International Comparative Study on Productive Ageing Detailed Request

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1 (July 3, 2013) International Longevity Center-Japan International Comparative Study on Productive Ageing Detailed Request As you know, ILC-Alliance s joint research has been growing each year and keeps contributing to better and productive quality of life among older people. ILC-Japan s International Comparative Study on Productive Ageing 2012 was completed with great achievement. This year, we also started a project: International Comparative Study on Productive Ageing and long-term care system While we have already requested your assistance in one component of the study last year, we are also preparing for other parts. The following is our request for your cooperation this year. I apologize that our requests are always on such a short notice, but we will truly appreciate your cooperation. Request Collecting Basic Data/Information for the International Comparative Study on Long-term Care and Personal Social Care We will appreciate if your Center could answer the following questions (please consult with experts in your country as needed) and send the response to us by the end of September, We are planning to use the responses as the basic information/reference in the International Comparative Study on Long-term Care and Personal Social Care. The questions are as follows. Questions (tentative) For your reference, information on Japan will be provided later for each question. I. Housing, long-term care and medical care: Overview 1. Housing system Q1-1: What kinds of systems are available as residence and facilities for older people? What laws set rules (e.g. establishment, administration, etc.) on such residence and facilities? Even if there is no specific law on such residence and facilities, please provide any information on residence which is generally known as housing for older people (e.g. Social Housing Law, Public Housing Law, etc.). A 1-1: Most French Elderly want to live and successfully live in their own home. - Some services are available when the housing needs adaptation to possible handicaps ( - When the elderly live in too uncomfortable housing or are isolated they can access a social housing Foyer-logement rental housing for older people including several independent quarters (with kitchen and bathroom) associated with optional services (meals, meeting rooms ). Elderly with low income can benefit of house benefit (allocation logement 1

2 social). - Q1-2: In the residence and facilities mentioned in Q1-1, what services are provided to the residents? A1-2 : At social housing for older people as well as in their own homes, the elderly can benefit from home care services including nursing, support in daily living,( personal care, meals in wheels ), medical care, rehabilitation care etc.. ers-a-domicile-ssiad/3 2. Long-term care system for community-residing older people (1) Recipients of long-term care services Q2-1: Please provide the definition of service recipients and detailed eligibility criteria to receive services under the long-term care system. Please attach any documents that explain the criteria and/or assessment tools to determine the eligibility. A2-1 The elderly who require care on a continual and steady basis for the whole or a part of basic movement in daily activities due to physical or mental problems. The elderly who require support to reduce or prevent aggravation of needs for care (frail elderly). The elderly fill a APA (Personalized Allocation for autonomy) request which includes : - A care plan according to the needs of the patient, - A benefit according to the income. - The needs are evaluated using a 6 degree scale called Grille AGGIR. In 2002 was created an allowance for the elderly needing care called APA (Allocation Personnalisée à l Autonomie). It is financed by the local councils and a new agency called CNSA (Caisse Nationale de Solidarité pour l autonomie).the CNSA is not financed by general taxation but by an extra work day for all employees, a 0.3% tax for the employers and the health system for the medical expenditures. This allowance is mainly given to dependant elderly but its objective is also to prevent the loss of autonomy of frail elderly. More than one million dependant people receive this allowance, mainly mildly impaired elderly and 61% of the beneficiaries live at home. A scale called GIR defines the degree of loss of autonomy. Frailty corresponds to the GIR 4 (very mildly impaired). The GIR 4 frail elderly represent 44% of the beneficiaries and 80% live at home. Q2-2: By whom and how are the eligible service recipients determined? A2-2: Local municipalities ( Conseils Généraux ) determine the eligible recipients. A municipal investigation team visits the applicant to assess his/her physical and mental conditions - Home care services will be provided according to the person needs - The APA benefit (see above ref.) will be given according to the income of the person Q2-3: Are there different eligibility categories, depending on which the amount and the kind of available services differ? A2-3: All elderly needing care are eligible. 2

3 The level of care is determined by the scale AGGIR. Scale GIR 1 to 6 -level 1: bedridden patient needing 24h/day care or end of life period -level 2: bedridden or able to sit needing assistance for most daily activities with mental impairment - level 3 : No mental impairment but needing assistance for personal care and activities -level 4: needing assistance for the transfers and some help for personal care and meals -level 5: partial assistance for meals, cleaning, laundry etc - level 6 : autonomous elderly The level 1 to 4 are eligible for the APA but the amount of the allowance depends on the income of the person. The level 5 and 6 can benefit from a home help. (2) Contents and provision of long-term care services Q2-4: What services are available under the long-term care system? Also, are the following services provided under the long-term care system (home care services) or by other systems and/or voluntary activities? (1) cleaning, (2) washing, (3) cooking, (4) shopping, (5) taking out the trash, (6) watching over, (7) accompanying to hospital, (8) accompanying when going out. A2-4 All the services listed above are available. In addition, the following services may be provided: - Visiting services: Workers visit the recipient s home to provide direct care, nursing care, rehabilitation and housework. - Day-care type services: Service recipients can go to a place (e.g. day care center) to receive care and rehabilitation. Some provide services specifically for people with dementia. - Short-stay: Service recipients can stay at a facility for a short period of time, receiving direct care, nursing care and rehabilitation. - Integrated services: Combination of visiting, day-care type and short-stay services in an integrated manner, provided by one service provider. Also, the services (1) to (5) can be provided according to the care plan established by the AGGIR visiting team. The services (6) to (8) are not covered by the home care services and therefore depend on voluntary support for the elderly. Q2-5: Are day care services available only for the care purposes? Or are there also services in which older people can gather to promote communication among themselves and social participation? A2-5: The objectives of the day care centers are to ensure both: - Rehabilitation, medical care, nursing. - Social interaction, recreational activities, physical and leisure activities The fee of a day care center is paid by both the social security system and the person Q2-6: Who/What organizations are the major providers of long-term care? A2-6 : Public organizations, mainly hospitals provide long term care. However, Private organizations (non for profit or for profit) provide home services and nursing home services. 3

4 The elderly in the private sector can obtain the APA. Who are the key players for dependant older persons living at home? - GPs, Specialists, Hospital-Community network. - Family care givers and Carers Support (Psychologist, Patient groups, - Care centres, Day hospital, Night watch, Volunteers) Home nursing care - Domiciliary care: Home help, meals on wheels, monitoring, community alarm system. The dependant elderly is at the centre of a network including all these professionals and structures. Public expenses for long term care either at home or in nursing homes are financed by the Health system, the local councils, the new agency CNSA, Social aid, housing benefit and tax exemption. The CNSA (Caisse Nationale de solidarité pour l autonomie) is not financed by general taxation but by an extra work day for all employees, a 0.3% tax for the employers and the health system for the medical expenditures. Q2-7: Are nursing and direct care separated as the long-term care service menu? Are qualifications for direct care staff and nursing staff separated or under the same qualification system? A2-7 The qualification of each professional (nurses, physiotherapists, psychologists etc ) is specific and needs training and a diploma delivered by the state. The home help and nurses help can benefit from the Recognition of Prior informal or work-based Learning which is an important step to the diploma. Q2-8: How is the cost for individual long-term care services determined (based on what standard)? How is such a standard set? A2-8 The cost of long-term care services is determined based on the standards set by the national government. Such standards are ruled in detail based on the kind of services The number of service hours is determined by the care plan established by the visiting AGGIR team. The cost for an individual who uses long-term care services is calculated based on these standards. The APA covers totally or partially the cost of the services determined by the care plan according to the income of the patient. These standards are revised periodically by the government. rnant_les_aides_techniques.pdf Q2-9: When providing long-term care services, do various professionals (e.g. direct care workers, nurses, rehab staff) form a team and visit recipients? Or do they visit the recipients separately? A2-9 Most of time they visit recipients separately. 6 Service coordination Q2-10: Who are the key players in coordinating services for individuals (e.g. public workers, care managers, etc.)? If available, please provide the document forms which are used to manage the benefits/services. 4

5 A2-10The AGGIR team evaluates the needs of the recipient and establishes a care plan including the number of needed professionals and the number of service hours. They do not coordinate services among the different providers and they do not assist in contracting. The urgent need for such coordination, particularly for mentally impaired patients has been tackled by the 3 rd national Alzheimer s Plan. Plan_Alzheimer_ pdf A number of case managers have been trained and hired to help the most difficult cases. A new coordination structure called MAIA is being experimented in most parts of France to facilitate the integration of all the services offered to the Alzheimer s patients pdf **************************************************************************************** *********** Q2-11: Do service coordinators arrange services only within the long-term care system? Or do they also coordinate services under other systems (e.g. medical care, voluntary support, etc.)? A2-11 They intend to coordinate all services but not the volontary support. Q2-12: How are the services coordinated? A2-12- When a care manager is appointed, she/he hires the different services requested by the care plan established by the APA team. When there is no care manager, the family has to contact all the professionals. The coordination between the staff members of different organizations is done on a voluntary basis. The present experimentation of the MAIA tends to integrate and coordinate all the services Home-based long-term care and medical care systems Q3-1: In your country, how is home-based medical care perceived (e.g. its purposes, roles, etc.)? A3-1 Most French elderly prefer to live as long as possible in their own home even when they need long term care. The development of the home care services allow them to stay at home unless they need a presence 24h/24.The system cannot provide that. In that case most elderly have to be institutionalized. Only the person who can afford to pay staff 24h per day out of their own pocket can live at home in these conditions. When an acute illness occurs, care is provided by the general practitioner in association with the home care services. When the case is too severe, the patient is sent to an hospital emergency room, then at best to an acute geriatric unit. If necessary the patient can be sent to a rehabilitation unit and then back home. Very often the patient becomes more dependant after a severe acute illness (ie, stroke, AMI, hip fracture etc ) and an institutionalization becomes necessary. When a patient strongly wants to return to his home in spite of the need of acute care, he/she can benefit of Home Hospitalization. 5

6 An hospital team visits the patient every day under the supervision of the general practitioner and provide the necessary technical care (IV drip, pressure sore cares etc ). The home hospitalization is financed by the health System.But a member of the family or a paid staff member must be present for the rest of the day if the patient is bed ridden. Not all families can afford that. Q3-2: Are home-based long-term care and medical care provided in collaborative ways? Q3-2 Most of time collaboration is established on a voluntary basis. However, through the MAIA system the current government policy is to provide various social security programs to older people in an integrated manner. II. Support outside of the medical and long-term care systems: Key players 1. Support activities: Background Q4-1: In your country, who/which organizations provide the services which tend not to be covered (or may be covered but not sufficiently) by medical and long-term care systems (e.g. watching over the elderly, taking out the trash, changing a light bulb, accompanying to hospital, social interaction, etc.)? Are there any laws regarding establishment and activities of such organizations? A4-1 There is no law regarding establishment and activities of such organizations. Sometime, the small local municipalities hire a multi-task professional to help the elderly accomplish these tasks. The home help paid by the municipalities can also collaborate to provide these services. Social interactions are mainly provided by volunteer organizations) Q4-2: In your country, are there any ideological and customary aspects that may influence such voluntary support activities for older people? A4-2 Support activities for older people are mainly provided by volunteer associations. Some of them are driven by religious inspiration (ie Secours catholique, or Union one (Secours Populaire Français, ). Most of them are independent of any ideology (ie Petits Frères des Pauvres, w ) Most of them do not take care only of frail elderly. Q4-3: In your country, are there currently any challenges regarding relationships within families and with neighbors in terms of daily support for older people? A4-3 The long term care services certainly help the frail and/or dependent elderly. Nevertheless most of the care (80%) relies on the family, particularly spouses or children (mainly daughters).this may lead to health problems for the family helper and even burn out. This question has been tackled by the 3 rd Alzheimer s plan, Measures have been taken to reinforce the respite care (respite hospitalization, day care centers, home help, systematic medical consultation for the 6

7 member of the family who takes care of a dependent loved one). In most cases, neighbors in big cities are not involved at all in the care of the elderly at home. The situation seems a bit different in small villages where a neighbor solidarity seems to persist. 2. Support activities: Current conditions Q5-1: Please provide some examples of voluntary activities to support older people A5-1 Free transportation to go to the bank, to church, to the market etc Organization of cultural activities (going to concert, art exhibition ), library on wheels, Home or institution visits, computer assistance, holidays organizations etc.. Q5-2: Who are the recipients of such voluntary support A5-2 Isolated frail elderly either at home or in institutions Q5-3: Are there any division of roles between voluntary support for older people and services under medical/long-term care systems? Is there any coordination between them? A5-3 They do not do the same tasks. Voluntary services are done under the supervision of the staff in institutions and/or hospitals. At home, the person and the family are the only representatives. Q5-4: Do governments provide financial assistance for voluntary support activities for older people? A5-4 As a whole, the answer is no. However some big volunteer organization receive some subsidies Q5-5: Are voluntary support activities for older people provided based on the goal to support their independence? A5-5 The main goal is to fight loneliness, to give emotional support, joy of life and help to live a happy life in spite of the handicap and /or isolation. By doing that they certainly contribute to support their independence. Their credo is to never do what the elderly can do by themselves 3. Voluntary activities: Key players Q5-6: Who are the key players to provide voluntary support for older people? A5-6 The volunteer associations are gathered in a big network called France-Benevolat ( There is a high number of them with different goals and organisations: some examples : Secours Catholique, Habitat et Humanisme, les petits frères des pauvres, Croix Rouge Française, Armée du salut, Secours Populaire Français, ADMR, Les Blouses Roses Some people provide friendship and care to the elderly they know without belonging to an association. Q5-7: Do governments implement any policies to increase the number of key players in such voluntary activities? 7

8 A5-7 The government subsidizes some associations but very often, because of the economic crisis, the subsidy decreases leading to tremendous difficulties to the association functioning. III. Care prevention 1. Care prevention system Q6-1: In Japan, insurers of medical insurance and municipalities provide preventive care for life-style related diseases (e.g. cancer, stroke). Meanwhile, there is also an idea of care prevention so that people would not become in need of care by maintaining physical and cognitive functioning. Such services are provided by local municipalities under the national long-term care insurance system. In your country, are there any such care prevention programs? If so, under what law do such programs exist? A6-1: The health system is more oriented toward acute care than toward prevention. Nevertheless, In France, it is possible to identify three categories of elderly: The elderly needing long term care (7 to 10%), the frail elderly (10%) and the healthy independent elderly (82 to 83%). Preventive measures are indispensable to prevent frail elderly to becoming dependent when a stress (acute illness, widowhood ) occurs. In order to screen for frailty, in the framework of the Plan Solidarité Grand Age a systematic preventive consultation at 70years old, given by the general practitioner, has been experimented. This was a failure because the GPs considered that it was impossible for them to run such a big evaluation. Now frailty consultations are established in the Hospital Geriatric Centres, mainly day hospitals.when frailty is diagnosed, rehabilitation care tries to reverse the process. One of the major objectives of the care for the frail elderly is to prevent the conversion of frailty to an advanced stage of loss of autonomy. The structure of care must face this challenge with two key objectives: the promotion of health as a state of physical, social and mental well-being and the promotion of activity. The health and care system must first promote healthy life style: - Education throughout life and health literacy - Healthy nutrition - Moderate and prolonged physical activity - Intellectual activity and social interactions - Prolonged professional activity and leisure activity - Personal commitment and responsibility The key players for prevention as a lifelong perspective are: GPs and paediatricians, Hospitals clinics, Schools, Universities, Mass media and the Work places. Q6-2 (if answered Yes in Q6-1): Who/what organizations are major providers of care prevention? How are these services financed? A6-2 For the frail elderly, the providers are the geriatric departments of hospitals (mainly academic hospitals), the GPs and some retirement insurances. Care prevention is financed by the health insurance of the Social Security System. 8

9 Q6-3 (if answered Yes in Q6-1): Who are the recipients of care prevention programs? How are these people found/reached out? What services are provided? A6-3: The frail elderly when a systematic screening is proposed on a voluntary basis in Geriatric Hospitals. But all citizens should consider prevention as a lifelong perspective and adopt healthy lifestyles. For the frail elderly, the hospital provides, management of risk factors, rehabilitation, nutrition counseling, physiotherapy for sarcopenia and equilibrium impairment, cognitive evaluation etc Q6-4 (if answered No in Q6-1): Are there any programs that are not primarily aimed at care prevention but considered effective (can be indirectly) in maintaining and/or promoting health? If so, please provide information on their (1) major providers, (2) financial sources, (3) service recipients and how these people are found, and (4) contents of the services. IV. Elder care, voluntary support for older people and care prevention: Challenges and direction Q7-1: Are there any challenges in administration of the systems? If so, what are they? Has there been (or will there be) any measures taken to overcome such challenges? A7-1The health System in France is very comprehensive and generous for acute care and rehabilitation care. Everyone is covered by the system but it is going to be difficult to sustain the cost and reductions are foreseen but not yet installed. The long term care in institutions is very costly for the patient and the families: The institution fees are divided in 3 parts: the dependency costs taken in charge by the APA, the medical costs paid by the health system, the food and accommodation costs (1500 to 4000 per month) ensured by the person and/or his/her family. This last part poses difficult problems to patients and families because this amount is higher than the average retirement pension in France (1200 per month). A law is in preparation to address this issue. There have been several governmental plans since 2001: Plan «Vieillissement et solidarités» Plan «Solidarité-Grand Age», voted in 2006, confirmed in 2007 until 2012: the annual number of new intitution beds progressively increases in order to maintain the objective of 467 places/1000 inhabitants of Three «Alzheimer» plans : in 2001, 2004 and 2008, the last one covers the period until html, Law «Handicap» 11/02/2005 : a tool for a decentralized management at the departement level - (Priac) : «programmes interdépartementaux d accompagnement des handicaps et de la perte d autonomie» All these plans were important tools to improve the integrated care for the elderly in France. They allowed an important development of Geriatrics, and in particular of Academic Geriatrics. The number of professors of 9

10 geriatrics was doubled. Q7-2: Have there been any amendments (or is there any plan to make amendments) in the long-term care system to further limit the eligible people (i.e. those with mild impairments can no longer receive services) in order to reduce the financial burden on the long-term care system? A7-2 No. the long term care system will not limit the eligible people but the government tries to find other sources of financing the system (taxes? premiums?); A law will decide the new process. Q7-3: Are there any challenges regarding service contents? If so, what are they? Has there been (or will there be) any measures taken to overcome such challenges? A7-3The challenges are: The improvement in quality of the services A better coordination and integration A financial help for the institutionalized elderly patients A strong emphasis on Prevention. Payment We have prepared 75,000 Japanese yen for the request to you. Thank you very much for your cooperation. Shinichi Ogami, Project Manager Mamiko Kashima, Chief, Administrative Section International Longevity Center-Japan 8th fl, 33 Mori-Building, Toranomon, Minato-ku, Tokyo , Japan ilcjapan@mba.sphere.ne.jp URL: 10