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

Tensions experienced by case managers working in home care for older adults in Quebec: first level analysis of an institutional ethnography

BACKGROUND

Case managers play a vital role in integrating the necessary services to optimise health-related goals and outcomes. Studies suggest that in home care, case managers encounter tensions in their day-to-day work, that is, disjuncture between what they should do, in theory, and what they actually do, in practice. However, direct exploration of these tensions is lacking. As such, this study aimed to describe the tensions encountered by case managers in public home care for older adults in Quebec and their influence on day-to-day work.

METHODS

An institutional ethnography was conducted through observations of work, interviews and a survey with case managers working in home care in Quebec. Data were analysed using institutional ethnography first-level analysis procedures. This included mapping the work sequences as well as identifying the tensions experienced by case managers through the words they used.

RESULTS

Three main tensions were identified. First, case managers perceive that, despite working to return hospitalised older adults at home safely, their work also aims to help free up hospital beds. Thus, they often find themselves needing to respond quickly to hospital-related inquiries or expedite requests for home care services. Second, they are supposed to delegate the care to "partners" (e.g., private organisations). However, they feel that they are in effect managing the quality of the services provided by the "partners." Consequently, they go to great lengths to ensure that good care will be provided. Finally, they must choose between meeting organisational requirements (e.g., reporting statistics about the work, documenting information in the older adults' file, doing mandatory assessments) and spending time providing direct care. This often leads to prioritising direct care provision over administrative tasks, resulting in minimal reporting of essential information.

CONCLUSION

The results are discussed using the three lenses of professional practice context analyses (i.e., accountability, ethics, and professional-as-worker) to formulate recommendations for practice and research. They suggest that, despite their important role, case managers have limited power in home care (e.g., with partners, with the hospital).

Subjective Social Status as a Predictor of Loneliness: The Moderating Effect of the Type of Long-Term Care Setting

Much has been written about the important role that subjective social status plays in older adults' well-being and subjective health. Less is known, however, about the potential role played by subjective social status in people's sense of loneliness. In the present study, the author examined the role of subjective social status as a predictor of loneliness in adult day care centers (ADCCs) and continuing care retirement communities (CCRCs) over a 1-year period. The main analyses consist of data from 245 respondents (141 ADCC participants and 104 CCRC residents) who completed the interviews in Waves 1 and 2. A significant interaction between subjective social status and type of long-term care setting was found. Higher levels of subjective social status were associated with lower levels of loneliness in CCRCs, but no such association was evident in ADCCs. These findings are interpreted in view of the characteristics of the CCRC as a total institution versus the ADCC as a setting that provides support for only several hours per day, several days per week.

Loneliness and Anxiety About Aging in Adult Day Care Centers and Continuing Care Retirement Communities

Background and Objectives

The present study compares how 2 settings: adult day care centers (ADCCs) and continuing care retirement communities (CCRCs) fare with regard to loneliness and anxiety about aging. Loneliness is a highly prevalent and distressing subjective experience of inadequate social relations, which has negative effects on health and well-being. Anxiety about aging is defined as worries brought up by imagining the negative consequences and losses associated with old age. The study also examines whether anxiety about aging accounts for differences in loneliness between the 2 settings. This study took place in Israel, where ADCCs are funded by the National Insurance Institute of Israel and CCRCs tend to be funded by private income and wealth. Despite notable differences between the settings, a common goal of both is to reduce loneliness among older adults.

Research Design and Methods

A cross-sectional design of 4 ADCCs and 4 CCRCs (N = 456).

Results

Compared with CCRC residents, older adults in ADCCs reported higher levels of loneliness (Mean [SD] = 1.46 [0.60], Mean [SD] = 1.78 [0.80], respectively, t [df]= −5.10 [448], p < .001) and higher levels of anxiety about aging (Mean [SD] = 2.96 [0.88], Mean [SD] = 3.27 [0.99], respectively, t [df] = −3.42 [440], p < .001). Anxiety about aging partially accounted for the differences between the 2 settings in levels of loneliness (B = 0.03, 95% confidence interval [CI]: 0.0037–0.0651).

Discussion and Implications

Although it is not possible to determine causality from this cross-sectional design, it is possible that CCRCs provide a better social outlet for older adults than ADCCs.

Finding the vulnerable among China's elderly: identifying measures for effective policy targeting

Facing a rapidly aging population, China has recently started to formulate and implement policies with the aim to provide old-age care. While well-developed old-age care policies commonly include a built-in component that assesses eligibility based on vulnerability, no such process is established in the context of China. Here, based on data from the China Health and Retirement Longitudinal Study collected in both 2011 and 2013, we (a) developed a simple and effective strategy for identifying vulnerable Chinese elderly, which can serve as a basis for policy targeting, and (b) improved the policy relevance and targeting efficiency of this vulnerability measure by including additional health indicators. Our vulnerability measures identify 35% to 46% of Chinese elderly as vulnerable, covering up to 67% of elderly at high risk of death or functional decline. They can serve as an initial screening step for more comprehensive geriatric assessments and enable policy makers to effectively target vulnerable elderly persons in China.

Between older adults' needs and the law: The Israeli Long Term Care Insurance Law from the Perspectives of Service Users and Providers

The Israeli Long Term Care Insurance Law (LTCIL) was one of the first long term care insurances in the world to support older adults and their family members and allow them to stay in their homes for as long as possible. The present study aimed to evaluate the perspectives of older adults, their family members and home care workers regarding the LTCIL. Views of workers of the National Insurance Institute (NII), which is directly responsible for the enactment of the law, are also integrated. Interviews were conducted between June 2016 and June 2017. Thematic qualitative analysis is based on interviews with 15 NII workers, 31 older adults, 31 family members, and 6 paid home care workers. The present study stresses the tension between the LTCIL and older adults' perceived rights and needs. It also demonstrates how even though the NII workers are engaged with various stakeholders, they often lack direct contact with older adults, their family members and paid home care workers: those most directly influenced by the LTCIL. Policy considerations are discussed.

Israel's Long-Term Care Social Insurance Scheme After a Quarter of a Century

Long-term care social insurance schemes exist in a number of countries, while the introduction of such schemes enjoys some support in others. Israel's long-term care social insurance scheme has been operating since 1988. This article examines the emergence, goals, design, and impacts of this scheme and draws out some of the lessons that can be learned from Israel's quarter century experience of long-term care social insurance.

The Long-Term Care Insurance Program in Israel: solidarity with the elderly in a changing society

The Long-Term Care Insurance Program (LTCIP) in Israel is a social security program administered by the National Insurance Institute (NII) since 1988. LTCIP focuses on home-based personal care services. Differently from most other programs under the responsibility of the NII, LTCIP benefits are in-kind benefits and are delivered via multiple for-profit and not-for-profit organizations. In recent years LTCIP has been the target of various legal amendments and numerous administrative changes. While many of these changes may have had significant effects on individuals, they have not altered the fundamental principles of the program. Thus, many of the characteristics of beneficiaries have remained quite stable over the years; other characteristics of the population of beneficiaries have changed over the years reflecting the aging of Israeli society. A central issue related to LTCIP is whether benefits are adequate to meet the needs of the growing elderly population of Israel. While the generosity of LTCIP benefits is questionable, economic and political struggles have limited the scope of changes introduced thus far.

Caring for the dying: from a "negative" to a "positive" legal right to die at home

The choice of the old and terminally ill to die at home has been the subject of various types of research. However, one of the aspects of this subject, which has been investigated very little, is its legal context. The absence of such legal research is contrasted by the vast amount of academic writing on the legal aspects of the right to die with dignity and euthanasia. The object of this article is to analyze and break down the "right to die at home" into its different legal components. This legal analysis will be based on Professor Isaiah Berlin's definition of two different concepts of liberty: negative and positive freedoms. The main conclusion from the legal analysis presented in this article is that it is important to understand that at the legal level the right to die at home is dependent on many different elements. These elements may be classed in two basic categories: negative and positive freedoms and rights. Even though the former is a necessary condition of the latter, without the latter the first remains purely theoretical for many old people.

Care-needs certification in the long-term care insurance system of Japan

The introduction of Japan's long-term care insurance (LTCI) system in April 2000 has made long-term care an explicit and universal entitlement for every Japanese person aged 65 and older based strictly on physical and mental status. At the start of the program, more than two million seniors were expected to apply for services to approximately 3,000 municipal governments, which are the LTCI insurers. The LTCI implementation required a nationally standardized needs-certification system to determine service eligibility objectively, fairly, and efficiently. The current computer-aided initial needs-assessment instrument was developed based on data collected in a large-scale time study of professional caregivers in long-term care institutions. The instrument was subsequently tested and validated by assessing data of 175,129 seniors involved in the national model programs before the start of LTCI. The computer-aided initial assessment (an 85-item questionnaire) is used to assign each applicant to one of seven need levels. The Care Needs Certification Board, a committee of medical and other professionals, reviews the results. Three years after implementation, the LTCI system and its needs-assessment/certification system have been well accepted in Japan. Despite the overall successes, there remain challenges, including area variations, growing demands for services, and the difficulty of keeping the needs certification free of politics. The LTCI computer network that links municipalities and the central government is instrumental in continuously improving the needs-certification system. Future challenges include promoting evidence-based system improvements and building incentives into the system for various constituencies to promote seniors' functional independence.