for specialist health care (mainly hospital and that this is cost-effective. UK

Providing specialized case management and medical care that is available in a community setting across 24 hours to the frail elderly living in their own home, e.g. Sweden

Evidence of the cost effectiveness of the provision of a continuum of care that is primary care led and spans from prevention to specialist hospital care to long-term care and palliative care is emerging. Wanless (2005) identifies current research that suggests that a mix of current service provision would improve outcomes at given costs and that this is achieved by meeting the older persons immediate needs while at the same time reducing the necessity for more intensive and expensive services downstream

Source: Wanless (2005)

4. Long-term Care - Focus on the Provision of Home-based Services

There has been a major shift in public policy internationally towards public long-term care programmes that provide increasing amounts of home care to older people. Taxed based systems are using assessment of need as a means of accessing long-term home care and resources are being shifted from residential care to provide a wide range of home-care services for older people and this larger share of resource in home care has:

• Increased the supply of home care providers
• Increased community based services such as personal care and respite services
• Developed a variety of consumer choice programmes
• Resulted in the development of and personal budgets and self determination funding strategies

There is an increasing movement into the provision of high levels of personal care at home with or without additional medical and nursing inputs and input from other members of the multidisciplinary team. In addition there is strong shift towards merging younger disabled and the elderly and utilizing strategies that encourage social integration through universal service, transport, community activities etc. There is view particularly in the UK that general services in the community can contribute more to the long-term care of older. In the UK a number of initiatives are being piloted:

Extra Care Housing – This may incorporate a number of different terms and models but the aim of this initiative in the UK is to offer a home-like environment in which care and support are available, but where an independent lifestyle can be retained for long as it is possible. This is particularly relevant for those who are experiencing cognitive impairment.

It is comprised of self-contained accommodation for rent and/or sale together with communal facilities and access to care, as well as support, services are available from a team based on site. Assistive technology is used as required. Extra care housing is seen by local authorities and health commissioners in the UK as offering both an alternative to residential care (e.g. meals and 24 hour cover) as well as another housing choice for older people. Most extra care schemes include residents with a range of dependencies and usually include facilities and services which are also used to support people living in the local vicinity.

Modifying an older persons home with appropriate equipment and aids as well as the use of assistive technology

In the UK Community Matrons are being developed – they can be from any skill set but focus is community case management. Anecdotal evidence from the NHS suggests that half the admissions to ED were not known to either health or social care systems.

Provision of increasing amounts of specialist services being based in the community such as specialist geriatric and rehabilitation services as well as 24 hour, 7 days per week specialist home-based care from a multidisciplinary team, e.g. Hospital at Home schemes (UK) and intensive home care programmes in Sweden.

The use of intermediate care strategies to rehabilitate older people after an acute episode, with or without extra care schemes but utilizing and including client pathways. This is an integrated approach where “step-down” rehabilitation / convalescent services are available in non-acute residential facilities. The aim of this programme is to promote independence and enable individuals to maximize their potential allowing them to return home as quickly as possible following an episode of ill health.

A referral criteria and assessment process is used to establish whether a person is suitable for admission to the facility in order to maximize its use. Admission is targeted at people who would benefit from a short period of re-enablement and who would otherwise face unnecessarily prolonged hospital stays or inappropriate admission to acute in-patient care, or inappropriate long-term care in residential/nursing .

Key Elements associated internationally with the increasing provision of aged care in the community are:

• Streamlined assessment processes across agencies and across time
• Transport resources available in the community
• A variety of funding streams that are coordinated at the consumer interface
• Wider choice of options for home-based care which include the range of services available as well as the timeframes in which they are delivered
• The ability of providers to balance risk against safety
• Increased community based packages that are tailored to meet the individuals needs
• Improve support for informal carers
• Tailored housing that meets older peoples disability needs
• Ability of services to address special needs of the cognitively impaired particularly in the community

5. Consumer Expectation and Empowerment

Internationally there is an understanding that older people need to achieve their own goals and be in charge of their own affairs in order to be self directed in their way of life and to meet their own preferences, needs and circumstances. Their ability to maintain their own dependence and a sense of control is embodied in the notion of “home”. Humanistic geographers discuss home as place, as a concept that has profound psychological connotations and involvement by the person living there and gives individuals a sense of their personal and cultural identity thus loss of home and institutionalization is a crisis involving identity. The ability to keep this central in an older persons life is the key to future care and Layard (2005) extends this to encompass the new science of happiness which looks at the effects on happiness that impact on older people as they age i.e.:

• Reduced financial income from capped superannuation and investments:
• Loss and changes to family relationships: This relates to those who are widowed or living alone
• Unemployment: This encompasses the feeling of being gainfully occupied and is dependent on an older person's quality of life in retirement and whether or not there are meaningful pursuits developed
• The level of safety and trust in the community, and the degree of social support from relatives and friends
• The effects on their health: The amount of chronic disease, illness disability or frailty experienced in older age
• The amount of personal freedom in ones life and how this relate to those living in a residential setting that has institutional rules
• The personal values attitudes and beliefs and this encompasses whether or not one has a spiritual belief

All of these conditions either singularly or fully are experienced by older people by the time they reach the end of their life. It is not surprising that depression rates are high or that people as they approach old age express the wish to stay in their own home for as long as possible so that they are surrounded by the familiar and achieve self-determination. That older people want to be in their own home or in “home-like” situations is recognized internationally as a key initiative. A survey was carried out in the UK by the Commission for Social Care inspection where people were asked about the care options they would choose if they needed care and the results are detailed in the following table.

Table 2: Preferences for Receiving Social Care in the UK - 2005

Source:” Wanless (2006)

Older people's preferences for services related to fundamental aspects of their care were also measured in 2002 in the UK and produced a numerical “utility score”, Wanless (2005) Personal care needs, such as washing, dressing, going to the toilet, and getting up and going to bed were most important followed by social participation. These two categories were twice as important as domestic care and it is interesting to note that in some Australian states, the United Kingdom and the Netherlands the focus for their resources is on the provision of personal care at home with minimal provision for household management and house cleaning.

6. Use of Technology

Telecare is the delivery of health and social care services to people in their own homes using a combination of sensor and information and communication technologies. Barlow et al (2005) Telecare aids professionals and gives the consumers an extra option of remaining in their own home with the ability to contact information / help, to monitor their health status or to be monitored for safety and care purposes. It does not replace personal care, human contact and communication rather it augments existing care.

Specifically telecare services are currently at two levels either as a direct response to unscheduled calls or as an information gatherer on the health and safety of the home user. Telecare provides: rapid response modes which are either client activated or automatically activated and require an immediate response; information and advice modes activated by the individual either automatically or as a timed response to help deliver health or other care related information (medication management); preventive modes of telecare which are normally activated in response to an individuals needs or health state where additional support is needed (this is still in the experimental phase at present).

Features of telecare lie in its speed of response in monitoring and safety situations however the differing modes place different demands on the service providers and these are summarized together with the different applications in the following table

Table 3: Application, User and Service Action and Provider Requirements for Telecare

Source: Barlow et al (2005)

Telecare has a set of common issues across western countries and these are: The major market drivers are eHealth and the workforce shortages, the growing demands of health and home care, coupled with the increasing numbers of elderly and decreasing costs of telecommunication costs are making telecare an attractive option.

Obstacles to the widespread introduction of telecare are the lack of evidence regarding efficacy and the consequent impact on investment and reimbursement together with a lack of centralized policy and investment as well as evaluation of successful implementation and use. Successful mainstream examples to date are Call Centres and health status monitoring (US veterans) together with pilot examples of monitoring in UK extra care schemes. Barlow et al (2005)

7. Quality Improvement

The OECD report of 2005 describes the evidence of quality in long-term care in western countries internationally as being variable and in many instances failing to meet the expectations of the public and the consumers. Adverse events and poor quality have been the key drivers of reform and key evidence of poor care lies mainly in the institutional arenas (which is not to say that home-care doesn't have its share of poor care as well but it is harder to monitor) and encompasses pressure sores, the prevalence of chronic pain, the prevalence of the use of tube feeding and the overuse of anti-psychotic drugs. OECD (2005) National standards are also variable with quality monitoring at various stages and levels of implementation and the development and measurement of outcomes are still in their infancy. There are many factors interlinked with poor outcomes of care and many of these are associated with the structure and process of long-term care. A survey of twelve western countries conducted by the OECD (2005) identified the following concerns in residential care:

• Recruiting and retaining an adequately educated and skilled workforce
• Putting in place or further developing quality assessment and monitoring systems
• Co-ordination of care services
• Resource constraints; limited financing
• Access to a broader range of services; more differentiation
• Use of physical restraints

There is a higher level of satisfaction expressed by the consumer about home care and this has been demonstrated in surveys internationally, OECD (2005). This has been one of the key influencers in the policy and resource shift to the provision of increased home care, however there are quality issues internationally surrounding home care services which are similar to institutional care with the following additional concerns:

• Lack of information about services

• Prevention of inappropriate residential admission

• Broader range of services; too little differentiation

• Adequate care supply for dementia cases

Efforts to improve quality internationally involve a number of strategies such as: Setting and monitoring national standards based on minimum requirements; establishing and monitoring outcomes of care; use of accreditation systems; linking performance monitoring with continuous quality improvement; self-regulatory approaches by providers and/or their associations; and consumer empowerment and market competition.

One of the most important trends internationally is the monitoring of quality and safety is the movement to the assessment of risk and an outcomes based approach. This replaces regular inspection with a combination of spot inspections at less frequent intervals with the rigor of self-assessment with the aim of making the process more reliable and transparent.

Consumer empowerment have included measures such as setting up residents councils and more effective means of dealing with complaints as well as “mystery shopper” approaches. Some countries have established independent aged care ombudsman that incorporate complaints, advocacy and representation.

8. Workforce

8.1 The Formal Workforce

All western countries report workforce shortages in long-term aged care yet the input of a skilled trained workforce is crucial to achieving quality outcomes. There are a number of key issues being experienced by all aged care systems internationally but few solutions are forthcoming. Factors affecting the supply of the workforce relate to the unpopularity of the aged care sector as an industry to work in; the ageing workforce populations and the lack of trained semi-skilled staff and a qualified professional workforce. Service delivery grapples with high rates of turnover and low rates of retention and this in turn is associated with the way the workforce is remunerated, the lack of training, their difficult working conditions and lack of career prospects.

The key question is whether or not there will be an adequate workforce available to meet higher levels of demand particularly in the community. Answers are few but the UK National Health and Social Care services are investing in the following strategies:

• Improving the remuneration levels and training qualifications of semi-skilled workers.

• Basing the training on nationally identified competency standards with incentives for training that offer ease of access to training opportunities and multi-cultural approaches to learning

• Adapting the training outcomes to accommodate the introduction of technology

• Development of a skilled qualified professional workforce e.g. Use of Gerontologist Nurse Practitioners, that are remunerated appropriately and have career prospects defined

• Linking outcomes of training to the quality of care delivered and monitoring this

8.2 The Informal Workforce

Given the uncertainty of supply of a formal workforce internationally the focus is turning toward supplying further support to the informal carers who for so long have cared for their older relatives or partners at home in the community. Strategies involve increasing or strengthening respite care arrangements, providing carer allowances as financial reimbursement and recognition for their role at minimum wage rates and making direct care payments so that the carer and their relative have control and flexibility over their daily living arrangements.

9. In Conclusion

All western countries are facing a number of issues associated with increasing elderly populations and the challenges of delivering increased quality long-term care in the future that is affordable to the government and the individual. Sustainability trends encompass new ways of funding to make the best use of public and limited private resources. This is occurring in tandem with new models of service delivery that are focusing more on home and community based long-term care, supported by primary care services that case manage health and wellness. There is a focus on supporting informal carers who are resourced an in receipt of respite care in addition there are strategies being developed to empower consumers and their carers to provide choice, flexibility and control over their daily lives. Continuums of long-term health and social care are being developed that span low level self care to high levels of hospital care and include palliative care at the end of life.

Key concerns remain however with the supply and quality of a skilled trained workforce. While western countries are all experiencing similar workforce issues, solutions are slow to emerge. The future of our aged care industry lies in finding appropriate workforce strategies to provide long-term care and this is now an urgent challenge.

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Brief Biography

Anthea H Penny

RGON, Adv. Dip. Nursing (Distinction), DHM, (Massey), MHealthMgt, (Hons), FCHSE.

Anthea is a qualified health professional, an experienced Chief Executive in the New Zealand health sector, a management consultant, a Director of R H Penny Ltd and a facilitator of health leadership development both nationally and internationally. She is also the inaugural recipient of the 2004 New Zealand Institute of Health Management Silver Fern Award for Excellence in Health Service Management.

Since 1993 Anthea has worked continuously as a management consultant, with national and regional funders and service providers of healthcare and rehabilitation in New Zealand , developing and implementing policy and strategy, reviewing/evaluating health and disability services across the service delivery spectrum. In particular Anthea has extensive experience in the Aged Care Sector.

As well, Anthea has developed and facilitated national health leadership programs for senior managers and clinicians in Australia and New Zealand and worked in conjunction with the Auckland University, New Zealand and the Australian College of Health Service Executives (ACHSE). In addition she has developed and facilitated with the Birmingham University (and latterly the NHS leadership Centre) international learning sets (a leadership program that focuses on strategic issues and thinking) for senior executives and clinician's working in the New Zealand and the English health sector. Within New Zealand , Anthea has developed and facilitated short courses, workshops, Learning Sets and national forums on health management and clinical issues and led six Masterclass study tours overseas.

Anthea is a Fellow of ACHSE, a former National President of the New Zealand Institute of Health Management, has presented a number of papers at national forums and conferences, published in national and international magazines/ journals and written numerous unpublished reports for the Ministry of Health, District Health Boards, the New Zealand Treasury, the New Zealand Accident Compensation Corporation and service provider boards.