HOME CARE ARRANGEMENTS IN EUROPE

HOME CARE ARRANGEMENTS IN EUROPE Workshop: Social Experimentation to Develop Innovative Home Care Solutions September 12 th 2011 Brussels http://www.cosmosmagazine.com/files/imagecache/news/files/news/old_090210.jpg Juliane Steinberg Rostock Center for the Study of Demographic Change

EU-DemoNet REPORT (2010) HOME CARE ARRANGEMENTS IN EUROPE - DETERMINANTS AND QUALITY OF LIFE by Gabriele Doblhammer, Juliane Steinberg, Daniel Kreft & Uta Ziegler 2

CONTENT DEMOGRAPHIC BACKGROUND THEORY - CARE REGIMES ANALYSIS: DETERMINANTS OF HOME CARE ARRANGEMENTS DATA AND METHOD FAMILY CHARACTERISTICS HEALTH FACTORS ANALYSIS: DETERMINANTS OF QUALITY OF LIFE 3

AGEING OF POPULATIONS Oldest age at which at least 50% of a birth cohort is still alive in eight countries 2000 2001 2002 2003 2004 2005 2006 2007 Canada 102 102 103 103 103 104 104 104 Denmark 99 99 100 100 101 101 101 101 France 102 102 103 103 103 104 104 104 Germany 99 100 100 100 101 101 101 102 Italy 102 102 102 103 103 103 104 104 Japan 104 105 105 105 106 106 106 107 UK 100 101 101 101 102 102 103 103 USA 101 102 102 103 103 103 104 104 Source: Doblhammer et al. 2009: Ageing populations: The challenges ahead, The Lancet, 374 (9696). 4

The proportions of the old and oldest old in Europe is growing! http://www.fotocommunity.de/pc/pc/cat/4743/display/25544691 That is probably accompanied by an increasing number of dependent persons; since age is the strongest risk factor for diseases and, hence, the occurrence of need for long-term care! 5

HEALTH OF AN AGEING POPULATION HEALTHY STATE PATHOLOGY IMPAIRMENTS FUNCTIONAL LIMITATIONS Diagnosis of a disease, injury, congenital or developed condition Dysfunction or structural abnormality in specific body systems: musculoskeletal, cardiovascular, neurological, metabolistic, etc. Instrumental Activities of Daily Living Restrictions in basic physical and mental actions: reach, ambulate, stoop, climb stairs, read normal print, speak clearly... http://web.ard.de/userbox2/files/tell-avision/resized/7/f/d/a/255-large.jpg Activities of Daily Living DISABILITY Difficulties doing activities of every day life (biological version) Source: Following Verbrugge, Jette 2004: The disablement process. DEATH 6

HEALTH OF AN AGEING POPULATION Activities of Daily Living DISABILITY Difficulties doing activities of every day life (biological version) Necessary to survive Basis ADLs (in a restricted version) (Katz, 1963) - Ability to perform personal care activities - Measures severe disability Based on biologic functions: - Bathing - Dressing - Going to the bathroom (toilet) - Transferring (received help or did not get out of bed) -Eating - Continence 7

HEALTH OF AN AGEING POPULATION There are increases in morbididy Disease & condition cardiovascular diseases +/- hypertension + arthritis + diabetes + pain + psychological distress + general fatigue/sleepiness, + dizziness + asthma - osteoarthritis - low back complaints - musculoskeletal pain/problems + depression - dementia +/- Change in prevalences and simultaneously reductions in functional limitations and disabilities! Age-adjusted self-care disability Europe (1980 to 2000) Men aged 70+ ADL-prevalences: Women aged 70+ ADL-prevalences BUT. -2.6% per year -7.2% per year Source: Christensen, Doblhammer, Rau & Vaupel: Lancet (2009) Äijänseppä, Notkola, Tijhuis, van Staveren, Kromhout, Nissinen (2005). 8

Number of men (75+) in need of care, 2000 to 2030, Index (Constant Health Scenario) Finland increase by 180% 250 225 200 175 150 125 100 Portugal increase by 48% Belgium Finland France Germany Italy Netherlands Portugal UK Czech Republic 75 2000 2005 2010 2015 2020 2025 2030 Source: ECHP, FELICIE, interim report wp7. 9

Number of women in need of care 2000 to 2030, Index, (Constant Health Scenario) 250 225 200 175 150 125 100 75 2000 Netherlands increase by 79% Germany Increase by 39% 2005 2010 2015 2020 2025 2030 Belgium Finland France Germany Italy Netherlands Portugal UK Czech Republic Source: ECHP, FELICIE, interim report wp7. 10

Elderly in need of regular help should have the opportunity to stay at home (European Commission 2007). 11

ATTITUDES TOWARDS CARE Live with one child Child should reg. visit & provide care Public or private service providers Nursing home INFORMAL CARE 54% FORMAL CARE 27% INSTITUTIONAL CARE 10% Others Source: Eurobarometer, 2007. 0 5 10 15 20 25 30 35 In percent Imagine an elderly father or mother who lives alone and can no longer manage to live without regular help because of her or his physical or mental health condition? In your opinion, what would be the first option for people in this situation? 12

Live with one child Public or private service providers A child should reg. visit & provide care They should move to a nursing home It depends/ None of these/ DK EU27 DENMARK SWEDEN FINLAND NETHERLANDS FRANCE AUSTRIA BELGIUM GERMANY GREECE SPAIN ITALY PORTUGAL POLAND BULGARIA ROMANIA CZECH REPUBLIC ESTONIA LATVIA 30 7 4 7 4 18 17 17 25 49 39 28 44 59 52 56 36 30 42 27 58 60 51 52 46 28 38 27 11 15 30 20 7 11 10 11 19 11 24 15 13 25 20 18 30 22 30 38 19 22 15 27 28 23 30 31 28 10 14 20 13 18 12 9 19 8 2 12 7 10 3 5 5 13 12 9 9 6 3 4 6 6 16 4 10 0 15 13 11 4 4 6 10 8 10 Source: Extract form the Eurobarometer 2007. 13

- THEORETICAL BACKGROUND - 14

CYCLE OF INFLUENCES - THE STATE & THE FAMILY WELFARE STATES & CARE REGIMES HISTORICALLY WELFARE STATES GROWN NATURE & CARE OF REGIMES THE FAMILY AVAILABILITY OF CARE RESOURCES CARE REGIMES (Bettio GEOGRAPHY & Plantenga 2004) OF FAMILY TIES (Reher 1998) Cluster I - Southern countries Informal Northern care dominates countries Cluster Independency II - Northern and countries Formal autonomy care dominates less geographical family ties, Cluster voluntary III - Netherlands relationships and UK Formal care established with informal Southern care being countries still important Cluster Familistic IV Germany cultureand Austria More informal Individual care utility that is and supported family by utility formal equivalent care arrangements Cluster V France and Belgium Formal care highly developed 15

CYCLE OF INFLUENCES - THE STATE & THE FAMILY AVAILABILITY OF CARE RESOURCES AVAILABILITY WELFARE STATES OF CARE & CARE RESOURCES REGIMES AVAILABILITY OF CARE RESOURCES Informal (family) Formal (professionals) Support by the state or community HISTORICALLY GROWN NATURE OF THE FAMILY 16

Familial Resources for care giving in Germany until 2050 Potential care givers Men 40 to 64 Employed Not employed Total 2006 2050 2050/2006 Change In Million in Million 12.4 02.2 14.6 11.1 01.5 12.6-1.3-0.7-2.0 Women 40 to 64 Employed Not employed Total 09.9 04.4 14.3 08.7 03.0 11.7-1.2-1.4-2.6 Men 65 to 79 Living with partner And not in need of care Women 65 to 79 Living with partner And not in need of care 03.9 03.3 03.2 02.7 04.3 03.7 04.3 03.6 0.5 0.4 1.2 0.9 Source: Schulz, 2010 17

PROJECTED SIZE OF THE CARE WORKFORCE, 2011 to 2031 Assumption: current inflow and outflow rates prevail Source: ENEPRI Research Report, Geerts, J. 2011. 18

RATES OF INSTITUTIONALISED PERSONS (POPULATION 65+) 10.0 9.0 8.0 8.8 8.7 In percent 7.0 6.0 5.0 4.0 3.0 2.0 7.4 6.8 6.5 6.4 4.9 3.9 2.9 1.0 0.0 Netherlands Sweden Denmark Germany France Belgium Austria Italy Spain Source: European Commission (2006) 19

CHARACTERISTICS, RESOURCES & NEEDS Predisposing characteristics Demographics & social structure Enabling resources Personal & family & community Needs Perceived & evaluated health Use of health services Source: Anderson (1995) (HOME) CARE ARRANGEMENT 20

DATA AND METHODS Survey of Health, Ageing and Retirement in Europe (SHARE) Wave 2 (2007) Population included (20.037 respondents N) Nine countries: Austria, Germany, Belgium,France, Italy, Spain, Sweden, Denmark and the Netherlands Aged 50+ years Living in private households Northern Europe (N=7.018) Central Europe (N = 8.507) Southern Europe (N = 4.512) 21

THREE QUESTIONS & THREE MODELS I. FAMILY MODEL How do family characteristics matter for the choice of a specific home care arrangement in general and in different European regions? II. HEALTH MODEL How do health factors matter for the home care arrangement chosen in general and in different regions of Europe? III. QoL MODEL How do home care arrangements and specific health parameters determine dependent people s quality of life? 22

DATA AND METHODS HOME CARE ARRANGEMENTS No care arrangement, no Limitations in Activities of Daily Living (ADL) No care arrangement, Limitations in Activities of Daily Living (ADL) Formal and mixed care Informal care CARE means PERSONAL CARE Including help with activities (e.g.: dressing, bathing / showering, eating, getting in or out of bed...) But not help with domestic tasks or paper work. 23

- DATA & METHODS - FAMILY MODEL

FAMILY MODEL DATA & METHODS I. Living Arrangement With partner/ without partner II. Geographical distance to the closest living child Daughter > 5 kms/son > 5 kms Daughter < 5 kms/son < 5 kms Daughter/Son in the same household III. Occupation of the closest living child Full-time/Part-time/Not employed/retired Multinomial logistic regression Controlled for age, education, country, gender, area of living Welfare state regions specific analyses??? H O M E C A R E A R R A N G E M E N T 25

- RESULTS - FAMILY MODEL 26

THE DISTRIBUTION OF TYPES OF CARE In percent 100 90 80 70 60 50 40 30 20 10 0 85.6 82.9 90.3 83.4 5.3 5.9 7.3 4.7 4.2 3.7 5 4.6 2.6 1.8 ALL COUNTRIES CENTRAL EUROPE NORTHERN EUROPE No care, without ADL limitations Formal and mixed care Informal care 2.8 9.1 SOUTHERN EUROPE No care, with ADL limitations 27

LIVING ARRANGEMENT 2 with Partner/Spouse (REF) 1.7*** 1.7*** without Partner/Spouse Odds Ratios 1 0.75*** 0 No care, with ADL limitations Formal and mixed care Informal care *** Sig > 0.01 ** Sig > 0.05 * Sig > 0.1 28

GEOGRAPHICAL PROXIMITY 2 Daughter > 5 kms (REF) Daughter < 5 kms Daughter in same household Son > 5 kms 1.74*** 1.68*** Odds Ratios 1 Son < 5 kms Son in same household 0.61*** 0.77* 1.33** 0 No care, with ADL limitations Formal and mixed care Informal care *** Sig > 0.01 ** Sig > 0.05 * Sig > 0.1 29

OCCUPATION OF THE CLOSEST LIVING CHILD 2 1.76*** 1.62*** 1.36*** Odds Ratios 1 0 Full-time (REF) Part-time Not employed Retired No care, with ADL limitations Formal and mixed care Informal care *** Sig > 0.01 ** Sig > 0.05 * Sig > 0.1 30

SUMMARY RESULTS - FAMILY MODEL LIVING ARRANGEMENTS North: partner is decisive!!! South: no significant results - partners not important? Central: a co-living partner important GEOGRAPHICAL DISTANCE TO CLOSEST LIVING CHILD North: no significant results South: risk of informal care higher if daughter lives in the same HH Central: only significant results with higher risks of informal care if child lives near by, slightly higher if it is a daughter OCCUPATION OF CLOSTEST LIVING CHILD North: risk of formal care is somehow higher if child is retired South: if child works part-time or is not employed, risk of receiving no care increases significantly (instable circumstances?) Central: risk of formal care higher if child is retired (or not employed) 31

- DATA & METHODS - HEALTH MODEL 32

HEALTH MODEL - DATA I. PHYSICAL HEALTH Limitations No, moderate, severe Stroke No/Yes Cancer No/Yes Heart Attack No/Yes II. MENTAL HEALTH Cognitive Impairments No/mild/moderate/Severe Depression No/Yes?????? H O M E C A R E A R R A N G E M E N T 33

-RESULTS - HEALTH MODEL 34

PHYSICAL HEALTH - Activity limitations 16 14 12 No moderate severe 10.6*** 13.3*** 14.8*** Odds Ratios 10 8 6 4 2 3.8*** 2.5*** 3.3*** 0 No Care, with ALD limitations Formal & mixed care Informal care *** Sig > 0.01 ** Sig > 0.05 * Sig > 0.1 35

PHYSICAL HEALTH Stroke Cancer Heart Attack 2.69*** 2.4*** 1.73*** 3 1.3*** 2.5 2 1.5 1.21*** 1.35*** 1 Odds Ratios 3 2.5 2 1.5 1 2.52*** 1.83*** 1.08*** Odds Ratios 3 2.5 2 1.5 1 0.5 0.5 0.5 0 0 0 36 Odds Ratios Informal care Formal & mixed care No Care, with ALD limitations Informal care Formal & mixed care No Care, with ALD limitations Informal care Formal & mixed care No Care, with ALD limitations *** Sig > 0.01 ** Sig > 0.05 * Sig > 0.1

MENTAL HEALTH - Depression 2.5 2 2.0*** 2.0*** Odds ratios 1.5 1 0.5 1.5*** 0 No Care but limitations Formal & Mixed Care Informal Care *** Sig > 0.01 ** Sig > 0.05 * Sig > 0.1 37

MENTAL HEALTH - Cognitive Impairments Odds ratios 3 2.5 2 1.5 1 2.45*** 1.9*** 1.5*** 1.6*** no 1.6*** 1.4*** mild 1.3** 1.3** 1.2* moderate severe 0.5 0 No Care, but limitations Formal & Mixed Care Informal Care *** Sig > 0.01 ** Sig > 0.05 * Sig > 0.1 38

RESULTS - HEALTH MODEL REGIONAL PARTICULARITIES Results are quite similar for all three regions. Noticeable differences are: PHYSICAL HEALTH Highest risk of receiving formal and mixed care in Southern Europe, especially for stroke patients surprising! explanation: lack of institutions? http://notjustaride.com MENTAL HEALTH North: risk of informal care is not at all significantly influenced Central: highest increase in the risk of informal care http://www.caregiverstrainingvideos.com South: severely cognitive impaired persons show higher risks of all types of care 39

- DATA & METHODS - QUALITY OF LIFE MODEL 40

QUALITY OF LIFE MODEL DATA & METHODS CASP-12 Range form 12 to 48 points Q U A L I T Y? SOCIO-DEMOGRAPHICS HEALTH Cut-off point: 34 Binary Logistic Regression O F L I F E CARE 41

-RESULTS - QUALITY OF LIFE MODEL 42

Distribution of QoL-Index over population Central Europe Mean points: 37.3 Northern Europe Mean points: 39.5 Southern Europe Mean points: 33.8 Selection effect? 43

FACTORS ASSOCIATED WITH POOR QUALITY OF LIFE SIGNIFICANT INFLUENCE Higher age Male gender Living without a partner Not participating in social activities Having difficulties to make ends meet Thinking there will be changes leading to worsening of living standard To be in need of care Activity limitations (severity grade) Diagnosis of cancer or stroke Cognitive impairments (severity grade) Having a depression NO SIGNIFICANT INFLUENCE Living area Education Distance to closest living child Heart attack diagnosis Care arrangement does not really matter 44

SUMMARY & POLICY IMPLICATIONS http://us.cdn4.123rf.com/168nwm/karimala/karimala0704/karimala0 70400026/865518-take-away-service-sign-painted-on-a-stucco-wall.jpg FAMILY Old people who live without a partner carry a very high risk of receiving no care although they suffer from limitations also if they have children. Part-time work as an instrument to balance employment and care for dependent elderly seems to be underrepresented. A new caregiver generation (old & retired) needs special and different support than caregiving persons that are still young and have to balance work and care. In Southern Europe formal care has to be established more widely. 45

SUMMARY & POLICY IMPLICATIONS http://us.cdn4.123rf.com/168nwm/karimala/karimala0704/karimala0 70400026/865518-take-away-service-sign-painted-on-a-stucco-wall.jpg HEALTH Formal and mixed care: Cognitive impairments ( Dementia) & physical diseases like strokes, heart attacks or cancer Informal care: Depressions and activity limitations Mild forms of disabilities are rather connected with receiving no care. Southern countries: High formal care use, probably as a substitute for lacking care institutions 46

SUMMARY & POLICY IMPLICATIONS http://us.cdn4.123rf.com/168nwm/karimala/karimala0704/karimala0 70400026/865518-take-away-service-sign-painted-on-a-stucco-wall.jpg QUALITY OF LIFE Quality of life is lowest in Southern and highest in Northern Europe. But people s perception and the institutionalised population have to be kept in mind. It is rather the care need than the type of care that has an impact on the quality of life. 47

THANK YOU FOR YOUR ATTENTION! Juliane Steinberg Rostock Center for the Study of Demographic Change Konrad-Zuse-Straße 1 18057 Rostock E-Mail: steinberg@rostockerzentrum.de www.rostockerzentrum.de www.zdwa.de www.demogr.mpg.de 48

BACK UP 49

Slovenia The institutional care is a form of care with the longest tradition in Slovenia and is the most spread in all Slovenian regions. In the last years many new homes for elderly were open or modernized. In the end of 2007 there were 55 public homes for elderly and 18 private homes for elderly in Slovenia. In public homes there were 12.318 places and in private homes 1.974 places were offered. In the end of 2006 there were 13.816 people older than 65 living in residential homes. According to the Strategy for elderly, the aim is to provide capacities to accept 5% of the population aged 65+ in the homes for elderly this means that there is a lack of 3.200 beds (the capacities cover 4,4% of the population aged 65+). The waiting lists for institutional care do exist on the national level but are unfortunately not updated and not accurate as well as overstrained: they cannot be used for planning and policy making purposes. In many homes the day care centres were opened, which have around 200 places. There is also nine sheltered housing available for more than 300 recipients. In homes for elderly there is more than half of persons aged 80+. Among them there are 86% of women. 50

1998 2000 76 74 72 70 68 66 64 62 Finland Portugal France 51 1992 1994 1996 1986 1988 1990 1984 1982 1980 1978 1974 1976 1972 1970

RESULTS FAMILY MODEL No care, with ADL Formal and mixed care Informal care Age groups 50 to 59 (REF) 1. 1. 1. 60 to 69 1.36 *** 1.19 1.60 *** 70 to 79 2.20 *** 2.19 *** 3.15 *** 80+ 3.81 *** 6.97 *** 8.51 *** Gender Female (REF) 1. 1. 1. Male 0.85 ** 0.81 *** 0.85 ** Country Austria 0.76 * 0.26 *** 1.32 Belgium (REF) 1. 1. 1. Denmark 0.59 *** 0.40 *** 0.70 * France 0.74 ** 1.70 *** 0.77 Germany 0.81 * 0.19 *** 1.39 ** Italy 0.52 *** 0.21 *** 1.56 *** Netherlands 0.49 *** 0.25 *** 0.66 ** Spain 0.51 *** 0.38 *** 1.95 *** Sweden 0.82 * 0.10 *** 0.46 *** Education Low degree (REF) 1. 1. 1. Middle degree 0.68 *** 0.89 0.66 *** High degree 0.45 *** 0.65 *** 0.56 *** Area of living Urban (REF) 1. 1. 1. Rural 1.04 1.08 1.07 Reference group: No care, no limitations in ADLs Valid 20,001, Missing 36, Total 20,037 Results more or less the same when calculated for welfare state regimes The older, the higher the risk Risk for men lower The higher the educational degree, The lower the risk No significant differences 52