Bericht über das Symposium „Langzeitpflege“

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Austausch zwischen Deutschland, Frankreich und Japan

Bericht über das Symposium „Langzeitpflege“03. und 04. April 2009, Tokyo

Den Bericht verfasste Anna Skarpelis (MPI für Gesellschaftsrecht), die englische Übersetzung Tracey Kimmeskamp.

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Inhalt / Contents Seite Foreword ........................................................................................................................................ 4 Vorwort ........................................................................................................................................... 5 Bericht über das Symposium „Langzeitpflege“ Austausch zwischen Deutschland, Frankreich und Japan

Eröffnung mit Zusammenfassung der Keynote-Speeches .............................................. 7 Session 1, Zusammenfassungen der Vorträge und Diskussion .................................... 12 Session 2, Zusammenfassungen der Vorträge und Diskussion .................................... 18 Session 3, Zusammenfassungen der Vorträge und Diskussion .................................... 25 Session 4, Zusammenfassungen der Vorträge und Diskussion .................................... 30 Zusammenfassende Kommentare ..................................................................................... 38 Abschließende Stellungnahmen der Delegationen ......................................................... 41

Report on the Tripartite Symposium on Long-term Care between France, Germany, and Japan

Opening and Keynote Speeches ........................................................................................ 44 Session 1, Summeries of the Presentations and Discussion .......................................... 49 Session 2, Summeries of the Presentations and Discussion .......................................... 54 Session 3, Summeries of the Presentations and Discussion .......................................... 60 Session 4, Summeries of the Presentations and Discussion .......................................... 65 Summary Comments ........................................................................................................... 73 Closing Comments from the Delegations ........................................................................ 75

Programm des Symposiums/Conference Program ............................................................. 78 Liste der Referenten und Moderatoren/List of Speakers and Chairpersons ................... 81 Anhang: Die einzelnen Beiträge (wie vorgelegt) Keynote Speeches Marion CASPERS-MERK

Die Versorgung Pflegebedürftiger in Deutschland ...................................................... 85 Marie-Eve JOËL

Issues in Care for Dependent People ............................................................................. 99 MATSUMOTO Katsuaki

Japan – Germany – France. A Comparison ................................................................105

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Vorwort Langzeitpflege in Deutschland, Frankreich und Japan Die demografische Entwicklung zeigt uns: Die Menschen leben länger, und sie altern gesünder. Das entspricht den Zielen unserer Gesellschaft und unserem individuellen Bedürfnis – und es ist gut, dass es so ist.

Die Gemeinschaften verändern sich jedoch mit dem zunehmend höhe-ren Anteil älter werdender Menschen. Gleichzeitig mit den sich verändernden Strukturen gehen Probleme einher, auf die wir reagieren müssen, wenn die Stabi-lität der Gesellschaft gewährleistet bleiben soll. Die sozialen Sicherungssysteme stehen dabei vor besonderen Anforderungen, weil die immer größere In-anspruchnahme von zunehmend weniger jungen, gesunden Menschen getragen werden muss. Alle, die auf unterschiedlichen Ebenen und vor unterschiedlichen Hintergründen Verantwortung tragen, sind gefordert, diese Veränderungen zu erkennen und in einen Gedankenaustausch einzutreten. Daran anknüpfend müs-sen Strategien entwickelt und neue Wege beschritten werden, um die Herausfor-derungen der Zukunft nachhaltig zu meistern, die Sicherungssysteme vor Über-forderung zu schützen und dabei den Generationen gerecht zu werden.

Die gesellschaftlichen Veränderungen treffen fast alle Industrienationen und ziehen weltweit Kreise. Im Frühjahr 2009 kam es deshalb zu einem Treffen der Verantwortlichen von Politik, Wissenschaft und Verwaltung aus Japan, Frankreich und Deutschland. Das Japanisch-Deutsche Zentrum Berlin und die zuständigen Ministerien aus den genannten Ländern haben am 3. und 4. Februar 2009 einen Austausch von Fachleuten im Rahmen des Symposiums „Langzeit-pflege“ in T ky , Japan organisiert, bei dem Unterschiede, aber vor allem Gemeinsamkeiten und Lösungswege erörtert werden konnten. Die Erkenntnisse des Symposiums sollen mit der vorliegenden Broschüre schriftlich festgehalten werden und in Erinnerung bleiben. Die Fortsetzung des spannenden Austausches ist vorgesehen, damit wir weiter voneinander lernen können. Bonn, im November 2009 Dr. Matthias von Schwanenflügel

Foreword

Dear Citizens,

A look at demographic trends shows us that people are living longer and are ageing in a healthier manner. This is in keeping with our society’s goals and with our individual needs – and it is good that this is so.

However, societies themselves are changing as the proportion of ageing citizens grows. We have to respond to this development if we are to maintain the stability of our society. The social security systems are being confronted with exceptional challenges in this context, as the steadily growing demands have to be shouldered by a steadily dwindling number of young, healthy indivi-duals. All of us, who bear responsibility, at different levels and in different con-texts, are being called upon to acknowledge these changes and engage in an exchange of ideas. Following on from this, we must develop strategies and embark upon new paths: to find sustainable solutions to the challenges of the future, to protect our social security systems from excessive pressure and, at the same time, meet the needs of all generations adequately.

Societal change is affecting almost all industrial countries and is having an impact all over the world. Against this background, a meeting was held, in the spring of 2009, among those in positions of responsibility in politics, science and the administration in Japan, France and Germany. Within the framework of the ‘Long-term Care’ symposium in Tokyo, the Japanese-German Centre in Berlin organised an exchange among experts, on 3rd and 4th February 2009, at which it was possible to discuss not only differences, but above all similarities and possible solutions.

The knowledge and insights gained from that symposium are to be documen-ted with this brochure and thus kept alive and in our minds. The continuation of this fascinating exchange is also being envisaged, to give us the opportunity to continue to learn from one another.

Yours faithfully,

Dr. Philipp Rösler


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Foreword Long-term Care in Germany, France and Japan Demographic development shows us that people are living longer and that they are aging more healthily. This correlates to the goals of our society and our indi-vidual needs- and that is a good thing.

The communities are changing, however, with the growing proportion of elderly people. Along with the changing structures come problems to which we must react if the stability of society is to be guaranteed. The social insurance sys-tem is facing particular challenges since the ever-growing demands must be met by an ever-shrinking number of young, healthy people. All those who, on differ-ent levels and with different backgrounds, are in a position of responsibility are requested to recognize these changes and to take part in an exchange of ideas. Following on from this, strategies must be developed and new paths explored in order to meet the challenges of the future in the long term, to protect the social security systems from overload and in doing so be fair on all generations.

These social changes affect almost all industrial nations and have a worldwide impact. Thus in the spring of 2009 a meeting took place of those in positions of responsibility in politics, economics and administration from Japan, France, and Germany. The Japanese-German Center Berlin and the relevant ministries from the three countries organized for 3 and 4 February 2009 an exchange amongst experts within the framework of the “Long-term Care” sym-posium in T ky , Japan, during which the differences but above all the similari-ties and solutions could be debated.

The insights gleaned from the symposium should be set down in writing along with this brochure and not be forgotten. The follow-up to this fascinating exchange has been arranged so that we can all learn further from one another. Bonn, November 2009 Dr. Matthias von Schwanenflügel

Vorwort

Liebe Bürgerinnen und Bürger,

die demographische Entwicklung zeigt uns: Die Menschen leben länger, und sie altern gesünder. Das entspricht den Zielen unserer Gesellschaft und unseren individuellen Bedürfnissen – und es ist gut, dass es so ist.

Die Gesellschaften verändern sich jedoch mit dem zunehmend höheren Anteil älter werdender Menschen. Darauf müssen wir reagieren, soll die Stabilität der Gesellschaft gewährleistet bleiben. Die sozialen Sicherungssysteme stehen dabei vor besonderen Herausforderungen, weil die immer größere Inanspruch-nahme von zunehmend weniger jungen, gesunden Menschen geschultert werden muss. Alle, die auf unterschiedlichen Ebenen und vor unterschiedlichen Hintergründen Verantwortung tragen, sind gefordert, diese Veränderungen zu erkennen und in einen Gedankenaustausch einzutreten. Daran anknüpfend müssen Strategien entwickelt und neue Wege beschritten werden, um die Herausforderungen der Zukunft nachhaltig zu meistern, die Sicherungssysteme vor Überforderung zu schützen und dabei den Generationen gerecht zu werden.

Die gesellschaftlichen Veränderungen treffen fast alle Industrienationen und ziehen weltweit Kreise. Im Frühjahr 2009 kam es deshalb zu einem Treffen der Verantwortlichen aus Politik, Wissenschaft und Verwaltung der Länder Japan, Frankreich und Deutschland. Im Rahmen des Symposiums „Langzeitpflege“ in Tokyo hat das Japanisch-Deutsche Zentrum Berlin am 3. und 4. Februar 2009 einen Austausch von Fachleuten organisiert, bei dem Unterschiede, aber vor allem Gemeinsamkeiten und Lösungswege erörtert werden konnten.

Die Erkenntnisse des Symposiums sollen mit der vorliegenden Broschüre schriftlich festgehalten werden und in Erinnerung bleiben. Die Fortsetzung des spannenden Austausches ist vorgesehen – damit wir weiter von einander lernen können.

Ihr

Dr. Philipp Rösler


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98

Tripartite Symposium on Long-Term Care

among France, Germany and Japan

Keynote Report

Marie-Eve JOËL

Professor Department Health Economics

University Paris Dauphine

99

ISSUES IN CARE FOR DEPENDENT PEOPLE

In France, the debate about creating a fifth branch of the social security system to finance the risk ofdependence, the senior citizens' solidarity plan (2007-2012) and the latest Alzheimer's plan (2008-2012) have placed the question of dependence at the centre of political affairs. Major steps havebeen taken towards improving awareness of the problem with the production of a set of reports andthe mobilisation of greater capacity for expert contributions. However, there are still inaccuracies inthe estimates of numbers of dependent people and of patients suffering from neurological disorders,particularly Alzheimer's and related diseases.Issues in caring for dependent people in France arise at a number of levels.

Issues in family care for dependent people

The burden that dependence represents for families is now better appreciated, from the viewpointsof both the practical support given by family members and the financial contribution made by theelderly person or their family. The SHARE survey shows a stable degree of family involvement inEurope in terms of "quantity", but wide variation in the forms this takes (cohabitation or supportfrom a distance). The forms of family involvement depend on the professional support available andon funding provision. The principal problem is to avoid discouraging family solidarity where itexists, because it contributes greatly to the provision of stable care and avoids the need for costlyemergency interventions, which are destabilising for the elderly person. But achieving this requiresknowledge of how effective the various means of recognising informal support are: remunerationfor family carers in the home (via the personal autonomy benefit), generalising care leave, greaterpension entitlements for employees with care responsibilities, training for carers, provision ofrespite packages and various forms of coordination (such as case managers or disease managers).

The question of "liberating" manpower is central: is it more worthwhile to help dependent familymembers for nothing, to receive an allowance for this help (with no value being placed on thehuman experience gained after the patient's death), to receive a salary together with everything thatgoes along with paid work (professional training, labour inspections, occupational medicine etc.), toemployee someone to provide the necessary care and support?

The issues of elderly people's and their families' ability to pay for dependence, the financialresources remaining to the still-healthy spouse and any contributions by children, i.e. theintergenerational transfer of charges, are now being raised in more realistic economic terms. Theimportance of the proportion payable by the elderly person and their family, or more exactly theacceptable amount, is at the heart of the political controversy about public and private dependenceinsurance. The equity of the public contribution is called into question because the level of theautonomy benefit is the same for everyone with an income of less than "2200 per month. Variousways of varying the benefit are being considered (establishing a decreasing scale for payingfinancial support, the personal autonomy benefit (APA, allocation personnalisée d'autonomie), ininstitutions according to the resident's income, varying the APA for Alzheimer's patients etc.).

The organisation of professional care, "industrialisation", new players, cultural change

The sociomedical institutional sector has been modernised in recent years at the instigation of thepublic authorities, bringing levels up to European standards. Several measures (generalising globalfixed payments, the convergence of treatment prices, converting hospital short-stay beds into bedsfor elderly people, setting up enforceable reference systems for accommodation costs etc.) have

100

contributed greatly to this evolution.Home help services are also undergoing modernisation and restructuring. The promotion ofinnovative action in home help and the professionalisation of home help work are now on theagenda. Public credits worth 77.7 million have been released. Another element to note is theinvolvement, however modest, of insurers in home help work.Two strong trends have emerged in the last five years:

1) In the area of accommodation, companies in the for-profit private sector have seen majorinternal and external growth. The traditional actors (public and not-for-profit operators,mutual insurers, religious foundations and congregations, together making up 80% of theaccommodation sector) have experienced difficulties, because maintaining institutions at thestandards required demands major capital investment, and the staff are not always able tosatisfy current requirements in terms of qualifications, evaluation etc. There is realcompetition between those actors (not-for-profit private, for-profit private, associations)who have reached a critical size and a sufficient level of professionalisation andmanagement.

2) In the home help sector, there are several provisions to enable the collective funding of jobsworking partly with elderly dependent people:

o support for jobs requiring few qualifications and a reduction in employment costs forlow-paid workers,

o policies to encourage individuals to employ staff (lowering of social securitycontributions, tax reductions or credits, measures to simplify administration such asthe "chèque emploi service" (service employment voucher)).

o These policies were reinforced by the 2005 law on developing personnal services .

Employment by mutual agreement has taken on a great deal of importance: among individualsemploying staff at home in the fourth quarter of 2006, 187,000 were receiving the personnelautonomy benefit, accounting for almost a third of APA recipients at home, and black-market workis very common in this sector of home care. Regulation of hourly wages for carers in the home ispartly covered by the regulations governing the sociomedical sector (in the context of a serviceproviders' association, for example) and partly by those on direct employment. This dual system ofregulation does not simplify the professionalisation of home help work and the improvement of carequality.

In addition, long-term care is set to develop considerably due to reasons relating to demographics,medical advances, the growth in women's employment and changes in lifestyle. This growth is farfrom over, because the baby boomer generation has not yet reached old age, when the risk ofdependence is highest.It raises several difficulties. The most sensitive point is finding the staff needed to sustain thegrowth of the sector in the medium term. A second issue relates to the need to manage the manydifferent actors, with different professional cultures, involved in working with dependent elderlypeople. Many experiments have been conducted with coordinated or integrated care networks,disease managers and care managers at different local, county or regional levels. But it is stilldifficult to identify an effective coordination model with unanimous support.Finally, we must not underestimate the cultural transformation under way in this "mass" growth inlong-term care. The logic of social support dominant until now is called into question. Themanagement culture among the operators of institutions and services is not yet sufficientlydeveloped. It cannot reasonably be supposed that local authorities will allocate significant funds tothis sector without requiring greater economic rigour and without evaluating the quality of theservices provided.

101

A relatively recent collective awareness of the problems associated with Alzheimer's disease

The sensitivity of French public opinion to the issue of Alzheimer's disease increased notably whenthe third Alzheimer's plan (2008-2012) was put in place. Putting the issue on the political agendaled to significant credits being made available for research. Improving quality of life for patientsand carers is a second and equally essential goal. In this context, of the 7,500 new places that willbe created for dependent elderly people in 2009, 70 to 80% will be intended for elderly peoplesuffering from Alzheimer's disease. One important innovation is the creation of centres for theautonomy and integration of Alzheimer's patients (MAIA, maison pour l'autonomie et l'intégrationdes malades Alzheimer). These are places where existing health and social services are coordinated,without new structures being added. Ten to fifteen projects will be trialled between 2008 and 2012.The main issue remains the capacity of civil society to mobilise to deal with the problem in the longterm in order to change society's view of patients and their families, leave denial behind, bettermeasure the scale of the problem and the difficulty of living with the disease on a daily basis andprovide appropriate support and care.

Dependence caused by mental disorders has its own specific characteristics. The burden on informalcarers is very different from that associated with physical dependence. Action on behalf of mentallydependent patients does not mean just looking after them; it involves a much more far-reachingdegree of care and responsibility. In the home, the provision of care for people suffering fromdementia is similar in numbers of carers to the provision of care for the most serious physicaldependencies. This means that provision relying on a single family carer is fragile, and that care(professional and informal) must be accumulated if the situation is to be managed. Setting uprational care is much easier for physical dependence, where the disabilities that need to becompensated for are known precisely.

In the case of Alzheimer's patients, where should the priority be in terms of local authority fundingsupport: cognitive rehabilitation, help for carers or improving patient well-being, and consequentlyhow should staff be qualified? There are many experiments in progress, but they are not beingevaluated globally and it is still difficult to draw definitive conclusions.

The funding and economics of dependence

Funding for dependence raises two types of questions:- What is the basket of services (more or less comprehensive) a dependent elderly person

needs access to (physical treatments, social support, housekeeping, technical assistanceetc.)?

- What proportion of the costs should be borne by the public purse? Alternatively, whichdependent elderly people should be eligible for public support: the poorest, the mostseriously affected, either physically or mentally? And what are the mechanisms that shouldprovide this collective support?

With regard to the first point, a prior question is to evaluate the needs of the dependent person. Thisdebate has an important place in the current context, and has mobilised large numbers ofprofessionals in the field. The allocation of the APA, the primary benefit for dependent elderlypeople, is based on the use of the AGGIR, a tool used to measure the level of loss of autonomywhich classify people in 6 groups : persons classified in groups 1 to 4 can receive l'APA but in eachgroup there is a maximum level of aid. There has been a great deal of discussion comparing thevalidity of the scales available on the market for elderly and disabled people and the diversity of

102

their use, evaluating their reliability, examining how they could be harmonised and made toconverge etc. The National Fund for the Independence of Elderly and Disabled People (CNSA,Caisse nationale de solidarité pour l'autonomie, national solidarity fund for independent life) iscurrently responsible for studying this central question with a view to defining good practice forprofessionals.

On the second point, discussions on the "fifth risk" (in addition to the four other areas covered bythe French social security system: health, safety at work, retirement and families) are stronglylimited by the financial crisis, the level of public debt and the potential growth in health andpensions spending. In addition, the financial circuits set up in the past to finance dependence inFrance are unusually complex. The National Audit Office (Cour des comptes) has emphasised theaccumulation over time of a great variety of services and the construction of financial circuits thatare difficult to understand and reform. In addition, the growth in funding requirements fordependence is constraint by the financial crisis, public deficits and potential growth of health andpension expenses.

In this context, the recent Senate report favours two types of proposals: private dependenceinsurance and funding for dependence taken from the capital of dependent people. The insuranceroute is put forward in a variety of proposals: converting life insurance policies into dependencepolicies, without considering the transformation as a fiscal innovation, i.e. without penalty for theinsured; enabling extra dependence contributions to be tax-deductible; enabling policies to betransferred when policyholders change wish to change insurer etc. A second proposal consists ofcreating a voluntary, limited share in the person's assets, affecting the APA recipients with the mostassets. Two levels of APA would be defined, with a share recoverable on succession of "20,000 forrecipients of full-rate APA with assets exceeding "150,000.

This viewpoint is not universally shared. A number of arguments have been made: equality oftreatment for citizens facing dependence and the need to rely principally on national solidarity todeal with this risk, with insurance funding only as a top-up. Whatever the result of the currentpolitical debate on funding for the "fifth risk", simplifying the existing financial circuits is anecessity. The division of certain costs between different public funding bodies (centralgovernment, social security and the département or county) needs to be revised, such as careassistants being funded from the care cost. With the rise in funding requirements for dependence, abetter legibility of the possible financial decisions and adjustments and control over how resourcesare allocated appear indispensable. But this cannot be achieved without modifying the respectiveroles of the public funding bodies responsible for dependence.

The debate on funding for dependence is sorely lacking in hypotheses on the economic rationalityof agents in the sociomedical sector.Few analyses are available on the strategy of long-term care providers in terms of client selection,the diversification of services, recruitment or service outsourcing. The debates about communityvalues and the risks of privatisation mask a real ignorance about the economic rationality of serviceproviders.Professional carers are described as providing a service with both medical and social components(in the sense of social bonds) in a complex relationship with the family carer. The question of theircontribution to managing the scarcity of resources in the field of dependence is rarely emphasised...Finally, the economic behaviour of dependent elderly people and their families is a confidentialsubject in terms of willingness to pay for a given service, decisions between buying services andmaintaining the value of capital, if such decisions are taken, the economic variables taken into

103

account when an elderly person enters an institution, by the person or the family etc.

Conclusion: a lack of prospective analyses

In prospective terms, it is currently fairly difficult to say what the structural dynamic of the Frenchsociomedical system will be tomorrow, the care norms that will prevail, the categories of staffrecruited, the way the sector is regulated and the breakdown between the public, private and not-for-profit sectors, the speed and nature of growth.Will financial constraints take priority?Is the main issue that is emerging a revision of the concept of intergenerational solidarity through along political process?Will the initiative come mainly from care personnel (women carers), who will provide the impetusfor redefining their tasks and negotiating their working conditions and the way the sector works?Will a medical logic aimed at targeting the pathologies that lead to dependence take priority?Ultimately, elderly people with major mental problems that would disrupt their environment wouldmake up most of the population of institutions, while all other forms of dependence would be caredfor in the home, except for a short period of palliative care.Will lifestyles change, radically transforming the services offered to "future dependent people"?

104

Three-Country SymposiumJapan – Germany – FranceA Comparison(Keynote Speech)

Matsumoto KatsuakiHitotsubashi University

1. Introduction of Systems

1965 Germany: Long-term care insurance

1997 France: PSDJapan: Enactment of the Long-Term Care Insurance Law

2000 Japan: Long-Term Care Insurance

2002 France: APA

2. Benefits

Japan

Long-Term CareInsurance

Germany


France

APA

Form Benefit in kind Benefit in kind

Cash benefit (norestriction on use)

Cash payment

(for application tonursing care servicecosts)

Beneficiaries Persons with long-term nursing careneeds

Persons with long-term nursing careneeds

Family caregivers

Persons with long-term nursing careneeds)

105

3. Finances (financial resources)

Japan


Germany


France

APA

Premiums 1/2

Tax 1/2

Premiums Primarily tax

4. Targeted Risk

Japan


Germany


France

APA

Targeted risk Risk of need for long-term nursing care inassociation withadvancing age

Risk of need for long-term nursing care

Risk of need for long-term nursing careassociated withadvanced age

Age of beneficiaries 40 or over No age limit 60 or over

106

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The purposes of this Act are to improve health and medical care and toenhance the welfare of citizens. With regard to people who are undercondition of need for long-term care due to disease, etc., as a result ofphysical or emotional changes caused by aging, and who require caresuch as for bathing, bodily waste elimination, meals, etc., and require thefunctional training, nursing, management of medical treatment, and othermedical care, these purposes are to be accomplished by establishing along-term care insurance system based on the principle of the cooperationof citizens, solidarity, and determining necessary matters concerningrelated insurance benefits, etc., in order to provide benefits pertaining tonecessary health and medical services and public aid services so thatthese people are able to maintain dignity and an independent daily liferoutine according to each person’s own level of abilities.

107

DignityHow to support the dignity of

persons with dementia

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Why Is This a Problem?

" Even if a person with dementia is aware of forgetfulness,there are very few cases where this person visits amedical institution on his/her own.

" It is often the case that the timing for consulting with adoctor depends on the understanding and awareness ofdementia of those around the person with dementia.

" This differs from cases of people with hypertension anddiabetes, etc.

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109

What Is Necessary To Solve This Situation?

" Based on the fact that there is not enough awareness ofdementia in the community, including by primary carephysicians,

# Intensive and extensive promotion of the program toimprove the clinical skill of primary care physicians forthe detection and the management of persons withdementia. In 2006, the Ministry of Health, Labor andWelfare started the program and as to 2008,approximately 14,000 doctors participated.

# Expansion of functions and personnel of the MedicalCare Center for Dementia (target is 150 locationsthroughout Japan.

# Guarantee of participation by care staff in periodiceducational program.

The current state is one where people with dementia arerefused medical admission into general wards and easily

bound by physical restrictions because they havedementia

" Unless medical/surgical support for physical complications isguaranteed, in-home care for people with dementia is difficult.

" The actual state is not made clear at the national level.

" In particular, there are actual situations where treatment is not carriedout as actively for people with dementia who have no relatives than forpeople with dementia who have family (Homma, 2007).

" In addition to investigating what kind of system would enable for supportto become possible in general wards, it is necessary to create aguideline (support of people with dementia, drug therapy, etc., andphysical restrictions in general wards) that takes the results of such aninvestigation into consideration as quickly as possible.

110

(From the Web site of the Supreme Court)

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# Enhance training program for primary careprimary carephysiciansphysicians that are currently being used, createguidelines for caring for people with dementia,and share these guidelines among healthprofessionals.

# Establish some kind of incentives for care forpeople with dementia

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128

The French Plan on Alzheimer’s Diseaseand Related Disorders 2008-2012

Symposium on long-term careTokyo, 3-4 february 2009

Sandrine LemerySteering committee for the Alzheimer plan

The French Alzheimer Plan

" Main challenges of the plan" Knowledge for action" Improving quality of life for patients and carers" Mobilising around a key social issue

129

Main challenges of the plan

TheThe burdenburden of Alzheimerof Alzheimer diseasedisease ((dementiadementia))in France (2000in France (2000 –– 2001)2001)

MENMEN

CardiovascularCardiovascular diseasedisease 8.9 %8.9 % (65(65 -- 94 %94 % deathsdeaths))

Lung CancerLung Cancer 5.7 %5.7 % (98 %(98 % deathsdeaths))

AlcoholAlcohol--relatedrelated diseasedisease 4.5 %4.5 % (23 %(23 % deathsdeaths))

AlzheimerAlzheimer’’s ands and relatedrelated diseasedisease 3.1 %3.1 % (24 %(24 % deathsdeaths))

WOMENWOMEN

AlzheimerAlzheimer’’s ands and relatedrelated diseasedisease 7.5 %7.5 % (20 %(20 % deathsdeaths))

CardiovascularCardiovascular diseasedisease 7.1 %7.1 % (71(71 -- 95 %95 % deathsdeaths))

NervousNervous depressiondepression 7.1 %7.1 % (2 %(2 % deathsdeaths))

BreastBreast CancerCancer 4.2 %4.2 % (86 %(86 % deathsdeaths))

Source : A. Lapostolle, A. Spira, Unite Inserm-Ined (U 569)

130

Grand A. et al., BEH 2006 ; n 5-6 :47-49

The Demographic Challenge: projected trendsof the number of elderly dependant people in France

and of the potential number of family carers (base 100 in 2000)

1<96; (# @< *+ C63>?

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TwoTwo previousprevious plans (2001plans (2001--2008)2008)

## ALD 15ALD 15 –– listlist of longof long--termterm diseasesdiseases

## 134 Memory Centres, 22134 Memory Centres, 22 ReferenceReference andandResearchResearch Memory CentresMemory Centres

## Places in Day Centres andPlaces in Day Centres and TemporaryTemporaryHospitalisationHospitalisation

## No majorNo major specificspecific effort oneffort on researchresearch

131

The main challenges of the plan# A commission chaired by Pr Ménard

$ 10 members, 8 working groups, 100 people, 3 months$ Report to the President on 8 november 2007

# A financial effort on 5 years

$ 200 M" for research$ 200 M" for medical care$ 1,2 billion euros for medico-social support

# Three main themes

$ Developing our understanding of the disease$ Improving the quality of life for patients and carers$ Mobilising society for the fight against dementia by developing a voluntary

approach and synergisms# A new governance based on transparency

$ Direct reporting to the President of the French Republic every 6 months$ Florence Lustman, Inspector general of finance, with a four member staff :

coordination and assessment$ Steering committee every month$ Supervisory committee every 4 month

Research : knowledge for action

132

Knowledge for action

# Objective : to discover or validate a diagnosis ortreatment within 5 years

# A foundation for scientific cooperation set on 29 june2008$ A national network of excellence$ Attract the best French and foreign researchers and

give support to the best teams$ Develop partnerships with industry, including drug

companies$ Develop relationships between all kinds of research,

public and private, fundamental, clinical, biological,social science

Improving quality of life forpatients and carers

133

Improving quality of life for patients and carersImproving support and respite for carers

# Developing and diversifying respite care services$ Evaluating existing facilities$ Experimenting innovative respite solutions$ Drafting specifications for a therapeutic dimension in all

structures$ Drafting a guide for respite centers

# Strengthening caregivers rights and education$ 2 days’ training a year for carers$ Support in returning to work

# Improving health monitoring for family caregivers

Improving quality of life for patients and carersStrengthening coordination between all actors

# Labelling integrated access points (« MAIA - maisonspour l’autonomie et l’intégration des maladesd’Alzheimer » - houses for autonomy and integration ofpeople with Alzheimer’s disease)

$ call for experimentation in july 2008$ 140 applications in october 2008$ 15 experiments selected - november 2008 – jan 2009$ « club of volunteers »

# 1000 “coordinators” (case managers) over the wholeterritory

134

Improving quality of life for patients and carersEnabling patients and their families to choose

support at home

# Reinforcing home support, favouring home interventionof specialised professionals$ 500 specialist teams in home nursing services

# Improving home-support using new technologies$ National and european calls for projects targeting

home automation and ICT

Improving quality of life for patients and carersImproving access to diagnosis and ensuring a

continuous chain of care# Developing and implementing a framework for diagnosis announcement

and follow-up# Experimenting new payment terms for health professionals# Alzheimer information card for patients in case of emergency situations

$ 100 000 edited cards – 10 000 distributed in 2008 by France Alzheimer onphysician request

# New local memory centers in zones without any$ + 24 in 2008, + 12 in 2009 / 366 CM, 234 labelled

# New research and resources memory centers in zones without any$ 3 in Auvergne, Corse and Limousin

# Strengthening the very active memory centers (122)# Monitoring adverse drug reactions# Improving correct use of drug

$ Study 10-2008 : 18% of alzheimer patients prescribed with antipsychotics

135

Improving quality of life for patients and carersImproving residential care

# Creating specific units for patients with behaviouralproblems within nursing homes$ Day units / day and night units$ 12.000 new places$ Reinforcing 18.000 places$ 180 M" investment credits in 2008

# Creating specialized cognitive behavioural units withinrehabilitation services$ 120 structures (24 in 2008)

# Setting up residential services for young patients# Creating a national reference centre for young patients

$ Selected in jan 2009

Improving quality of life for patients and carersDevelopping skill sets and specific training for all

care professionals

# New jobs of case-managers and « gerontologyassistants »

# Training for ergotherapeuts and psychomotricians

# Training for all staffs

136

Mobilising around a key social issue

Mobilising around a key social issueProviding information and increasing

awareness amongst the general public

# Setting up a telephone helpline and local web sitesfor local information and orientation

# Holding regional conferences to support theimplementation of the plan

# Studying disease knowledge and attitudes$ Qualitative study in oct 2008

137

Mobilising around a key social issuePromoting an ethical debate and approach

# Creating a national center for ethics on dementia$ Selected in jan 2009

# Adapting the legal status of those with dementia# Organizing conferences about the autonomy of

patients$ Patient representation$ GPS bracelets

# Informing patients and families about trialsimplemented in France$ Agreement with ONRA (Toulouse) for access through

Internet to the therapeutic and diagnosis researchprotocols performed or scheduled in France

Mobilising around a key social issue Makingdementia a European priority

# Making the fight against Alzheimer’s disease a priority for theEuropean Union$ Conclusions adopted at the competitivity council on 26

september and 2 december 2008$ Conclusions adopted at the Health council on 16

december 2008# Publicizing and promoting research at the European level

$ 22 sept : meeting of financing and research agencies# European conference on 30-31 october 2008

138

Mobilising around a key social issueAdditional measures

# Opinion and knowledge survey (INPES)$ 2008 and 2011$ 2 000 participants, after a qualitative study (130 participants)

# A medico-economic study (DREES)$ Costs at home and in institutions, / disease stage$ From the viewpoint of families and community

# Website www.plan-alzheimer.gouv.fr

William Utermohlen’sSelf-portrait from 1967 1996

1997

199819992000

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La DSS et les grands dossiers de la protection sociale

150

0

Present Condition of Long-Term CareInsurance System and Prospects

Feb 2, 2009

Takashi YoshinoDirector of Long-Term Care Insurance Division, Health & Welfare

Bureau for the Elderly, MHLW

Tripartite Symposium on Long-Term Care

Session 2$ Establishment of social Long-TermCare cost sharing system

1

Needs for long-term care are increasing more than ever due to an increasingnumber of the elderly who need long-term care and prolonged periods ofnursing care for each person as the population ages.On the other hand, a change is also occurring in families who had supportedthe elderly who need long-term care due to an increase in the number ofnuclear family and aging of family members who care for the elderly.

To establish a system where long-term care for the elderly is supported by thesociety as a whole (long-term care insurance system)

Independence support To aim at supporting the independence of elderlypersons, more than just looking after those requiringlong-term care

User-friendly A system where users can receive comprehensivelyhealth care and welfare services from various entities oftheir own choice

Social insurance system To build a system where the relationship betweenbenefits and costs is clear

Background and Significance of Introduction of the Long-Term Care Insurance System

151

2

Previous system

(1)Apply at the administrative officewindow, and municipalities determinethe service.

Long-term care insurancesystemsystemsystem (at a time of revision)(at a time of revision)

(2)Apply separately for medical care and(2)Apply separately for medical care andwelfare services.

Users can choose the type of serviceand facilities they use.

Users will make a long-term careservice usage plan (care plan) and usemedical care and welfare servicescomprehensively.comprehensively.comprehensively.

(3) Services provided mainly bymunicipalities and public organizations(Council of Social Welfare, etc.).

Services provided by various organizationssuch as private companies, agriculturalcooperatives, consumers’ cooperatives, andNPO, etc.

(4) For middle and high income earners,services are hard to use due to anexpensive cost to bear.e.g. In the case where the householder’s annual

employment income is 8 million yen, and his or herelderly parent receives a pension of 200,000 yenper month:

% Special nursing home for the elderly will cost190,000 yen per month

% Home helper service will cost 950 yen per hour.

Users will pay 10% charge for the serviceregardless of their income.e.g. In the case where the householder’s annual

employment income is 8 million yen, and his or herelderly parent receives a pension of 200,000 yen permonth:

% Special nursing home for the elderly will cost 50,000yen per month

% Home helper service will cost 400 yen every 30 to 60minutes.

Difference between the Previous System and Long-Term CareInsurance System from the Users’ Point of ViewInsurance System from the Users’ Point of View

3

Pay 90% ofcosts

PremiumsWithheld from pensions,

in principle

National poolNational poolof moneyof money

National HealthInsurance, HealthInsurance Society, etc.

10%copayment

Use of service

Insured persons

Municipalities (Insurer)

20% 30%

Tax

PremiumsPremiumsPremiums

MunicipalitiesMunicipalities Prefectures StatePrefectures State12.5% 12.5%(*) 25%(*)12.5%(*) 25%(*)

FinanceStabilizing Fund

(FY2009-2011)

Service providers% In-home service

- Home-visit care- Day service for care, etc.

% In-facilities service- Welfare facilities for the

elderly- Health facilities for the

elderly, etc.

(27.27 million people) (42.76 million people)

Individualmunicipality

Housing and foodexpenses

Certification of long-term care needs

Application

12.5%(*) 25%(*)12.5%(*) 25%(*)*As for benefits for facilities, the*As for benefits for facilities, thestate bears 20% and prefecturesstate bears 20% and prefecturesbear 17.5%.bear 17.5%.bear 17.5%.bear 17.5%.

50%

50%Decided based on theDecided based on thepopulation ratio

Note: The number of Category 1 insured persons is from Report on Long-Term Care Insurance Operation (provisional) (December, 2007), Ministry of Health, Labour and WelfareThe number of Category 2 insured persons is a monthly average for FY2005, calculated from medical insurers ’ reports used by the Social Insurance Medical Fee PaymentFund in order to determine the amount of long-term care expenses.

Structure of Long-Term Care Insurance System

152

4

% Long-term care expenses (all expenses minus copayment) are financed one-half by taxesand one-half by premiums.

% As for premiums, 20% of them would be paid by Category 1 insured persons and 30% byCategory 2 insured persons.

% As for taxes, the state bears 25%, and prefectures and municipalities bear 12.5%respectively. (As for facilities expenses, however, the state bears 20%, and prefectures andmunicipalities bear 17.5%.).)

% Of 25% of expenses borne by the state, 5% is provided as adjustment grants which aim atadjusting insurance finance of municipalities.

State

Prefectures

MunicipalitiesMunicipalitiesMunicipalitiesMunicipalitiesMunicipalities

Category 1insured personsinsured personsinsured persons

Category 2insured persons

TaxesPremiums50% 50%20%

30%

25%

12.5%

12.5%

Composition of financial resources for long-term care expenses

5

2000

2001

2002

2003

2004

2005200620072008

2,911 yen

(National average)

3,293 yen

(National average)

4,090 yen

(National average)

Operation period (FY) BenefitsService plan Insurance premiums

Thethird

phase

Thesecond

phase

Thefirst

phase

Theffirstphase

Thhesecond

phase

Thethird

phase

The Long-term Care Insurance Scheme is operated in three-year cycles.# Municipal governments formulate a long-term care insurance service plan where three years

are regarded as one phase (however, one phase is five years until FY2005) and review it everythree years.

# Insurance premiums are set every three years based on projected service costs specified in aservice plan so that financial conditions can be balanced throughout the next three years.(Insurance premiums are not changed during such three years.)

153

6

% Half of the long-term care insurance expenses is divided according to the population ratio of thoseaged 65 or over and those aged 40-64. Accordingly, municipalities (insurers) cover 20% of half thetotal expenses by premiums imposed individually on the elderly.

% From the standpoint of having people bear the cost in response to their ability to pay and givingspecial consideration to low-income earners, the Category 1 premium, in principle, shall bedetermined 6 levels according to municipal inhabitant tax, etc., imposed on each insured person.

Level 1

Welfare recipients

Level 2All members of a

household being exemptedfrom municipal inhabitanttaxes, pension benefitreceived annually by theinsured person being

800,000 yen or less andother conditions

Level 3All members of a

household being exemptedfrom municipal inhabitanttaxes, pension benefitreceived annually by theinsured person exceeding

800,000 and otherconditions

Level 4The insured personbeing exempted from

municipal inhabitant tax(At least one municipalinhabitant tax payer isin the household.)

Level 5The insured personpaying municipalinhabitant tax andhaving an income ofless than 2 million yen

Level 6The insured personpaying municipalinhabitant tax and

having an income of 2million yen or more

Income

Premiums:multiplicationof the standard

amount

Level 1 Level 2 Level 3 Level 4 Level 5Level 1 Level 2 Level 3 Level 4 Level 5Level 1 Level 2 Level 3 Level 4 Level 5Level 1 Level 2 Level 3 Level 4 Level 5Level 1 Level 2 Level 3 Level 4 Level 5Level 1 Level 2 Level 3 Level 4 Level 5 Level 6

The insured person payingmunicipal inhabitant tax

The insured person being exemptedfrom municipal inhabitant tax

0.5

0.75

1.0

1.25

1.5

Premiums from theCategory 2 insured

20%(average)

Premiums from theCategory 1 insured

30%Municipalities’contribution

Prefectures’contribution

12.5%

State25%

12.5%

4,090 yen per month(national average)

Premiums from the Elderly (Category 1 Premium)

7

Users

Municipality’swindowforapplication

Doctor’so

pinion

Certificationoflong-termcare

need

Supportlevel1 and 2

In-facility service" Special nursing home for the elderly" Health care facilities for the elderlyrequiring long-term care

" Sanatorium type medical carefacilities for the elderly requiring care

Long-term

careutilization

plan

(careplan)Care level

1-5

Notapplicable

Long-term care preventionservice

" Day care for care prevention" Day rehabilitation service for careprevention

" Home-visit care for care prevention,etc.Community-based long-termcare prevention service

" Small-scale multifunctional in-homecare for care prevention

" Daily-life group care for the elderlywith dementia for care prevention, etc.

Long-term careprevention projectsC

areplan

forcareprevention

Bedridden or demented personsrequiring long-term care services

Persons who might be in need of long-term care and require daily livingsupport

Preventive

benefits

Com

munity

supportprogram

Care

benefits

Procedures for the Use of Service

Investigationfor

certification

Persons whomight be in need ofdaily living supportor long-term careor long-term care

In-home service" Home-visit care" Home-visit nursing" Day service" Short-stay service, etc.Community-based service

" Small-scale multifunctional in-homecare

" Nighttime home-visit long-term care" Daily-life group care for the elderlywith dementia, etc.

Services which cope withmunicipalities’ needs

154

8

Source: The World Health Report 2006, WHOCountries are ranked in the order of longest life expectancy among 24 countries above.

Finland 75 15 82 9 Australia 78 2 83 3

Pakistan 62 22 63 23 The United Kingdom 76 12 81 14

Singapore 77 8 82 9 Swiss 78 2 83 3

Malaysia 69 20 74 19 Sweden 78 2 83 3

Korea 73 18 80 17 Spain 77 8 83 3

Japan 79 1 86 1 Russia 59 24 72 22

Israel 78 2 82 9 Portugal 74 17 81 14

India 61 23 63 23 Norway 77 8 82 9

China 70 19 74 19 The Netherlands 77 8 81 14

The United States 75 15 80 17 Italy 78 2 84 2

Canada 78 2 83 3 Germany 76 12 82 9

Brazil 67 21 74 19 France 76 12 83 3

Men Rank Women Rank Men Rank Women Rank

Life expectancy (age)

Country

Life expectancy (age)

Country

%The average life expectancy is 79 years for men and 86 years for women, which are the longest in the world.

International Comparison of Life Expectancy

9

#Although the ratio of population over 75 years of age in Japan is now one to ten, it is estimated the ratiowill be one to five in 2030 and one to four in 2055.

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2007 2010 2015 2020 2025 2030 2035 2040 2045 2050 20550

5

10

15

20

25

30

Population (10,000) (%)

65-74 years old

Peak of populationgrowth (2004) 127.79

million people 12,777

1,476

1,270

8,302

1,729

11.6%(2007)

11,522

1,401

2,266

6,740

1,115

19.7%

8,993

1,260

2,387

4,595

752

14.0%

26.5%

Source: Up to 2005: Population Census, Statistics Bureau, Ministry of Internal Affairs and Communications; In 2007: Population Estimates (annual report), Statistics Bureau, Ministry of Internal Affairs and Communications; In andafter 2010: Population Projection for Japan (estimated in December, 2006) (Moderate projection), National Institute of Population and Social Security Research

Estimated number of2003 (Population

Projection for Japan)

Actual number(Population Census,

etc.)

9.9%(2007)

12.2%

Increase in the Number of the Elderly Aged 75 or over

Under 14 years old

15-64 years old

Population 75 yearsold or over

Ratio of people aged 65 to74

Ratio of the elderlyaged 75 or over

155

10

• Increase in the elderly population (the first baby boomers join the elderly)" Increase in medical care cost for the elderly" Enhancement of measures for preventing the elderly from becoming in need of long-term

care (or support) in addition to long-term care services" Promotion of individual care

• Increase in the number of the elderly suffering from dementia" Promotion of care and long-term care for the demented elderly

• Increase in the number of elderly couple household and single-elderly-person household" Securing housing for the elderly" Establishment of “Living-alone model” that family members are not counted on to provide

long-term care• Advancement of super-aging society in urban areas

" Securing housing for the elderly in urban areas"Countermeasures for increasing demand for services based on a future image of the elderly

• Shortage of housing for the elderly"Development of housing for the elderly and medical care environment (medical treatment

and long-term care services)

Problems and Countermeasures based on a Future Image of the Elderly(from a viewpoint of the Long-Term Care Insurance Law)

11

$Increase in long-term care expenses due to changes in population compositionDeclining birth rate and expanding life span brings about changes in population composition.Specifically, an age group to support Japan shrinks and the elderly especially those aged 75 orover increase in number, which means the number of certified persons requiring long-term careor support increases and long-term care expenses expand.

For the purpose of sustaining long-term care insurance system in future, burdens andbenefits need to be reviewed.

The long-term care insurance system is supported by premiums (50%) paid by people aged 40 orover and taxes (50%). In future fewer supporters have to bear a burden of increasing long-termcare costs.

Future Prospects of Long-Term Care Insurance System

156

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157

+

Population in 1000 (Projection)11. koordinierte Bevölkerungsvorausberechnung

0

10.000

20.000

30.000

40.000

50.000

60.000

2005 2010 2020 2030 2040 2050

Jahr

Po

pu

lati

on

in1

00

0

unter 20 Jahre

20 bis unter 60 Jahre

60 Jahre und älter

Quelle: Bevölkerungsvorausberechnungen, Statistisches Bundesamt

,

Age Structure

Quelle: Statistisches Bundesamt, 11. koordinierte Bevölkerungsvorausberechnung.

158

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62

03

18 7

282

35

80

435

6

872

26

4

89

25

41

916

62

3

956

37

6

97

12

09

99

14

67

101

08

44

670

14

7

676

20

0

68

24

31

6988

46

68

32

42

67

947

2

685

52

4

67

915

9

685

55

8

68

83

71

256

28

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27

5

251

33

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25

52

52

24

63

21

243

50

7

24

70

69

24

50

49

248

67

8

252

73

8

0

200000

400000

600000

800000

1000000

1200000

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Pflegestufe I

Pflegestufe II

Pflegestufe III

Care level

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Maryse CHAIX- Assistant Director for Territories and Social Work DGAS 1

Maryse Chaix: Secureness of Quantitative Workforce and Human RessourcesDevelopment

1.1. Assessments and issues (1/4)" In 2020, there will be 4 million people aged 80 years and older, an

age at which the prevalence of dependence begins to rapidly increase(that is 80% more than in 2000) (Court of auditors-November 2005)

" Government policies (see intervention: role of housing and institutionsfor the elderly) are developing the means for a personalised responseto the care of dependant persons: in institutions, in the home oraccording to intermediary methods (temporary placement, familyplacement, day care placement, etc.)

" The structures and services fall under the authority of various statutes,i.e. hospital, territorial (administrative department and CCAS-localsocial welfare centre) private not-for-profit and private commercialstatutes.


1.1. Assessments and issues (2/4)" The profiles of professionals who work with the elderly are changing

as a result of the change in care methods, to reinforce thecoordination of treatment and develop a geriatric field, for dependantpersons placed in institutions for shorter periods of time at the end-of-life.

" Tensions are already appearing, particularly for nurses andcaregivers. These tensions are becoming apparent in a sector whichis growing steadily (+ approximately 3% per year; government plansto create spaces or services), is largely female (nearly 90 %) and isfacing fierce competition from health care institutions. These tensionsdiffer from one area to another (urban or rural) and the turnover isgenerally significant.

167


1.1. Assessments and issues (3/4)" Home care is experiencing increased difficulties related to the major

increase in needs and the massive recruitment of personnel amongwomen over the age of 40 who are returning to work, a breedingground which is likely to diminish in the years to come. The salary andforced part-time work are a specific difficulty which continues to be anunappealing aspect of the profession.

" Out of a total number of jobs, in the field of care for fragile persons,which should increase from 1.366 million in 2005 to 1.718 million in2015, the most recent estimates evaluate the number of paramedicaland social professionals caring for dependant persons at 700,000(CAS - DARES – professions in 2015). Half of them are home careproviders.


1.1. Assessments and issues (4/4)

" The recruitment needs required to replace retired employees (impactof the end-of-career of the baby boom generations) and theemployment increase (particularly of nursing assistants, medical andpsychological assistants and social assistants) are estimated at30,000/year (354,000 in 10 years).

" The challenges to be taken up are significant and must lead tocombined responses (care method, money availability, qualificationsof professionals, cooperation processes) and must take into accountthe stagnation prospects of the working population.

168


2.2. The development strategy of an HRresponse adapted to these challenges

2.1 Measures taken and measures to be supported in termsof qualifications

" diplomas based on fields of professional competence which arecommon to a practice in different social and medico-social sectors(elderly persons, the disabled, etc.):

– Accessible both through training (initial and continuous) and the validation ofprofessional experience;


– Whose structure allows for the implementation of bridges from one diploma toanother and facilitates horizontal professional mobility (between sectors: theelderly, the disabled, early childhood, exclusion…for same-level professions) orvertical mobility (promotion within a sector, for example with the elderly, to a higherlevel of qualification) without having to take the entire training course in either case;

– For the retraining of unemployed workers and recruitment to a first level ofemployment on the labour market, completed by the development of theprofessional promotion of employees to higher levels of qualifications (avoid theforeseeable competition in the coming years on the labour market of otheremployment sectors on significant levels of qualifications).

169


2.2 Measures linked to the organisation of structures andservices

" Encourage legal groupings of structures so as to benefit from a widerperimeter of human resources management, facilitate mobility (fightagainst professional wear) and the mutualization of more sought-afterqualifications (social and medico-social groupings for cooperation);

" For home care: increase the working time offered (fight against forcedpart-time) by diversifying the activities of structures, by organisingversatility while respecting the natural lifetimes of accompaniedpersons; role in the context of the national office of services topersons (ANSP) and the development of the universal serviceemployment voucher;


" Fight against the isolation of professionals by developing thesupervision of services, particularly home care services.

2.3 Work on the representations and attractiveness ofthese professions

" Both with regard to the general public, young people, employees inretraining (jobs with great human wealth and a local communityaspect). Major communication campaigns are being carried out forthis purpose.

170


2.4 Organise cooperation among those involved

" The State (major orientations, government plans, etc.), the regions(which received competence in terms of initial health and socialtraining in January 2005) and social partners (lifelong learning) byfacilitating the shared conclusions and implementation of veritableregional recruitment and qualifications development plans (tested inthree regions, financially supported by the French NationalIndependent-Living Support Fund (CNSA) and will becomewidespread in 2009).

171

172

Symposium on long-term care3-4 February 2009TokyoSession 2

Secureness of Quantitative Workfaceand Human Resources Development

Andreas KrögerManaging Director of AHK Pflegeteam GmbH, Berlin

Andreas Kröger, AHK Pflegeteam

Current situation and developments in personnelrequirements in long-term care

1. The number of care patients will rapidly increase in the next decades.Currently 68% of the patients are being cared for at home – of these abouttwo thirds by family members and one third by nursing services – 32% arebeing cared for in care homes.

2. The number of employees in the long-term care industry will triple by 2050to up to 1.6 million, and the market volume is to increase to 85 billioneuros.In 2007 more than half a million people worked in the long-term careindustry generating 25 billion euros.Currently it is estimated that 100,000 illegal workers from EasternEuropean countries are working in home care.

173


Recruitment of personnel

# Job advertisements in daily papers and city magazines# Job centres# Internet presence# A company’s name recognition within the city# In-service training of caregivers to become state-certified geriatric nurses

and full-time vocational training of mostly young applicants is absolutelynecessary

# Contacts# Partnerships with educational institutions# Partnerships with other care providers# Improving the company’s image through public measures


Employee turnover in the long-term care industry

The alleged reasons are quickly established: hard work, low wages, bad image,few opportunities for advancement and opting out of the profession. However itis worth taking a closer look.First, a distinction should be made between taking time-out of a career andemployee turnover.There are family-related interruptions in the careers of women who make up 85%of long-term care staff.The work is carried out in shifts and in combination with part time work.Regularly changing apprentices and trainees.

The main reasons for handing in one’s notice in the service business is, firstlyhuman resource management and the lack of possibilities for advancement.Only then is it due to salary levels.

Two factors must be taken into consideration: finding a work/life balance and thephysical stress on an ageing staff.

174


Measures for retaining staff and limiting employeeturnover

# Multiple-step application process to obtain and retain goodlong-term care workers

# Comprehensive on-the-job training standards# Continuous meetings with employees (corporate identity,

distinctiveness of the company)# Offer of additional incentives for the employees: bonuses,

company retirement plans# Improvement of working atmosphere# Corporate suggestion scheme# Collaboration in coordinating staff substitutions


Human resource development

# Advanced training and further education# Internal career planning# Establishing additional levels of hierarchies# Knowledge of existing employee potentials: language

skills, specialisation# Financial development opportunities

175


Improving the image of the long-term careprofession

Parallel to understanding the need for care, the work of the long-termcarers should be extended to include social and physical aspects. It isnecessary to improve the image of the long-term care profession in orderto sway young people to train for this profession. The search foralternative, more fragmented types of care not only benefits those in needof this care, it also re-establishes the attractiveness of the work.Politics and all those involved must work together to improve workingconditions and to adjust the enhancements of the modular system of long-term care insurance to include psycho-social factors such as those whichhave already been implemented in the care of dementia patients inGermany.

176

0

Long-term Care Infrastructureand

Staff RecruitmentFebruary 3, 2009

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Session 2 # Quantitative Expansion and QualitativeImprovement of Long-Term Care Service Staff

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Matrix of Long-term Care Insurance Services

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B[R_J]N <XVNHome-visit Services

Home-visit Care, Home-visit Nursing, Home-visitBathing Service, In-home Care Support etc.

Day Services

Day Care, Day Rehabilitation Service etc.

Short-stay Service

Short-stay Daily Life Services etc.

Residential Services

Day Care Services for the Elderly at Fee-chargingHomes and People with Dementia etc.

In-facility service

Special Nursing Homes for the Elderly, HealthCare Facilities for the Elderly Requiring Long-term

Care etc.

3

Long-term Care Staff

The Elderly who NeedLong-term Care

Care Manager% Ensuring that the elderly who need long-term care receive good, appropriate services in

their own homes, the care manager formulates care plans and establishescommunication with long-term care service providers based on requests of recipientsand their families, plus their mental / physical conditions and circumstances.

% It is essential that the care manager must be fully qualified by passing the CareManager Exam. Only those who have work experience in certain areas of nursing andcare are eligible to take the exam.

Certified Care Workers and Home Helpers% Certified care workers and home helpers provide services for the elderly who need long-

term care in their own homes or in long-term care facilities. Services include bathing,toileting assistance and eating assistance.

Certified care worker- Qualification- Fully qualified by passing the national exam or by completing training courses at college

Home helper [Grade 1, Grade 2, Grade 3, Basic Training]- Certified by completing training courses which are designated by prefectural governors- Training courses are provided at different grades from basic to grades 1 – 3 and each grade

refers to specific types of services.Long-term care facility staff

* Only certified care workers and home helpers are appointed to deliver home visit services.

Coordination

*

178

4

FY2000 FY2001 FY2002 FY2003 FY2004 FY2005 FY2006

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BJ[]']RVN 25,443 10.8% 30,376 12.0% 32,788 12.3% 36,175 12.9% 39,564 13.3% 43,892 14.1% 48,773 15.2%

EX]JU 236,213 100.0% 253,951 100.0% 265,560 100.0% 281,480 100.0% 298,141 100.0% 312,369 100.0% 321,753 100.0%

9ÛU']RVN 146,513 46.9% 185,719 45.6% 217,497 44.4% 271,942 45.1% 334,089 47.5% 388,397 47.8% 418,869 49.3%

BJ[]']RVN 166,198 53.1% 221,918 54.4% 272,753 55.6% 331,561 54.9% 369,914 52.5% 423,925 52.2% 431,190 50.7%

EX]JU 312,711 100.0% 407,637 100.0% 490,250 100.0% 603,503 100.0% 704,003 100.0% 812,322 100.0% 850,059 100.0%

* The actual figures are used each year.* “Full-time” refers to care workers who work during all working hours whereas “part time” refers to care workers who do not work full time (those who may work at more

than one facility and office, thus being restricted by time and wages; short-hour part-time workers).

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Data source: “Survey of Institutions and Establishments for Long-term Care”, Statistics and InformationDepartment, Minister's Secretariat, Ministry of Health, Labour and Welfare, JAPAN

5

Current Circumstances Surrounding Professional Caregivers

1. Wages of professional caregivers&Wages of professional caregivers vary depending on the years of employment, the average age etc. and are

therefore difficult to compare. However,% Wage scales for those who work in the long-term care industry tend to be lower than wage scales for

those who work in many other industries.% Wages of home helpers and certified care workers tend to be lower than wages of other types of

workers in the medical and welfare field.Male-female Ratios, Average Ages, Years of Employment and Average Wages of Ordinary Workers in Different Occupations

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All Industries 68.0 41.9 13.3 372.4 32.0 39.2 8.7 241.7Retail 60.7 38.8 11.7 325.0 32.0 38.7 7.8 213.260.7 38.8 11.7 325.0 32.0 38.7 7.8 213.2

Catering 64.9 37.2 8.1 304.6 35.1 40.6 6.9 196.4Hotel 58.0 41.1 9.1 285.9 42.0 39.5 6.2 196.3

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Nurses 6.0 33.4 5.8 307.1 94.0 35.8 6.6 313.4Assistant Nurses 7.2 38.0 8.4 275.7 92.8 44.5 10.0 275.3

Child Care Nurses 5.0 29.7 5.8 238.0 95.0 33.1 7.9 216.1Care Managers 22.8 38.6 6.7 284.8 77.2 45.0 7.1 261.8Home Helpers 17.8 36.7 3.5 239.3 82.2 45.3 5.1 207.4

Welfare Workers (welfare facilities) 29.5 32.6 4.9 225.9 70.5 37.4 5.2 204.4Sales Assistants (department stores) 28.7 39.0 13.2 300.8 71.3 38.3 9.5 202.5

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(Data source) “Basic Survey on Wages 2007”, Ministry of Health, Labour and Welfare, JAPANNotes(1) “Ordinary workers” refers to all workers except short-hour part-time workers.

Short-hour part time workers are assigned to work fewer hours per day than ordinary workers, or even when they are assigned to work the same hours per day as ordinary workers, the number of days short-hour part timers work per week is smaller than the number of days ordinary workers work per day.

(2) “Service providers” refers to those who provide professional services, services in the academic and development research fields, as well as those who provide washing services, hairdressing and beautyservices, bathhouse services, daily life services, leisure services, waste disposal services, automobile services, machine repair services, renting services, and advertising services. Political, economic andcultural organizations are also included in this category.

(3) “Welfare workers (welfare facilities)” refers to those who are engaged in long-term care work at welfare facilities for children, the disabled and the elderly.

179

6

2. Worries, anxieties and dissatisfaction regarding working conditions& The number of professional caregivers, who express worries about working conditions, particularly

about their low wages, is relatively high.

(Source) “Survey of Work Conditions in Long-term Care Services 2007”, Care Work Foundation

Worries, Anxieties and Dissatisfaction Regarding Working Conditions (Multiple Answers)

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Measures Most Effective in Preventing Frequent Staff Turnover and Promoting Stable Employment

3. Measures for preventing frequent staff turnover and promoting stable employment at care serviceestablishments

& The measures considered to be most effective by care service establishments are as follows:% =VY[X_N `X[TRWP LXWMR]RXW\ RWLU^MRWP `JPN\ JWM `X[TRWP QX^[\% 9JLRUR]J]N \]JOO LXVV^WRLJ]RXW J] `X[T% 6[NJ]N XYYX[]^WR]RN\ OX[ ]NVYX[J[b \]JOO ]X KNLXVN [NPÛJ[ #YJ[]RLÛJ[Ub NOONL]R_N RW J LJ[N OJLRUR]b \R]^J]RXW$% >R\]NW ]X \]JOO VNVKN[\ JKX^] ]QNR[ `X[TRWP QX^[\ JWM ]QNR[ MN\R[N\ #YJ[]RLÛJ[Ub NOONL]R_N RW J QXVN'_R\R] \R]^J]RXW$

(Source) “Survey of Conditions in Long-term Care Services 2007”, Care Work Foundation

180

8

$ There are more female professional caregivers than maleprofessional caregivers (approx. 80% are female).

$ The ratio of temporary staff has been on the increase in recent years.(Approx. 80 % of home-visit staff are on a temporary basis.)

$ High accession rate and high turnover rate (accession rate: approx.27%, turnover rate: approx. 22%)

) In 2005, when there were 1,120,000 professional caregivers in total, approx.310,000 started their new jobs at care service establishments and facilitieswhile approx. 240,000 left their jobs (including career moves to other careestablishments).

$ Wages for professional caregivers are lower than the average wageof all workers

$ There are many employable care workers with appropriatequalifications(Approx. 270,000 of 470,000 certified care workers are actually engaged inwelfare / care services (as of 2005).

Summary of the Employment Situation for Professional Caregivers

9

[Letter of the Law]

The Japanese government recognizes that professional caregivers play an

important role in realizing a safe and secure society for the elderly, and with the

intention of securing a stable source of excellent manpower in long-term care

services, the Japanese government will, by April 1, 2009, take into consideration

pay scales for professional caregivers and other work conditions, discuss the

parameters of measures conducive to better work conditions for professional

caregivers, including their wages, and take actions accordingly.

Supplementary Provision

This law shall be put into effect from the day it is proclaimed.

The establishment of the “Law Concerning Better Treatment ofProfessional Caregivers for Securing a Stable Source of Manpower” wasagreed unanimously during a regular diet session in 2008.

Law Concerning Better Treatment of Professional Caregiversfor Securing a Stable Source of Manpower

181

1010

[Current Situation of Welfare and Care Services]

& The ratio of active job openings toapplicants is high compared to otherindustries.

Measures for Securing a Stable Source of Manpowerfor Welfare and Care Services

& Wages are low compared to otherindustries

& As well as dissatisfaction with wages,complaints about physical and mentalstress are significant.

& The turnover rate is high compared toother industries

& Approx. 75% of welfare and careworkers leave their jobs within threeyears of being hired.

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182

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Definition of “Care Needs Certification” andMethod of Assessment

TAKAKO TSUTSUI, Ph.D.Chief, Administration

Dept. of Health and Social ServicesNational Institute of Public Health

Feb 3,2009


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Content

183


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1. Overview of Long-Term Care InsuranceSystem in Japan, Germany and France


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Increase in the Number of the Certified Persons

184


4H7@?8 0;6@G>! 16D6B)

Care (Case) Management in Each Country

DE FR

Introduced with reform of2008

Care plan prepared byMunicipalities, etc.

!"

Care plan prepared by care managers

Dept. Social Services, National institute ofPublic Health, Japan

6

Number of Benefit Recipients

Care Lev.5 412,000<11%=

Care Lev.4 523,000<14%=

Care Lev.3 645,000<18%=

Care Lev.2 707,000<19%=

Care Lev.1 623,000<17%=

Support Lev.2 416,000<11%=

Support Lev.1 331,000<9.0%=

GIR1 79,000<E%=

GIR2 289,000<29%=

GIR3 201,000<20%=

GIR4 439,000<43%=

Care Lev.3 252,000

<13;=

Care Lev.2 683,000

<35;=

Care Lev.1 1,033,000<52;=

<End of 2006=Source: Institute for Health Economics

and Policy<2008=

<End of 2006=Source: Harada<2007=

TotalF1,968,505

TotalF1,008,000

TotalF3,360,000<As of Feb 2008=

185


4H7@?8 0;6@G>! 16D6B*

Upper Limit of Monthly Benefit

Care Lev.5 2,756 EUR





Support Lev.2 800 EUR

Support Lev.1 382 EUR

GIR1 1,067 EUR

GIR2 914 EUR

GIR3 686 EUR

GIR4 457 EUR


Care Lev.2 921 EUR

Care Lev.1 384 EUR

Reference: Institute for HealthEconomics and Policy <2008= Benefit for care at home

Reference Shinoda<2008=

Benefit (service) for care athome

1 EUR = 130 YENBenefit for care at home


4H7@?8 0;6@G>! 16D6B+

Institution Determining the Care Level

DE FR

Judged by MDKJointly established by the healthinsurance funds in each state

Judged by the prefecture

!"

Care needs certification boardestablished in the municipalities

186


4H7@?8 0;6@G>! 16D6B,

2. Care Needs Certification inLong- term care insurance system

-What is Care Level?-

municipalities

Process Until the Use of Long-Term Care Insurance Services (1 Month)

Care management

Care needs certificationsystem

187


4H7@?8 0;6@G>! 16D6B%%

Standards for Care Needs Certification inGermany

Class Criteria Required caretime

Upper limit forpayments

(in-home and in-kind benefits)

Reference(Japan / in-home)

Care Level I(Medium Level)

Requiring assistance at least one time aday for at least two activities in one ormultiple fields with respect to body care,feeding and moving around. In addition,requiring assistance with householdchores several times a week.

At least 90 min/dayAmong this, at least45 min. of basiccare

384 EUR 2,058 EUR(Care Level 3)

Care Level II(Severe Level)

Requiring assistance for at least threetimes a day at different hours withrespect to body care, feeding andmoving around. In addition, requiringassistance with household choresseveral times a week.

At least 3 hours/dayAmong this, at least2 hours of basiccare


Care Level III(Top Level)

Requiring assistance for 24 hours a dayincluding nights with respect to bodycare, feeding and moving around. Inaddition, requiring assistance withhousehold chores several times a week.

At least 5 hours/dayAmong this, at least4 hours of basiccare

1,432 EUR 2,756 EUR(Care Level 5)

Source: Matsumoto (2008)

Standards for Care Needs Certificationin France

Class Image of ConditionUpper limit for

payments(in-home)

Reference(Japan /in-home)

GIR1 [Top Level]Persons who completely lost independencephysically and mentally, and who need permanentassistance by another person

1,067 EUR 2,756 EUR(Care Level 5)

GIR2 [HighLevel]

Persons who cannot move their body but have notcompletely lost their mental functions, or personswho lost mental independence but maintain theirphysical activities


GIR3 [MediumLevel]

Persons who require a significant level of dailyassistance from the aspect of physicalindependence


GIR4 [Low Level] Persons who need assistance with standing / sitting,dressing / undressing and meals 457 EUR 1,498 EUR

(Care Level 2)

GIR5[FragileElderlyPersons]

Persons who need limited assistance none 1,275 EUR(Care Level 1)

GIR6 [Independent Persons] Persons who are independent none 4

Source: Shinoda (2008), Matsuda (2006)/;DG# 5C8?6@ 5;EI?8;F! 36G?CB6@ ?BFG?GHG; C<

4H7@?8 0;6@G>! 16D6B%&

188


4H7@?8 0;6@G>! 16D6B%'

Feasibility:Feasibility: 4.714 million persons are certified as requiring long-term care (support) (as of September 2008)The total number of valid applications is 45.155 million(April 2008 to December 2008)

Cost:Cost: The cost of the clerical work for the care requirementcertification was 61.6 billion Yen (estimated) in fiscal2003, which corresponds to about 1% of the costs for thelong-term care benefits.Huge additional costs are anticipated if all applicants arecertified by medical doctors.

Objectivity:Objectivity: Check the condition of the applicant while comparingit with standards. Obtain results that do not depend on thequality of the certification research staff.

Caregiver ResearcherElderly

Time Sampling Survey

567

8

Method of research

We were able to collect data on some 10 million minutes of in-home services provided.

189

An efficient needs assessment program

There was a question ofassessment standards.

Once a decision has been made regardingeligibility, it would be necessary to devise asystem to rank the eligible people accordingto their nursing care needs.

You needcare You don’t

needcare

Fullassistance

Independent

H

H

HH

H

H

H

H

HHH

567

88

seconds

190


4H7@?8 0;6@G>! 16D6B%*%*

3. Estimation model for the“The time index for Care Needs

Certification” in Care Needs Certification

0.01sec

Assessment 73 questions 200012 questions related to medicaltreatment

Initial DecisionInitial assessment system

Assessment

Assessment data of theresearch items(73 basic attributes of theelderly person)

191

2-3. Maintaining a sitting position with feet on floor. Circle only one.

1. Able to do2. Able to do only by holding onto something3. Able to do only with support from somebody4. Unable to do

2-6. Walking Circle only one.

1. Able to do independently2. Able to do only with support3. Unable to do

He is 80years old.

Level

Level

Care Needs Level ??

??

Tree Regression

The Elderly Survey (73items)

Mental/Physical state of elderly

7scores

192

Result of Medical care received during 14 days (12 items) past

Direct living assistance(6) Indirect living assistance

(7) Assistance for behavioral problem

(9) Medical care activities

(8) Rehabilitation activities

Estimated nursing care times

(1) grooming

(2) elimination

(5) moving

(4) bathing

(3) eating

11min

3min

18min

7min

11min

8 min

6 min

1 min

15 min

1 min

Total Estimatenursing caretimes

81min! Don’t forget that the “Estimated nursing care times” doesn’t translateexactly to real time

Total estimate for the nursing care times

11 3 18 7 11 8 1 15 6 1 min81 min

Level 1

Supportneeded

Level 2 Level 3 Level 4 Level 5

Care Needs Level 3!! Level5Level4Level3LevelLevel 1

Care NeedsLevel

193

Trial project data from fiscal 1998(data from 168,528 elderly persons)

0$$%- 2;69?B= GC G>; 76G>ECCA "

'&' ?G;AF

Initial decision logic

Tree regressionGive scores (standardization of categoryscores) to the selection branches of theresearch items from the results of theresearch items (73items)

Use the dual scaling method as thestatistical method to integrate theattributes of the elderly person

Assessment data of the researchitems (73 basic attributes of theelderly person)

Paralysis

hearing

vision

Paralysis andlimitation of joint movementlimitation of joint movementlimitation of joint movement

Mobility, etc.

Advanced mobility,Advanced mobility,etc.

Special care,etc.

Personal care,etc.

Behavioralproblem

Communication andCommunication andunderstanding

7 physical andmental status indicesmental status indicesmental status indices

Certification logic at the time of the start of the system in 2000


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2009: Review of the assessment items and tree models (74items)

• Certification assessment items in 1999• = 73 items+ items related to special medical care (12 items)

Change of Certification Assessment Items in Japan

194

Special medical care

Revision of 2009: Certification Assessment Items

1-1 Existence of paralysis1-2 Limitation of joint movement1-3 Turning over in bed1-4 Sitting up in bed1-5 Remaining in sitting position1-6 Standing on both feet1-7 Walking1-8 Standing up from a sitting position1-9 Standing on one foot1-10 Bathing1-11 Nail cutting1-12 Vision1-13 Hearing

2-1 Transferring2-2 Moving around2-3 Swallowing2-4 Taking meals2-5 Voiding2-6 Defecation2-7 Oral hygiene2-8 Face washing2-9 Hair washing2-10 Putting on and takes off a jacket2-11 Putting on and takes off trousers2-12 Frequency of going out

3-1 communication3-2 Understanding a daily schedule3-3 Answering date of birth and age3-4 Immediate memory3-5 Remembering own name3-6 Recognizing the season3-7 Recognizing the place3-8 Wandering3-9 Being lost out of one's residence

4-1 Suspiciousness4-2 Confabulation4-3 Affective incontinence4-4 Day-night disturbances4-5 Compulsive behaviors (e.g. frequent asking)4-6 Verbal outbursts4-7 Resistance against caregiver4-8 Restlessness4-9 Wanders aimlessly in the house during the day4-10 Collectionism4-11 Violent behaviors, destruction4-12 Severe memory disturbances4-13 Monologue4-14 Selfish behaviors4-15 Incoherence of thought

5-1 Taking medication5-2 Financial management5-3 Making decisions5-4 Non-adaptation to groups5-5 Shopping5-6 Cooking

Results ofthe assessment ofthe elderly person

Categorization of 73 assessment datainto 7 groups (At time of system start in 2000)

Development of Mental and Physical Status Indices(Intermediate Evaluation Items)

Group 1 (Paralysis andlimitation of joint movement)

Group 2(Personal care)

Group 3(Cognitive functions)

Group 5(IADL InstrumentADL )

?

5050

100

Group 7(Behavioralproblem)

?

50505050

100

Group 1(Paralysis andlimitation of joint movement)

Group 2(Mobility)

Group 3(Advancedmobility)

Group 4 (Special care) Group 5 (Personal care)

Group 6(Communicationand nderstanding)

Categorization of 74 assessment datainto 5 groups (Revised in 2009)

From 7to 5

groupsgroupsgroupsGroup 4BPSDbehavioraland

psychologicalsymptoms ofdementia

195

Primary model project data from fiscal 2007(data from 34,000 elderly persons)

0$$%- .6G>?B= DE;D6E6G?CBF """

&)$ ?G;AF

Give scores (standardization of categoryscores) to the selection branches of theresearch items from the results of the researchitems (74items)

Assessment data of the research items(74 basic attributes of the elderlyperson)

Paralysis

Hearing

Vision

Paralysis andlimitation of joint movementlimitation of joint movementlimitation of joint movementlimitation of joint movement

Personal care

BPSD

Cognitivefunctions

IADL

5 physical andmental status indices

Use the dual scaling method as thestatistical method to integrate theattributes of the elderly person

Certification logic at the time of the system revision in 2009Certification logic at the time of the system revision in 2009Certification logic at the time of the system revision in 2009Certification logic at the time of the system revision in 2009

Initial decision logic

196

Definition of the Term “Need of Care” and Method of Assessment of “Need of Care”

Session 3 – Symposium on Long-Term CareTokyo, February 3

rdand 4

th, 2009

Emilie Delpit, National Solidarity Fund for Independent Living (CNSA), France

Prerequisite: The different kinds of assistance to elderly people with loss of autonomy

Helping people with loss of autonomy must meet two requirements:

- The medical needs "to cure"- nursing care services- drugs

The assessment of these needs is medical. These aids and services are prescribed by a doctor.

- Developing autonomy needs: "to care, either at home or in institutions. They cover the needs of:- human aid- Technical Aid- home adaptations ...- support to caregivers (financing day care services) ...

The assessment of these needs must take into account the overall situation of the person, hisenvironment.

I-Aid for autonomy are granted according to people needs

1 / An allowance served according to help neededAgeing people losing their autonomy will receive an allowance: the personal autonomy allowance(APA)

- Created by the law of 20 July 2001 and in force since 2002, today it is attributed to 1 094 000beneficiaries (as at 30 June 2008) - 62% at home - 38% in institutions. It is a financialallowance to eligible persons to enable them to finance the various aids to independence,beyond care. It is paid and funded by the general council (local authority).

- It is a benefit in kind: it is assigned to meet a specific need, it covers only direct costs incurredto support the autonomy needs, adopted in a personal aid plan.

o The higher the level autonomy loss, the more the allowance level funded by the APAwill be high.

o There is a effectiveness control of the aid and a possibility of recovering the amountsnot used for this purpose.

- It is a universal benefit and it is not subjected to income conditions or to maintenanceobligation. It is not subjected to an appeal on succession. But the beneficiaries participate inthe financing of this plan of assistance, depending on their resources.

Apart from this specific provision, the loss of autonomy may have other complementary financial aid:- With tax incentives: tax cuts for the use of home help;- Extra legal aid may be granted by various agencies including the general advice (welfare).

2 / The evaluation of the situation and needs of the individual at the heart of the device

The APA implies having been defined:- The definition of eligible persons- The definition of assistance plan

These two elements are based on an assessment.

197

The assessment of the level of dependency: eligibility

The APA is paid to people over 60 who are unable to bear the consequences of lack or loss ofautonomy related to his physical or mental.

People are losing their autonomy beneficiaries of this provision are those who need assistance for thecompletion of the essential activities of life or who require regular monitoring.

A tool is used to measure the level of loss of autonomy: the grid AGGIR.

It can classify people into 6 groups (GIR). Those classified in the first 4 groups (GIR 1, 2, 3, 4) areeligible persons classified in groups 5 and 6 are not.Each GIR level is applied to a ceiling of support, that the aid will not exceed.

The assessment of the situation of the person is carried out by the team of medical and social Council.It involves a home visit by a member of the team.

- The assessment of “needs care”: the development of the care planThe aid plan is developed for people remaining at home by the team medical and social. It isestablished taking into account the environment (social environment, family planning and housingequipment). It identifies a caller's needs and aid of all kinds necessary to maintain at home, by natureand quantity). These may include:

- Intervention of professionals (home help, home care)- Services (porting meals)- Equipment (remote, work to adapt, medical bed ...)

There are several methods of intervention of professionals in the home, from direct recruitment to theuse a service provider. The legislator gave a preference to use a home-help service.

For people in institutions, an assistance plan is not developed. The assessment of the situation ofindividuals and their classification in a GIR sets the price of the property that will be applicable. Thiswill cover the self-implemented by the establishment.

II-The assessment of the needs of people: the issues

1 / The reliability of the assessment of the situation of people

Particular attention is paid to discussions on the reliability of tools and processes to assessment.

Indeed, the reliability of the tool is first essential in terms of regulatinf expenditure. The classification ofpersons into GIR 4 (eligible) rather than GIR 5 (ineligible) has a direct impact on global expenditures.This question is connected to debates about the progress of the beneficiaries of APA more dynamicthan anticipated and still maintaining strong.

The reliability of the tool, and more widely of the evaluation process, is also essential to ensure equaltreatment of persons in the national territory.

Finally, neurodegenerative diseases such as Alzheimer’s are becoming more and more important inthe challenges of supporting the elderly. The reliability of AGGIR to assess the level of dependencyassociated with these diseases is debated.

- A scientific committee was set up in 2001 to adapt the tools for assessment: it has launcheddifferent works which led to some strong conclusions (for instance, the importance of theorganization of the assessment). A new guide to fill the grid AGGIR was developed andpublished in 2008.

- Tests are conducted on the use of new tools. The SMAF tool used in Quebec is experiencedin some territories.

198

2 / The assessment of need for care: the convergence of approaches whatever age of thepeople concerned with lack of autonomy

AGGIR is used to determine eligibility. It is not relevant for the development of care plans. The law of11 February 2005 has also set up an evaluation system for the disabled and led to the creation of aneeds assessment tool for people in order to elaborate the care plan: the GEVA.

These approaches developed for disabled people inspire possible future developments in the elderly,especially as the law provides for a convergence of system between the two categories of people.

The law gave the National Solidarity Fund for Autonomy (CNSA), founded in 2004, a mission ofexpertise in assessment. A committee of the Scientific Council was set up on this issue. It has ledworks on tools and approaches to assessment. His first scientific meetings are devoted to this issue(11 and 12 February 2009). This work adopts a cross-approcach of assessment of the elderly anddisabled.

3 / The harmonization of assessment methods between public and private systems

The government works on the evolution of the long term care system are considering the developmentof private insurance as another level of coverage.

Insurance contracts, which are already significant in France (around 3 millions), all have differentdefinitions of dependency. They are generally based on AGGIR including adaptations.

There is an issue of lisibility of contracts by the people and their families and good coordinationbetween the public and private systems.

Thus, the reflections on the reliability of tools and approaches to assessment and their developmentshould be discussed between public and private sector under a public-private partnership. A prospectcould be the gradual harmonization of tools and approaches and, where appropriate arrangements formutual recognition of situations.

(The different levels of loss of autonomy result of the grid AGGIR

- GIR 1: those confined to bed or chair, having lost their autonomy mental body, locomotive and social, which require continuousand indispensable stakeholders. - 87 000 (8%)

- GIR 2: those confined to bed or chair whose mental functions are not totally corrupted and require support for most activities ofdaily living, or those whose mental functions are affected but who have retained their motor skills. - 305 000 (28%)

- GIR 3: those who maintained their autonomy mental partially self locomotory but which require daily and several times a dayfor self-aid equipment. 216 000 people (20%)

- GIR 4: People who do not only transfer but, once lifted, can move inside the housing. They must be helped to the toilet anddressing. 486 000 people (44%)

- GIR GIR 6 and 5: people with little or no care.Source : DREES – June 30, 2008

199

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Pflegebedürftigkeit: Gewichtung der Bereichebei der Ermittlung eines Punktwertes ( IPW)

156. Gestaltung des Alltagslebens undsoziale Kontakte

205. Umgang mit krankheits-/therapiebed. Anforderungen

404. Selbstversorgung(Alltagsverrichtungen)

152./3. Kognitiver Status undVerhaltensprobleme

101. Mobilität

207

Fünf Stufen der Pflegebedürftigkeit (IPW)

P1: geringe ...P2: erhebliche ...P3: schwere ...P4: schwerste Beeinträchtigung der Selbständigkeit

P5: P4 + besondere Bedarfskonstellation

0 70 10010 30 50

P1 P2 P3 P4/5

• Anderer Maßstab: Zeitaufwand vs. Grad der Selbständigkeit

• Andere Inhalte: Begrenzung auf Alltagsverrichtungen vs.umfassendes Verständnis von Pflegebedürftigkeit

• Andere Spreizung der Stufen bzw. andere Abstände zwischen denStufen (!)

Unterschiede zwischen alter und neuerStufensystematik ( IPW)

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Integration of Care in Municipalities

Almut Satrapa-SchillRobert Bosch Foundation, Stuttgart

Integration of Care in Municipalities (1)

Robert Bosch Foundation deals with social questionsLife in old age – age and DemographyOld age has two sides:- potential, innovation, creative power, social commitment, personal responsibility- chronical diseases, multimorbidity, dementia, intensive care, dignified dealing with dying

and death


What do the elderly want and need?

- community- family (still) service provider

- ageing and old age are changing- old age is becoming more colourful and more individual

- necessity of medical attendance and care is fluent – from loss of daily routine skills to avery high level of care

- different variety of offers


Health care professions

- professionalism- interdisciplinarity- relief through service assistants, daily routine carers, back staff- civic commitment – including the fit elderly

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appropriate services for older fellow citizens


215

„Pflegestützpunkte“

Dementia and multimorbidity as a special challenge

Municipal model projects of the Robert Bosch Foundation- working together for a better live with dementia (e.g. Lern-Werkstatt Arnsberg)- palliative care for the elderly


What do we need in connection with demgraphical change?

- change of consciousness in all people- changed image of old age- transfer of innovative approaches and well succeeded models (the wheel doesn’t have to

be newly invented)- interdisciplinarity, networks, cooperation- new tasks that need differentiation- changed responsibilities in health care professions- active communities- civic commitment (yound and old)- research focussing on health care provision (e.g. dementia, multimorbidity, quality,

efficiency, cost-benefit analysis) and transfer into practice


German-Japanes prospects

www.bosch-stiftung.de

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222

Development ofCommunity Care in Japan

Hiroshi TakahashiRikkyo University

I Development ofCommunity Care in Japan

223

1 Introduction of Community Care" In Japan, long-term care for elderly people had been supported by the medical care

system and the elderly welfare system for a long time. Because the latter systemhad been a system for low-income elderly people only, medium-income elderlypeople in need of long-term care had had to stay in elderly hospitals.

" As a result of the increases in the elderly population due to the aging of theJapanese population, it became difficult for hospitals and facilities to accommodatethe increasing need for long-term care for elderly people and it became necessaryto prepare for the challenge of providing in-home long-term care services.

" In Japan, in-home long-term care for elderly people had been provided by familiesof the elderly people in need of such care, and the families had used hospitals andfacilities only when it had become difficult for them to provide in-home long-termcare.

" In the 1970s, the need for social support for in-home long-term care increased andhome help services were institutionalized as public services. In that decade,advanced concepts of community care developed in the United States and Europewere brought into Japan and facilitated discussions on the way facility-based careand community care should be, and those discussions led to the development andimplementation of care-related policies.

2 Implementation and Institutionalization ofIn-home Care Services

" In the late 1960s, the Japanese government started providing subsidies to promote the home helpsystem. The system had originally been a system for low-income households only, but was graduallyexpanded in the 1970s. In the 1980s, the system was evolved into one that covers all ordinaryhouseholds.

" In around 1970, hospitals and local governments started providing home-visit nursing services. In1982, the Elderly Health Law was enacted and the Law institutionalized the provision of home-visitnursing services for discharged patients. In the early 1990, a Home-visit Nursing System wasestablished in Japan.

" In 1990, a national plan (including numerical targets) to improve existing policies for elderly peopleand develop and implement new and effective policies for elderly people was established by thenational government. The national plan included plans to improve and expand existing home helpservices as well as facility-based day services and short stay services. Under the national plan, thenational government promoted services that form the basis of community care. In addition, thenational plan required the local governments to develop and implement health- and welfare-relatedplans for the elderly and to develop and implement, in a systematic manner, services that form thecore of community care.

" In 2000, the Long-Term Care Insurance Law was put into effect and the above-mentioned servicesstarted to be provided as important in-home care services.

" In parallel with the above-mentioned developments, non-institutionalized support activities by localresidents to provide various support to elderly people in need of in-home care also gainedmomentum. Because such activities are ones that strengthen the sense of solidarity among localresidents and make the society recognize the importance of informal care, a law was enacted thatallowed organizations engaged in such activities to operate as NPOs.

224

3 Institutionalization of Management OrganizationsIn-home Long-Term Care Support Centers

" To realize a concept of community care, it is necessary to (1) improveexisting formal in-home care service systems and create new and effectiveformal in-home care service systems and (2) promote informal careactivities whereby local residents support elderly people who live in theirhomes and are in need of in-home care.

" As efforts to achieve the above-mentioned goal continued, voices calling fora management function which allows informal support services andinstitutionalized services provided at the homes of elderly people to becentrally coordinated increased. These voices also emphasized the need tostudy Western countries’ concepts of care management and apply them toJapanese systems.

" In the 1990s, the national government embraced these ideas and decided toestablish, through the use of subsidies, organizations that support in-homelong-term care and to deploy nurses, public health nurses and socialworkers at such organizations. The number of such organizations to beestablished in each municipality was to be determined according to thepopulation of the municipality.

4 Introduction of the Care Support Specialist Systeminto the Long-Term Care Insurance System

" In the Long-Term Care Insurance System established in 2000, promotion of in-home careservices was designated as a main objective, and enhancement of community-based in-homecare services as well as care services provided at facilities and hospitals was designated as apolicy objective. In addition, to make it easier for users of in-home care services to use suchservices, a Care Support Specialist System was introduced into the Long-Term Care InsuranceSystem. The Care Support Specialist System is a system whereby applicants meeting thespecified requirements are certified as Care Support Specialists whose job is to prepare in-homecare service plans based on care needs assessments and manage the implementation of theplans.

" Applicants for certification as Care Support Specialists are required to have a public health-,medical care- or welfare-related national qualification. To be certified as a Care SupportSpecialist, the applicant must take an examination and complete a training course. Today, CareSupport Specialists are more often called Care Managers than Care Support Specialists.

" Each Care Support Specialist is to join an in-home care service office. The job of the CareSupport Specialist is to prepare a service plan for each of the elderly people who live in theirhomes and have been certified as elderly people in need of long-term care by selecting, basedon the results of the assessment conducted, appropriate in-home services from a list of a widevariety of in-home services in such a way that all of the services selected are covered by theLong-Term Care Insurance System and to manage the implementation of the plan (i.e. theprovision of the services). Nowadays, hospitals and facilities are also hiring Care SupportSpecialists so that they can prepare better care plans and implement prepared care plans moreeffectively.

225

5 Introduction of Community Comprehensive SupportCenters in 2005 under the Long-Term Care Insurance Law

" The Long-Term Care Insurance System institutionalized in 2000 was significantly reformed in 2005. The purpose of the reformswas to make the System capable of coping with (1) the anticipated changes in the ways citizens aliment elderly people (i.e. theanticipated sharp increases in the proportions of single-person households and elderly couple households and in the number ofelderly people living in urban areas) due to the anticipated rapid increases in the population of Senior Elderly People and tochanges in the lifestyles of Japanese citizens that have been caused by socioeconomic changes and (2) the anticipated sharpincreases in the number of elderly people suffering from dementia while reducing the risk of depletion of the nation’s financialresources for social security.

" As part of the reforms, efforts were made to (1) reduce the proportion of the facility-based care services, which require highercosts, (2) reform service schemes taking into consideration the anticipated increases in the number of elderly people who live intheir homes and need medium/high level care and (3) strengthen management functions in communities. These efforts led to arecognition that it was necessary to “develop community comprehensive care systems.”

" As a result, it was decided to establish, taking into consideration the sizes of the areas in which elderly people live their everydaylives in their municipalities, “Community Comprehensive Support Centers,” as organizations responsible for developing communitycomprehensive care systems and to deploy specialists, such as public health nurses, certified social workers and chief CareSupport Specialists (i.e. experienced Care Support Specialists who have completed the specified training course), at the Centers.

" It was also decided to use, as the fund for establishing and operating Community Comprehensive Support Centers, 3% of thefinancial resources reserved for the provision of services under the Long-Term Care Insurance System. As a result, more than90% of the municipalities established Community Comprehensive Support Centers in 2006. As of present, more than 5000Community Comprehensive Support Centers have been established in about 1800 municipalities.

" The Community Comprehensive Support Centers are responsible for (1) addressing, upon request from insured elderly peopleand their families, problems relating to elderly people that are difficult to solve through the provision of Long-Term Care InsuranceSystem-based services alone (such as elderly abuse problems), (2) the care management for long-term care preventionintroduced as part of the 2005 reforms, (3) the care management for making the long-term care prevention program available tothe elderly people not eligible for the services provided under the Long-Term Care Insurance System in addition to the eligibleelderly people and (4) providing guidance and coordination for the Care Support Specialists performing care management work inlocal communities based on the concept of continuous and comprehensive care management.

" In the beginning, many Community Comprehensive Support Centers were tied up with long-term care prevention-related work.However, Community Comprehensive Support Centers gradually started to engage themselves in community care managementactivities, which constitute their main task, and it is expected that the Centers will actively pursue the task in the future.

II The Way Ahead - AnticipatedDevelopments and Prospects for

the Future

226

1 The Need to Enhance Community Care amid the Rapid Aging ofthe Population of Japan and the Intensifying Trend of the Aging

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2 Enhancement of Services and CommunityCare Management Functions

" We are facing the problem of rapid aging of the populations of urban areas, and it is necessary to departfrom the traditional “either facility-based care or in-home care” approach and improve and restructureservices based on a new perspective.

" One important factor regarding this is measures to ensure the provision of better dwelling-type facilities,about which a presentation will be made in the next session.

" It is also necessary to (1) ensure that facilities that will be developed in the future will be more compact thanthe existing facilities, (2) deploy facilities in communities in a seamless manner, (3) ensure that an around-the-clock care system will be established in each local community and (4) enhance management functionsto coordinate the necessary services in a timely manner according to changes in the statuses of elderlypeople regarding the level of required care.

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" It is necessary to so enhance coordination functions that services of other systems as well as informal careservices can be utilized to meet livelihood needs that cannot be met through the Long-Term Care InsuranceSystem alone.

" It is necessary to develop and widely implement support methods that utilize potential abilities of elderlypeople and help facilitate self help.

" It is necessary to develop and implement service methods which ensure that elderly people can choose theoptions they like most and realize the principle of self support.

" It is necessary to further enhance community comprehensive care to achieve these.

" These are the tasks to be addressed in the future.

228

3 Community Comprehensive Careas a Strategic Concept

" The concept of community comprehensivecare systems has been used as a keyconcept for policy programs. I would like toexplain this in a reorganized manner.

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Care for Elderly People Suffering from Dementia thatRequires Community Comprehensive Care

Significance of comprehensive andcontinuous support

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" The concept of community comprehensive care is alsoimportant in the area of dementia care, because thenumber of elderly people suffering from dementia willincrease in the future. In this regard, specializedmedical care for dementia, long-term care and localcommunities’ understanding and cooperation willbecome important.

" It will be difficult for hospitals and facilities to providecare to vast numbers of elderly people suffering fromdementia. In addition, burdening hospitals and facilitieswith such a task is not appropriate. Therefore, it isnecessary to develop dementia care systems which arebased on community care. Such systems should beones that allow early detection and the provision ofappropriate care based on the results of assessments,and these cannot be achieved without using communitycomprehensive care approaches.

231

4 Future of Community Care - from simulations bythe National Council on Social Security

" The National Council on Social Security established bythe Cabinet last year has published their numericalsimulations regarding how medical care and long-termcare will change in the future. I would like to explain thefuture prospects in a specific way using part of thesesimulations.

" The basis of this concept is to facilitate and enhancecommunity comprehensive care, and I have shown whatservices should be developed and how it should bedone based on simulations on the increases in thenumbers of elderly people. Here I will present some ofthe results obtained from the immense work. -

232

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233

III Examples of Implementation of the Conceptof Community Care

Next, I will present pioneering examples ofimplementation of the concept of communitycare in Japan in the area of long-term care.All of the examples are cases found in local

cities. The task to be addressed in the future isensuring that large cities follow suit.

1 Disaggregation of Aggregations of FacilityFunctions and Incorporation of Disaggregated

Components into the Community

" The case of Kobushi Home in Nagaoka City

234

Elderly people’s desire to live theireveryday lives in the local communities

in which they have built their livesExisting facilitieslocated outsidethe community

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2 Example of a Small-scale,Multi-functional Base

" The case of Sakura Home in Tomonoura,Fukuyama City, Hiroshima Prefecture "

a small-scale, multi-functional in-homelong-term care base that believes in andis implementing the concept of informalcare

The Concept of Small-scale, Multi-functional In-home Long-Term Careand the Community Care

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Philosophy of Sakura Homein Tomonoura, Fukuyama City

A home where the abilities and experiencesof elderly people are welcomed

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Long-term carehelpersDay services, daycareHome-visit nursingHome-visitrehabilitationHome-visit bathingassistanceWelfare equipment

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University- Miyazaki Municipal

University- Local residents- Friends and

neighborsBoard of Directors

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Mother’s HomeInmates and their families

Family doctorsIn-home curesupport clinics

NPO Home Hospice MiyazakiHome-visit Long-Term Care

Station “Parion”In-home Long-Term CareSupport Office “Parion”

Formal servicesLong-Term Care

Insurance System-based services

HospitalsHospices

Pharmacists

Visitingnurses

Care ManagersPreparation of care plans

DentistsInformal services

Livelihood support asan alternative to

support by the family

240

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243

244

1

Roles of Housing and Institutions for the ElderlyHousing with Care, Residential Homes and Nursing Homes

International Symposium on Long-Term Care

Mariko Sonoda

Department of Architecture

Meiji University

’

Satisfaction with housing

" In Japan, 20% of senior citizensare dissatisfied with their housing.

" In Germany and France, thispercentage is low

Convenience of current housingwhen health has deteriorated

" In Japan, 47% said someproblems exist, and 19% saidserious

" In Germany, 34% said someproblems exist

" In France, 26% said seriousproblems exist.

table2 Japan Germany France

Convenient 12.2% 26.6% 22.4%

Somewhatconvenient

21.3% 19.4% 26.8%

Somewhatinconvenient

47.3% 34.1% 24.7%

Veryinconvenient

18.9% 19.7% 26.1%


Satisfied 34.9% 74.5% 68.4%

Somewhatsatisfied

46.6% 21.3% 26.3%

Somewhatdissatisfied

15.6% 3.6% 4.9%

Verydissatisfied

2.9% 0.6% 0.4%

245

Desire concerning housing whenhealth has deteriorated

" In Japan, Germany, and France,70% desire to stay in their ownhomes.

" In Japan, 13% want to live in anursing home.

" Those wanting to live in housingfor the elderly account for 18% inGermany and 13% in Franceboth figures are higher than thatfor Japan.

" In Japan, 7% desire to live in ahospital, which is a highpercentage compared to theother countries.


Currentresidence

50.5% 40.0% 38.9%

Currentresidenceafterrenovation

16.5% 30.5% 34.4%

With one ofchildren

3.6% 4.7% 4.2%

House forthe elderly

5.9% 17.7% 13.3%

Nursinghome

12.5% 4.7% 5.8%

Hospital 7.2% 0.1% 0.1%

’

’

Changes occurring from 1990 to 2005,the number of people who desire toremain in their homes is increasing.

Since the Long-Term Care InsuranceSystem started in 2000, the number ofpeople who wish to live in a nursinghome is increasing.

The number of those desiring to live ina hospital is extremely low, it stillaccounts for 7%

Between 6 and 8% of people desire tolive in housing for the elderly. Thispercentage has remained fairlyconstant for 15 years.

table4 1990 1995 2000 2005

Currentresidence

59% 62% 60% 67%

With one ofchildren

4% 3% 3% 4%

House forthe elderly

8% 6% 8% 6%

Nursinghome

8% 7% 12% 13%

Hospital 19% 18% 14% 7%

246

’

In Japan, 1.2% of personsaged 65+ live in shelteredhousing for the elderly and3.2% live in nursinghomes.

The percentage of peoplewho live in nursing homesdoes not differ greatly withpercentages in the US andEuropean countries

the percentage of peopleliving in sheltered housingfor the elderly is extremelylow.

3.25.3 4.4 3.5

1.2

6.2

4.17.8

0

2

4

6

8

10

12

14

JAPAN U.K. USA DENMARK

sheltered housing

per cent / Age 65+ population

nursing home, etc.

Fig. The elderly living place, percentage of age 65+ population

’

In Japan, 16% of seniorcitizens aged 65+ arecertified as being insuredby Long-term CareInsurance.

Level -1 of care need;88% use in-home servicesand 7% use in-facilityservices.

Level-5 of care need; 60%live in long-term carefacilities.

Level-4 of care need; 49%live in long-term carefacilities.

14%14%

26%

32%

8%

14%

16%

13%93%85%

70%

52%

40%

6%6%4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

LEVEL1 LEVEL2 LEVEL3 LEVEL4 LEVEL5

in-home care

in-facility

care

intermediary

nursing care

long-term carehospital

Fig. Using care services by Level of care need

247

7

Sheltered housing" Public sheltered housing

" Non-profit sheltered housing

" Private residential homes

" Non-profit residential homes

" Group-home for Dementia

Care accommodation insured by Long-term care insurance" Nursing homes (intermediary)

" Nursing homes

" Long-term care hospitals

In-facility care involves muchgreater cost than in-home care.Users of services that are coveredby the Long-Term Care InsuranceSystem, 29% use in-facility servicesand 71% use in-home services.Those using in-facility servicesrequire an average of 286,000 yenper month, which is 2.5 times theaverage amount needed for users ofin-home servicesNew construction of long-term carefacilities costs between 7 and 10million yen per bed.

8

0

50

100

150

200

250

300

350

in-home care in-facility care

110thousands YEN

286thousands YEN

thousands YEN

Fig. The monthly average cost of Long-term CareInsurance per a person

248

Large-scale long-term care facilities are isolated from the community, and shared“private rooms” do not adequately guarantee the living quality and dignity ofinhabitants.The following reforms are being made to address this situation:

" The size of long-term care facilities will be made smaller, having a capacity of 29 people orless.

" In principle, newly constructed long-term care facilities will feature one-person rooms andunit care.

" Existing long-term care facilities will be improved, shifting from shared rooms to one-personrooms and unit care.

However, the existing hospital model for supplying care services - the ratio of staffmembers to inhabitants is 1:3— remains unchanged.If one-person rooms and unit care are to be provided, it will be necessary to doublethe current number of staff members.

It will be necessary to increase the supplyof housing for the elderly with care

For-profit enterprises already supplyhousing with care to wealthy classes.However, a problem is expensive residencefees and monthly use charges.

Efforts are underway to expand the supplyof housing with care for poorer classesthrough use of public housing and socialhousing. But, most of public/social housingare older and not equipped with elevators.

The biggest problem is insufficient supply ofhousing with care for the middle class. Theprimary reasons for this are a lack of projectimplementers.

3.25.3 4.4 3.5

1.2

6.2

4.17.8

0

2

4

6

8

10

12

14

JAPAN U.K. USA DENMARK

sheltered housing

per cent / Age 65+ population

nursing home, etc.

Fig. The elderly living place,percentage of age 65+ population

249

250

Ministry of Labour, Social Relations, Families and Solidarity

Roles of housing and institutions for the elderlyGilles De La Gorce, Directorate-General for Social Action (DGAS)

Symposium on Long-Term CareTokyo, February 3rd-4th, 2009

1. The Context: Policy on home care and the fitting of medical equipment in careestablishments

Since 1975, French policy for dependent elderly people has focused on two areas: developingcare in the home and improving conditions in care establishments. These areas werereinforced in 2002 by a series of reforms.

Care in the home relies on a series of support measures:

- Personal autonomy benefit (APA, allocation personalisée d'autonomie), created in 2002: abenefit which decreases in line with earnings to finance the purchase of goods and services tocompensate for loss of independence.- Health insurance, either via services providing nursing care in the home or directly(independent doctors and nurses, hospital care in the home)- Provisions to reduce taxes for employing staff working at home- Social action by local authorities

Main issues:

- The organisation of how services are provided: multiple parties involved, but a predominantrole for the département (administrative division analogous to a county).- The professionalisation of care staff: policy to increase the value of care work (diploma ofsocial life auxiliary and planned salary review through collective agreement), which remainsunattractive as salary increases come into conflict with funders' pricing policies.- Adaptation of housing: possible through the use of housing grants and possibly the APA, butdifficult in practice. Inadequate preventive work.

Institutional care was profoundly revised in 2002, with pricing reforms distinguishingbetween three sections in establishments' budgets: the healthcare section, funded by a healthinsurance contribution, the dependency section, funded by the APA in the institution, and theaccommodation section, funded by the resident or by the département's social care budget.This pricing is combined with a 5-year agreement (known as a "tripartite agreement", becauseit is signed by the establishment, the state and the département), which includes commitmentson the part of the institution relating to quality of service, users' rights etc. Establishmentswith such agreements are known as residential centres for elderly dependent people (EHPAD,établissement d'hébergement pour personnes âgées dépendantes).

Main issues:

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- Scale of the establishment's remaining responsibilities resulting from the growing financialburden associated with improving buildings and the quality of care.- Lack of funding consistency arising from the accumulation of various benefits: APA,housing benefits, tax credits, social support.- Difficulty of including quality requirements in pricing.- Difficulty integrating specialist hospital services in accommodation for dependent elderlypeople in long-term care units, whose costs are often too high for them to apply EHPADpricing.

Between the home and institutions, a range of intermediate provision has developed:

- Residential centres for elderly people (EHPA, établissement d'hébergement pour personnesâgées), which also take some elderly dependent people. Certain centres do not havesufficiently dependent a population to become EHPADs. These consist mainly of shelteredhousing, groups of independent housing units with shared facilities or services, and ruralhomes for elderly people (MARPA, maison d'accueil rurale pour personnes âgées), smallliving units designed to preserve rural lifestyles.

Issues: we may wonder about the advantages of developing this type of establishment, whichdoes not always have the facilities to care for a dependent population. An extra difficulty liesin the age of many of these structures, since the facility dates back to 1958. In urban areas,where the housing market is stretched, sheltered housing plays the role of social housing forfragile elderly people. The future doubtless lies in mixed facilities combining the advantagesof the EHPAD with those of sheltered housing, which would be more suitable for situationsthat may evolve towards greater dependency.

- Temporary accommodation aims to preserve the person's independence and provides respitefor family members caring for a dependent elderly relative in the home.Issues: organising the management of temporary accommodation, particularly arrivals anddepartures, to keep a sufficiently high occupancy rate. Combining such accommodation withan EHPAD makes this management easier.

- Day accommodation takes elderly people living at home one or more times a week. Nightaccommodation is a still unusual variant.Issues: the occupancy rate, but also funding for transport, as the high cost of transport is oneof the barriers to the development of day accommodation: transport may be funded by theestablishment or the local authority.

- Care within a family, provided by individuals for a fee. The care providers must be approvedby the département. The recipient and provider of the service may be bound by a contract.

Statistical data (as of 31/12/2007)

EHPAD: 492,000 places subject to tripartite agreementsRetirement homes not covered by agreements: about 45,000 placesAlzheimer-specific units: 28,000 placesSSIAD (nursing services in the home): 95,000 placesSheltered housing: 150,000 places, of which 22,000 are subject to tripartite agreements

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Recipients of the APA, according to the person's degree of dependency on 30 June 2008

Home Institution Total

Numberin thousands

In %Number

in thousandsIn %

Numberin thousands

In %

GIR 1 20 3 67 16 87 8

GIR 2 121 18 184 44 305 28

GIR 3 149 22 67 16 216 20

GIR 4 385 57 101 24 486 44

Total 675 100 419 100 1094 100

2. A few types of response in terms of housing for dependent elderly people

The sector of housing for elderly dependent people is rich in innovations designed to taketheir needs into account better. Here are a few examples:

L'Orbe, Charles-Foix hospital, Ivry-sur-Seine, a follow-up and long-term care centre with90 beds built in 1990. The spatial organisation has more in common with the design of avillage, with its squares and meeting places, than the traditional hospital model. In the centreare two freely-accessible patios, there are gardens inside the building and there are nocorridors. The bedrooms are arranged around a central space varying in width like asuccession of small squares. Bathrooms, care facilities and nurses' offices form kiosks in thecentre of this space. This organisation in the form of a loop suits the wandering of disorientedpeople, leading to a reduction in aggression among residents and making the carers' workeasier.

Family home, Rueil-Malmaison, created in 1987, a small living unit based on the principleof the cantou, which aims to give residents a degree of social usefulness by involving them inmeal preparation and simple domestic tasks. The space is organised by arranging thebedrooms around a shared space, with an easily accessible garden extending the commonroom.

Relais Sépia, Descartes (Indre-et-Loire), a resource centre to help elderly people live athome, built in 1994 as part of an experimental programme. Inspired by the British communitycare system, the centre provides day accommodation and temporary housing with 17bedrooms. Thanks to good coordination of arrivals and departures, the establishment has anoccupancy rate of 97%, putting it on a sound financial footing. The garden is freely accessibleand its stabilised earth paths are adapted for wheelchairs and people with reduced mobility.The light flooding into the day centre's dining room through its large windows is muchappreciated by its users.

Résidence Louis-Fort, Villeurbanne, created in 1995 on the ground and first floors of ablock of flats. It consists of 13 studio flats (upstairs) built around collective services(downstairs). The idea is to respect people's autonomy, even partial, as much as possible andto enable individualised follow-up. The centre's incorporation into a normal block of flatslimits costs and ensures good social and urban integration. The layout is organised accordingto the care priorities, which involve maintaining physical and mental activity.

Saint-Apollinaire inter-generational neighbourhood, Dijon. Created in 2000, this projectconsists of half family housing and half housing for elderly people. The tenants sign an "inter-

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generational charter", a moral commitment to mutual support (such as babysitting in exchangefor shopping, for example). Protected housing for six disoriented people is located at groundlevel. The building also has collective housing for 14 people with a high degree of physicaldependency. A family life area is designed to promote communication between thegenerations. A free internal telephone network provides added security for elderly residents.

3. Perspectives

The senior citizen solidarity plan (Plan Solidarité grand âge) 2007-2012. This plan,currently in progress, has the global aim of improving care for dependent elderly people. Itconsists of several measures relating to accommodation for elderly people:

- Developing care in the home: doubling the number of home hospitalisation places, creating6,000 home nursing care (SSIAD) places a year (7,500 from 2010).- Creating the right to respite care for family carers: creating 2,100 day care places and 1,100temporary accommodation places a year, and setting up three months' unpaid "family care"leave which can be extended up to a year for employees wishing to care for a dependentrelative.- Accelerating the effort to create accommodation places (7,500 a year) and strengthening thefitting of medical equipment in EHPAD centres when their tripartite agreements are due forrenewal.

Alzheimer's Plan (2008-2012). This plan, currently in progress, includes specific measuresfor the accommodation of elderly people suffering from neurodegenerative diseases:

- Reinforcing support in the home, favouring interventions by specialist personnel: 500specialist teams, with 5000 places for services in the home, will be created between 2009 and2012.- Improving support in the home with new technology: a call for projects specificallytargeting home automation and ICT designed to compensate for the loss of orientation andindependence characteristic of Alzheimer's disease.- Creating or identifying 30,000 places in units adapted or reinforced for patients sufferingfrom behavioural problems within EHPADs. A major investment programme will providefunding for these adapted or reinforced units.

The draft "fifth risk" bill provides for the financial help for people accommodated ininstitutions and the support for housing to be adapted included in the APA to be reinforced.

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255

Impressum

Die in diesem Band geäußerten Meinungen geben ausschließlich die Auffassung der Autorinnen und Autoren wieder.

Abdruck und sonstige publizistische Nutzung – auch auszugsweise –nur mit vorheriger Zustimmung des JDZB und mit Nennung der Autorin bzw. des Autors sowie der Quelle gestattet.

Im Allgemeinen erscheinen die japanischen Eigennamen nach der in Japan üblichen Reihenfolge: Familienname – Vorname.Transkriptionen japanischer Namen und Wörter erfolgen nach der modifizierten Hepburn-Umschrift. Ausnahmen können in Zitaten und bibliographischen Angaben vorkommen.

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Bericht über das Symposium „Langzeitpflege“03. und 04. April 2009, Tokyo

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