Guiding principles. ⢠Long term care insurance is not a fully comprehensive scheme covering all needs of people requiring care, it is rather a partial coverage.
Structure of presentation The health advisory board General facts about the statutory long term care insurance Criteria for eligibility General and special problems Some results of assessments Problems to be solved in near future Summary and challenges for the far future
The health advisory board (M DK) of all social health and nursing care insurances in lower saxony
Lower Saxony
M EDI CAL ADVI SORY BOARD (M DK) Our scope: sociomedical expertise and consultation for the social health and nursing care insurances in lower saxony Our supervisory board: the associations of the social health and nursing care insurances Our financing: lump sum per insured person ( ca. 18 DM or 8 US $),budget:80 mio.DM,38 mio.US $ Our guideline: independency in our sociomedical way of thinking
M DK Long Term Care I ndividual Expertise assessment of care level + follow up, rehabilitation, auxiliary devices, restructuring of surrounding, institutional care
Basic Expertise: to solve fundamental questions, e.g. quality assessment of home and institutional care
Consultation I nsurances and their associations, ministry of social affairs,
Centre Organisation of the MDKN 35 Advisory and Examination Centres in Lower Saxony 155 medical experts 92 nursing staff
Special divisions Hospital Remedies
Pharmacology Nursing Care Dentistry
Rehabilitation
Treatment Failure Appliances
I nformatics
Some general facts about the Social (Statutory) Long Term Care I nsurance in Germany
Guiding principles Long term care insurance is not a fully comprehensive scheme covering all needs of people requiring care, it is rather a partial coverage insurance system with limited though generous benefits: ± In home care the benefits are intended to supplement the professional care and attention rendered to the beneficiary by his family, by friends or other informal carers ± in institutional care benefits are aimed at relieving the beneficiary(as far as possible) from care-related expenditure. Hence it follows that people in nursing homes have to pay their own living and accomodation
Funding and Administration Compulsory system for all people employed Long-term care insurance follows health insurance Two branches: ± Social Care insurance scheme (approx. 92% of population), pay-as-you-go-system ± Private care insurance plan
Equal contributions from employers and employees, beginning with 1.3 per cent in 1995, income related XSWRDÄFHLOLQJOHYHO³ZKLFKLVUDLVHGHYHU\\HDU Implementation by the health insurances
Guiding principles Home care is preferred to institutional care Regardless of the level of care a person receives prevention and rehabilitation are given priority over care Beneficiaries may choose freely among Germany`s 8600 nursing homes and almost 13.000 home care agencies.
Range of benefits Home Care at the applicants home
± Direct compensation:direct payment to applicant or relatives ± Indirect compensation: compensation of costs for professional service providing care Stand-in Care Ä+ROLGD\³&DUH Part-time Care in a day or a night centre Short-term Care up to four weeks a year Technical Aids Nursing Care Courses I nsurance Cover for I nformal Carers Permanent I nstitutional Care
Philosophy of the Statutory Long Term Care Insurance Deficiency compensating ÄWROHDGDVIDUDVSRVVLEOH an independent and Care
Promoting/Activating Care
§2 SGB XI Abs.1
selfdetermined life corresponding to the GLJQLW\RIPDQ³ ÄWRUHFRYHUDQGSUHVHUYH the physical, spiritual and PHQWDOUHVRXUFHV³
Criteria for eligibility
S G B XI
A person is eligible if
he or she requires frequent or substantial help with normal day-to-day activities of life due to a physical,mental or psychic disease or handicap and the need for care will exist for an estimated period of at least six month
A person is deemed to need care if he or she needs somebody to help, supervise or guide him or her to carry out the activities of daily life
The accepted normal day-to-day activities of life are in the areas of:
Personal hygiene Nutrition M obility Housekeeping
Areas taken into account personal hygiene
washing bathing showering dental hygiene combing shaving toilet assistance
mobility getting out of or going to bed getting dressed or undressed walking standing climbing stairs leaving and getting back to the home
Areas taken into account Nutrition: eating feeding preparing the food in bite-size and ready to eat
Housekeeping
grocery shopping cooking cleaning dishwashing changing and washing linen and clothing heating the home
Comparison §14 Abs.4 SGB XI Normal day-to-day activities of life
Personal hygiene Nutrition M obility Housekeeping ? ? ? ? ? ? ? ?
Nursing model (Nancy Roper) The 12 activities of daily life
to excrete to keep clean and dress to eat and drink to move to sleep to regulate body temperature to breathe to be engaged with activities to communicate to feel and behave like a man or woman to take care for the security of your surrounding to die
Care Levels Care level 1 (considerable need for care): ± at least once a day ± two aspects of basic care affected ± 9o minutes/ day (45 minutes basic care)
Care level 2 (severe need for care): ± at least 3 times a day ± 3 hours/day (2 hours basic care)
Care level 3 (extreme need for care): ± around the clock ± at least 5 hours/day (4 hours basic care)
Showering: 15-2o min. Time Frames for Bathing: 20-25 min. help Dental hygiene: 5 min. Combing: 1-3 min. Preparing the food: 2-3 min. Shaving: 5-10 min. Drinking and Eating: 15-20 Washing of whole body: min. 20-25 min. Washing of hands and Getting out or going to bed: face: 1-2 min. 1 -2 min. Getting completely dressed or undressed: 8-10 min.
Problems
General Problems The Social Long Term Care Insurance is not a fully comprehensive scheme In terms of the Social Insurance the need for care is following the definition of the law, it is not up to the individual perception or judgement The evaluation of the medical requirements to claim settlement is assigned to expert examiners, not to the therapists.
General Problems Persons with a need for care because of deficits in housekeeping but no need for basic care : no claim to benefits of the insurance because of missing need for basic care. Care level 1 is not reached.
Special Problems The Downgrading of the Care level because of reduction of need for Care: successful rehabilitation successful supply with auxiliary devices (e.g. catheter, duodenal probe, handicap adjusted equipment and rebuilding of the appartment (wheel chair) increasing confinement to bed
Special Problems: Persons with a need for Care but not in the areas taken into account M entally handicaped children Aged people with senile dementia Hyperactive children
Special Problems To assess the care level for children: Children with a need for long term care must be compared with healthy children of the same age During the first year of life the need for long term care is a rarity In the subsequent years only the need for basic care exceeding the age-related need for care is counting for the claim of benefits
Decrease of need for normal care in healthy children with increasing age referring to areas of life activities in hours/day
Age
0-1
1-2
2-3
Personal hygiene
1,25
1
1-0,75 0,75
Nutrition
2-1
1
0,75
Mobility
2
2
1
Housekeeping ?
?
?
3-6
6-12
0,750,0 0,75- 0,50,5 0,0 1-0,5 0,50,0 ?
?
Special Problems Delimination between Therapeutic Care (Health Insurance) and Basic Long Term Care (Long Term Care Insurance)
Results
Orders for expertise 1998-2000 Year Orders for expertise
Outpatient I npatient Primary (home) (I nstiexpertise tutions)
Follow Cont up radi ction
1998 1.454.382
77,9
20,0
58,4
34,9
6,7
1999 1.431.169
78,6
20,7
56,4
37,6
6,0
2000 1.432.683
77,4
21,9
55,7
38,4
5,9
Recommendations for Care Level Expert Outpatient recomm Home care endation 1988 1999 2000 Care level 0 Care level I Care level I I Care level I I I
I npatient I nstitutional care 1998 1999 2000
32,4
31,6
33,1
18,9
17,0 16,9
41,9
43,8
43,9
38,0
39,8 42,5
19,9
19,2
18,0
32,7
33,7 32,6
5,8
5,4
5,0
10,4
9,5
7,9
Number of Beneficiaries Home Care
Care level I Care level II Care level III
I nstitutional Care
31.12. 1998
31.12. 1999
31.12. 1998
31.12. 1999
616.506 = 50,3 % 471.906 = 38,5 %
668.314 = 52,2% 472.189 =36,9%
187.850 =36,7% 210.525 =41,2%
203.950 =37,4% 226.657 =41,5%
138.303 = 11,3%
139.876 =10,9%
113.028 =22,1%
115.376 =21,1%
511.403
545.983
1.226.715 1.280.379
Problems to solve in future
Supplementary law for Social Nursing Care Insurances Considerable need for general surveillance and attention in home care
Considerable and permanent reduction of daily living competences with the following impairments and handicaps: ± ± ± ± ± ± ±
Uncontrollable leaving and getting back to the home (tendency to get off ) Being unaware of and giving rise to endangering situations I mproper use of dangerous objects or potentially endangering substances Violent or verbal-aggressive behaviour, misjudging situations I nadequate behaviour in context with the situation I nability for perceiving their own personal physical and emotional feelings Disturbances of the day/night rythm
± ...
Quality assessment Foundations in social law: § 80 SGB XI und ab 2002 § 80 b SGB XI
Number of assessments: 650 out of 2.400 institutions for nursing care 500 occasions (s. 1996) 150 random samples(s. 2000)
600 prof. inst. care 50 prof. home care
Quality assessment -
Results of nursing care quality random sample
4 % optimal 64 % appropriate 22 % inadequate 10 % endangering
sample by occasion
1 % optimal 65 % appropriate 22 % inadequate 12 % endangering
Quality assessment Processual quality: concept for nursing care random sample
sample by occasion
34 % fulfilled 32 % fulfilled 32 % partly fulfilled 29 % partly fulfilled 34 % not fulfilled 39 % not fulfilled
Summary The statutory long term care insurance in Germany is
politically stable generally accepted in the population confirmed in structure and criteria by the supreme court of justice in general on the way to be further improved by legislation and the supreme court in detail has induced a market of nursing care enterprises
Challenges for future The statutory long term care insurance has to meet 5 extreme challenges :
to finance demography, to face the inevitable rise of senile dementia to protect women against the pressure of overburden to solve the decline of family organisation to assure the quality of institutional and home care
