The silent crisis: women and the need for long-term care insurance. Part 2

As the number of people living longer increases and the proportion of women to men in the older age brackets grows larger, the imbalance between economic and social factors also increases. Women make up greater numbers of nursing home and assisted living facility residents, and must impoverish themselves to qualify for Medicaid assistance to remain in these facilities. Women also make up the majority of caregivers for elderly parents remaining at home, causing physical, mental, and emotional stress, in addition to affecting their working lives and earning potential. These economic and physical stressors are the subject of the second part of a three-part examination of women's need for long-term care insurance.

[Public health nurses' activities after the initiation of long-term care insurance (Part 1). Focus on operations for long-term care insurance]

OBJECTIVE

We conducted a nationwide questionnaire survey to elucidate the present status of public health nurses (PHNs) after initiation of the Long-Term Care Insurance (LTCI) system, in order to study the influence of the allocation of PHNs upon the performance of the system.

METHODS

In March 2001, a questionnaire was mailed to 1,344 municipalities throughout Japan (all cities and 23 wards in Tokyo; one quarter of towns/villages).

RESULTS

Responses to the questionnaire were received from 569 (42.3%). The largest percentage (36.4%) of PHNs was assigned to Elderly Health, 29.8% was assigned to Maternal and Child Health, and 10.2% assigned to the LTCI. Among LTCI operations, follow-up of individuals not certified as requiring care, guidance for the family caregiver, and counseling/grievance procedures were performed with participation of PHNs in more than 80% of municipalities. In urban areas, PHNs participated in training/guidance/advice for care certification investigators/care managers, guidance for service providers, and preparation/coordination for the Certification Committee for Long-Term Care Need in 60-80% municipalities, while those who participated in these activities were only 30-60% in towns/villages. The participation ratios were highest in municipalities where PHNs were allocated to the LTCI department for almost all of the activities except individual counseling. More PHNs from LTCI departments participated in certificating of care need and improving quality of care plans/services than from other departments in offices of municipalities. On the other hand, more PHNs in Welfare or Public Health-Welfare sections than in the LTCI were involved in individual counseling, guidance for both clients and caregivers, or in case management. Training or guidance for service providers was conducted in nearly 50% of municipalities and the performance rates were lower in towns/villages. In open-ended items of the questionnaire, the following problems were mentioned: difficulties in collaboration between sections; large workloads for certification of care need/care management, and difficulties in capturing information about clients.

CONCLUSION

The allocation of PHN influences the activities of the LTCI system, especially in relation to quality assurance. Recently, the sections to which PHNs are posted have expanded to include LTCI and Welfare. While improvement in the quality of LTCI services is anticipated, efforts are needed to strengthen collaboration among different departments. In towns/villages, performance rates of activities such as guidance for service providers of LTCI are low, suggesting the support from prefectural health centers in necessary.

[Are mental disorders given due consideration in the adjustment of stage of care according to the German Health Care Act? Assessment of cognitive impairment by medical expert record (MDK) and standardised methods of the research team]

Fifty-eight recipients of long-term care insurance benefits were interviewed during home visits by a research team. Fourty-eight percent of the interviewees achieved less than 22 points in the Mini-Mental State Examination (MMSE), clearly indicating cognitive impairment. Comparison of the authorized examination on the one hand and the findings of the research team on the other showed: neither CNS-specific diagnoses (77.8% sensitivity) nor CNS malfunction adequately recognised cognitive impairment. In 41% of the cognitively impaired, authorised examination found only minor or no functional CNS disorders. A comparison of the 'recognised' and 'not recognised' cognitively impaired and physically handicapped applicants found that a higher stage of care was allocated to the group with recognised dementia but that, in all MDK parameters, there was no judgmental difference in medical expert records between patients with unrecognised cognitive impairment and physically handicapped persons.

The long term care insurance law in Japan: impact on institutional care facilities

BACKGROUND

Following the introduction of the public long-term care (LTC) insurance in Japan on 1 April 2000, funding that had been split between the health and social welfare sectors was unified. All elderly people 65 and over have become entitled to receive benefits according to their eligibility level, regardless of income or family support. Except for those assessed as in the least dependent group, individuals can choose either community care or institutional care, with only the cost of food an additional payment for the latter.

METHOD

Review of the development and implications of long term care insurance provision for older people and analysis of quality based on resident level data.

RESULTS

Despite the structural changes, the impact of the new programme has had minimal impact upon the providers of institutional care. The three types of facilities that had provided LTC have continued to function independently, basically retaining the same staffing requirements and charges. For indicators adjusted for risk, the quality of care tended to be higher in designated LTC hospital beds.

CONCLUSIONS

Appropriate balance between institutional and community care and triaging among the three different types of facilities remains difficult because decisions rest with the individual. Indicators of quality must take into account differences in case-mix among the facility types. However, there are few incentives for providers to improve quality because demand is likely to be increasingly greater than supply. Whether the generous provisions of the new programme will prove to be sustainable remains to be seen.

[Burden on family caregivers of frail elderly persons one year after the introduction of public long-term care insurance service in the Onga District, Fukuoka Prefecture: evaluation with a Japanese version of the Zarit caregiver burden interview]

The present study was conducted to investigate the factors related to the feeling of psychological stress, called heavy burden, in caregivers who took care of frail elderly persons 1 year after the introduction of the public long-term care insurance system (i.e., kaigo hoken) in the northern part of Fukuoka Prefecture, Kyushu, Japan. Forty-seven caregivers answered a self-administered questionnaire involving the Japanese version of the Zarit Caregiver Burden Interview (ZBI) and thus described their own caregiving situation. Compared to caregivers with a light burden, heavily burdened caregivers were less likely to have time to go out without their frail elderly, but tended to spend a longer time with them in providing for their physical care. Compared with less burdened caregivers, heavily burdened caregivers tended to be concerned with what others thought or said and more likely to use a short-stay service (i.e., temporary nursing home assistance). More social services should be provided to let caregivers have their own time without caring for their patients. In addition, local governments and caremanagers should help caregivers to understand the benefits of services available for the elderly and their caregivers.

[Nursing in the framework of long-term care insurance as a basic principle of a specific nursing approach of rehabilitation?]

Activating nursing based on the criteria of the long-term care insurance may be understood as a second specific and nursing approach of rehabilitation beneath medical rehabilitation. Activating nursing is unspecific, characterized by the norms and guidelines of the long-term care insurance, but defined as the general norm of practical nursing. A professional nursing definition for a specific concept is lacking just as funding of nursing science. Adhering to activating nursing as a nursing complement to medical rehabilitation in the framework of long-term care insurance requires professional development and funding. Furthermore, more support of social law is necessary, which depends on professional nursing and nursing science-based indication and the intervention approach. The article develops an approach--based on a study about rehabilitation of people in need for care--and reflects on implementation and acceptance by people in the need of care.

Finance issue brief: long-term care insurance: year end report-2002

A 1996 federal law made it more attractive for states to consider long-term care insurance, and states have responded by implementing policies to make the purchase of these long-term care coverage more affordable and consumer-friendly. At present, policy makers continue to debate the future role of private long-term care insurance in subsidizing the increasing demand for long-term care services.

Long-term care policy reform in Japan

The implementation of Japan's Long-Term Care Insurance Scheme in April 2000 was the culmination of some 30 years of policy deliberation on aged care. Understanding the policy debate surrounding the Long-Term Care Insurance scheme and its financing arrangements requires an appreciation of rapid demographic and social change, especially in family structures and attitudes to caring for aged parents; but the pressures that population aging and economic downturn are placing on Japan's pension and health insurance systems also must be recognized. Even more generally, the delicate balance of political interests in Japan's central governing body, the Diet, has shaped the implementation of Long-Term Care Insurance as a forerunner to other reforms in social security and health insurance.

Aged care service delivery in Japan: preparing for the long-term care insurance scheme

The implementation of Japan's Long-Term Care Insurance Scheme in early 2000 presaged many changes in service delivery and much debate among service providers, different levels of government, academic analysts, and major media interests. The first part of this paper gives an account of the major changes in the organization of service delivery that have increased opportunities for private sector providers, including large corporations, and restructured contractual relationships between municipalities and providers in all sectors. New arrangements for client assessment, classification, care management, and extended service types are then outlined. An assessment is then made of the likelihood that the expected outcomes of the scheme will be realized, with the concerns of welfare professionals that the public welfare system is under threat juxtaposed with bureaucratic goals of liberalizing the provision of long-term.

[Comparison of expertises between long-term care insurance (SGB XI) and the law on ambulatory care for disabled individuals in Berlin (HPG)]

A long-term care insurance (SGB XI) was established in Germany in 1995. Previously, care for predominantly disabled and disabled elderly people in Berlin was regulated by a law enforced by the Berlin government (HPG). The objective of this study was to investigate the differences in age, sex, diagnosis and care of the disabled individuals at home. In a cross-sectional study, the social medicine certificates of 3.916 disabled individuals were evaluated. The certificate assesses the grade of disability and the care needed for a person entitled to benefit from either the HPG or later from SGB XI. Disabled females benefiting from the HPG and SGB XI regulations are in the majority. The male: female ratio for HPG was 1:2.215 and for SGB XI 1:2.759. The differences between male and female as well as between HPG and SGB XI are statistically significant. The even higher proportion of females for those benefiting from SGB XI is due to the demographic change over time. The results of the study also show that the certificates differ in diagnosis, in the care needed at home, and in the grades of disability. By logistic regression analysis, the univariate method shows the amount of care needed at home to be greater for the HPG than for the long-term care insurance. The collective of disabled persons benefiting from HPG were derived from the ambulatory and the stationary sector. In this study, those individuals who were investigated and supported by SGB XI originated from the ambulatory sector, although the law also supports those under hospital care. By calculating analysis of multivariate logistic regression with grades of disability taken as dependent and disability of a given person as independent variables related to the grades of disability when applying SGB XI were compared to HPG. The independent variables have different hierarchies for both laws and need to be divided into more specific subgroups. Interestingly, age and sex did not influence the grading of disability. Diseases leading to disability differ between male and females. Males suffer mostly from neurologic and psychiatric and females from orthopaedic diseases. The criteria for the particular grades are too broad and a better specification is suggested, in that the grades should be increased from three to five. For exceptional cases, a more flexible procedure should be allowed, which is possible under the present SGB XI regulations.

The health and social system for the aged in Japan

Japan implemented a new social insurance scheme for the frail and elderly, Long-Term-Care Insurance (LTCI) on 1 April 2000. This was an époque-making event in the history of the Japanese public health policy, because it meant that in modifying its tradition of family care for the elderly, Japan had moved toward socialization of care. One of the main ideas behind the establishment of LTCI was to "de-medicalize" and rationalize the care of elderly persons with disabilities characteristic of the aging process. Because of the aging of the society, the Japanese social insurance system required a fundamental reform. The implementation of LTCI constitutes the first step in the future health reform in Japan. The LTCI scheme requires each citizen to take more responsibility for finance and decision-making in the social security system. The introduction of LTCI is also bringing in fundamental structural changes in the Japanese health system. With the development of the Integrated Delivery System (IDS), alternative care services such as assisted living are on-going. Another important social change is a community movement for the healthy longevity. For example, a variety of public health and social programs are organized in order to keep the elderly healthy and active as long as possible. In this article, the author explains on-going structural changes in the Japanese health system. Analyses are focused on the current debate for the reorganization of the health insurance scheme for the aged in Japan and community public health services for them.

Germany's long-term care insurance model: lessons for the United States

The implementation of public long term care (LTC) insurance in 1995 in Germany is an important public policy development that offers lessons for the U.S. The German LTC model is comprehensive and mandatory, covering 88 percent of its population, by equal premium contributions on wages from employees and employers. The new German system has uniform eligibility and benefit criteria, covers both institutional and home care, pays for family caregivers, is financially solvent, and is considered a success by the public. In contrast, the U.S. financing of LTC is largely private, with the government serving as the safety net for the majority of the LTC costs after individuals spend down their resources. This paper considers whether a German-type LTC system is feasible and affordable and discusses the issues and complexities of public LTC insurance, including cost containment, home care services, quality control, and administrative structure.

Changing systems in health and social care for older people in Japan: observations and implications for interprofessional working

The impact of a rapidly ageing population on the development of insurance policies and health and social care services of older people is a major concern in Japan. The discussion in this paper draws on information gained from recent visits to leaders of these services in Japan. The paper briefly reviews the policy and demographic background to recent legislative changes in the long-term care insurance system, models of care management and assessment and outstanding challenges for health and social care professionals. Some key issues have emerged with implications for interprofessional working, such as the lack of integrated care systems, contradictions within the scope and responsibilities of care management, and the absence of quality and ethical frameworks to safeguard the interests of the service user and carer.

The new public long-term care insurance system and feeling of burden among caregivers of the frail elderly in rural Japan

The present study was conducted to investigate the factors related to the feelings of burden (i.e., stress) among caregivers of the frail elderly in rural Japan after the introduction of the new public long-term care insurance system in 2000. Forty-one out of 42 caregivers answered a self-administered questionnaire (i.e., the Japanese version of the Zarit Caregiver Burden Interview (ZBI)) regarding their caregiving situation. Compared with lightly burdened caregivers (n = 20; ZBI > or = 41), those heavily burdened (n = 21; ZBI < or = 40) attended the frail elderly with greater numbers of behavioral disturbances (2.2 +/- 2.6 vs. 0.6 +/- 1.0, p = 0.02) and those with dementia (60.9% vs. 39.1%, p = 0.08). Heavily burdened caregivers spent a longer time with the elderly (17.9 +/- 6.1 hours vs. 11.8 +/- 8.4 hours, p = 0.01) as well as in providing for their physically care (14.0 +/- 7.9 hours vs. 8.6 +/- 8.2 hours, p = 0.04), thus having less time to go out unaccompanied by their patients (1.1 +/- 1.6 hours vs. 2.4 +/- 2.3 hours, p = 0.04). Such caregivers tended to be depressed (70.0% vs. 42.9%, p = 0.08), although they used more social services (5.2 +/- 2.0 vs. 3.7 +/- 2.1, p = 0.03) than the lightly burdened caregivers. In addition, more than half of caregivers (56.1%) in the present study were depressed. This rate was higher than the rates in our studies before the introduction of the new public long-term care insurance system (a rural town: 53.3%, an urban town 46.6%). Furthermore, the number of social services used by caregivers did not seem to increase after the introduction of this insurance system (before: 4.1 +/- 2.0, after: 4.4 +/- 2.1). These findings suggest that the quantity and quality of social services for the frail elderly and their caregivers may not suffice even after the introduction of the new public long-term care insurance system.

Israel's long-term care insurance law after a decade of implementation

Israel's Long-Term Care Insurance (LTCI) law has been in effect for a decade. It is timely to review the effects of this legislation with a view to identifying possible directions for reform and lessons for other countries considering the introduction of a similar social insurance scheme. The paper considers the law's effects in terms of the size and characteristics of the beneficiary population, the coverage of the scheme, its financial standing, the rate of institutionalization of the elderly, the caregiving burden, the service delivery system, and the overall scope of long-term care services for the aged. Israel's experience has lessons for financing arrangements, target efficiency, service delivery arrangements, and the construction of the burden of care.

[Application behavior and disability in ambulatory care according to SGB XI. A structural regional approach]

A REGIONAL ANALYSIS: The target of this task undertaken by a geographer was an analysis according to limited regional areas, of application for and demands on benefits granted by the statutory social long-term care insurance body, and hence an interdisciplinary estimate. Definite differences between individual areas in Schleswig-Holstein were seen, and it was partly possible to explain why such differences exist. The infrastructure, the housing space ownership conditions and individual self-assessment are essential factors when applying for benefits. Identification of the geography of the relevant residential location was effected by the individual zip code. In 79.8% of the cases included in a random test the locations were clearly defined. The combination of geography and epidemiology enables a clear allocation of medical phenomena also for further research concerning differences between well-defined areas.