For the most part long-term care (LTC) has not been among the main concerns of health policy makers. Cost-containment issues, perhaps an excessive focus on specialized medical care, and the fact that families have always been and remain the major providers of LTC have contributed to a slow development of public long-term care services (WHO, 2000). However, demographic transitions are resulting in dramatic changes in health needs around the world. Care for the chronically ill and for those with disabilities and a steep rise in the numbers of elderly are a growing challenge in practically all societies.

Definition And The Target Population In Need Of LTC

LTC includes activities undertaken for persons who are not fully capable of self-care on a long-term basis by informal caregivers (family and friends), formal caregivers, and volunteers.

The target population includes those who suffer from any kind of physical or mental disability requiring assistance with the activities of daily living.

LTC encompasses a broad array of services such as personal care and assistive devices that are designed to minimize, restore, or compensate for the loss of independent physical or mental functioning.

Disability also results in difficulties in accessing health care and in complying with health-care regimes, and it affects the ability of the individual to maintain a healthy lifestyle to prevent deterioration in functional status. Therefore, LTC includes efforts to ensure access to acute, chronic care and rehabilitation services and to prevent deterioration of the functional capacity of the disabled (such as, for example, preventing bedsores and preventing depression). The central role of the family in providing LTC requires significant efforts to inform and guide the families (WHO, 2002).

The Uniqueness Of Long-Term Care

Whereas more traditional health care is concerned with cure and recovery, LTC attempts mainly to contribute to alleviating suffering, maintaining the best possible quality of life, reducing discomfort, improving the limitations caused by diseases and disability, and maintaining the best possible levels of functioning (Larizgoitia, 2003).

An additional significant difference between LTC and the acute sector is that the provision of LTC is heavily based on unspecialized, labor-intensive, and relatively unskilled providers. Professionals (physicians, nurses, social workers, and others) are involved to a degree that is significantly less than that in acute care. LTC allows lay volunteers, in particular the family, to take part in its implementation. Indeed, in most countries, care is still predominantly a family task – mainly performed by women. Despite the increasing role of the government, nongovernmental organizations (NGOs) and the private (for-profit) sectors in service provision, informal care has remained the dominant form of care (Wiener, 2003). However, the increasing proportion of women in the labor market and the declining ratio between those needing care and those who are potential caregivers are raising questions of whether informal care will maintain its predominant role.

Links between LTC and acute health systems can encourage continuity of care. These connections may reduce acute hospital stays and create an incentive to provide adequate home health care and rehabilitation, especially if the health-care providers can enjoy the benefits of reduced institutional long-term care. At the same time, there are concerns about linking LTC with primary health care that generate interest in independent models of LTC. The impact of integration on incentives to provide adequate LTC are neither certain nor easily predictable. Within health systems, there is concern for a preference toward addressing acute care needs over those that are more chronic or function related. A related concern is for the overmedicalization of LTC services if provided in a medically oriented system and the consequences of higher costs as a result. In addition, in the United States, for example, the integration of acute and LTC has depended on integrating medical and social care funding streams. There is a belief that such integrated funding is the basis for program integration. However, although such linkage is necessary, it is insufficient. Successful integration requires a major reorganization of the programmatic infrastructure, which can then be reinforced with funding approaches (Kane, 2003).

In general, most developed countries have not fully integrated LTC within the acute system. Some countries have made an effort to partially integrate components of LTC (e.g., Germany), where it is administratively but not financially integrated. Other countries have implemented demonstration projects that fully integrate acute and LTC such as the PACE program in the United States and the SIPA program in Quebec (Be´land et al., 2006).

The PACE – program for all-inclusive care of the elderly – was implemented experimentally in one neighborhood in San Francisco in the 1970s and has been expanded to some 36 locations throughout the United States. The model enables the resources for acute and long-term care to be pooled. Disabled elderly who join the program receive a variety of services under one roof. Those eligible for the program are disabled elderly who are eligible to enter long-term care facilities from Medicaid, but who remain in their homes. The program is funded on a capitation basis by Medicare and Medicaid.

SIPA – French acronym for system of integrated care for older persons – is an integrated system of social, medical, and short and long-term hospital services offered in both the community and institutions to vulnerable elderly persons. It has been implemented in Canada. Its distinguishing features are community-based multidisciplinary teams with full clinical responsibility for delivering integrated care through the provision of community health and social services and the coordination of hospital and nursing home care; all within a publicly managed and funded system.

In the absence of integrated systems, many countries have been experimenting with various coordinating mechanisms such as care management.

Conclusions

Care for people with disabilities is a major challenge in industrialized as well as in developing countries. We have shown that although almost all industrialized countries offer a broad package of services, their level and mix vary among countries. In some areas there seems to be more convergence, whereas in others, policies have taken a different route and differ on principles of targeting, entitlement, and finance. There is much to be learned from the experience of industrialized countries in defining the range of options and in learning from some of the disadvantages and advantages of these systems. Unfortunately, the ability to learn from the experience is limited by the lack of adequate systems for monitoring outcomes and evaluating implementation, as well as in difficulty in ‘comparing apples and oranges.’ As LTC programs continue to develop, it is hoped that more attention will be given to systematic and comparative evaluations.

Bibliography:

1. Be´ land F, Bergman H, Lebel L, et al. (2006) Integrated services for frail elders (SIPA): A trial of a model for Canada. Canadian Journal of Aging 25(1): 25–42.
2. Berg K and Mor V (2001) Long term care assessment. In: Maddox (ed.) The Encyclopedia of Aging, 3rd ed., pp. 631–633. New York: Springer.