Long term care: a complex challenge

Page 27 

Long-term care is a particularly thorny issue for healthcare policymakers because it is so intertwined with other areas of public policy, like housing and social security. Yet it is an increasingly important area of healthcare. Quality indicators can help to achieve improvements.

What exactly is long-term care? The definition given by the Washington DC-based Institute of Medicine in 1986 is a useful start: ¡§a variety of ongoing health and social services provided for individuals who need assistance on a continuing basis because of physical or mental disability. Services can be provided in an institution, the home or community, and include informal services provided by family or friends as well as formal services provided by professionals or agencies¡¨. This definition offers some hints as to why it has been difficult to establish long-term care as an integral part of social security.

The first of these lies in the difficulties encountered when identifying the line between public and private responsibility. It is easy to agree that care for an elderly woman who is alone, impoverished and frail should be a public responsibility. But what if her husband is alive, or there is money in the bank ¡V should she still qualify for public services? And, with most hands-on care for older people in the community provided by family members, would offering formal services cause families to withdraw their care?

Cost is clearly another concern, but formally establishing long-term care as an independent social security programme may not be as costly as some may fear. For a start, compared to healthcare, allocating long-term care resources should be easier because needs do not change as rapidly, and high-cost technology is not as important. Moreover, elderly individuals may prefer the care given by family or friends. Within Japan¡¦s first year of implementing its public long-term care insurance programme, expenditures have been more than 10% lower than projected.

Long-term care poses challenges to policymakers because these services are intertwined with the medical, social and housing sectors, with no clear criteria for delineating the responsibility of each.

With the global ageing of society, a new framework for the sharing of public/private responsibility is clearly needed. Equitable access to a standard package of long-term care services and ensuring their quality will be key responsibilities of government.

Measurement is therefore vital. There are three facets of quality in long-term care: compassionate care as given by family members, comfort as provided in the service industries, and professional competence of the staff. The last aspect has not received the attention it deserves. Those receiving long-term care are not in a state of steady and irreversible decline: the quality of life of individuals and their informal caregivers can be improved, accidents (such as falls) avoided, the rate of decline slowed down and hospitalisation avoided if appropriate care is provided.

To measure the professional competence of care, at least three sets of tools must be available: reliable and valid assessment instruments; a database of the assessment information; and statistical methods for evaluating quality. Regarding the first, the development of the Minimum Data Set in the US, which began to be developed in the 1980s, was a breakthrough towards monitoring and improving the quality of care by obtaining accurate information on the functional, cognitive and emotional status, and the care provided in institutional settings.

It grew out of the need for a uniform, comprehensive assessment system based on strict criteria of reliability and validity. The MDS has been mandated in virtually every nursing home in the US since 1991, and for Ontario¡¦s complex continuing care hospitals/units since 1996. It has been translated and validated in over 20 countries. Moreover, its use has improved the quality of care.

MDS assessments have enabled the development of quality indicators (QIs), like those developed by David Zimmerman et al. (see references), examining items like the incidence of new fractures, behavioural symptoms and cognitive impairment, as well as indicators like dehydration, changes in range of motion, weight loss and use of physical restraint or hypnosis.

A home care version (MDS-HC) and a mental health version (MDS-MH) of the MDS have been developed by interRAI, an international non-profit organisation of researchers and clinicians.

These instruments share core assessment items so that seamless care can be provided regardless of site, while also having specific items tailored to meet specific needs of each individual. For example, MDS-HC has items on informal support, ability to perform household chores, adherence to care programmes, etc.

The statistical methodology has been developed to monitor the quality of nursing homes in a given jurisdiction. However, comparisons among countries are problematic and adjusting for the differences in status of the newly admitted patients and the differences in the rates of decline of those already admitted, are needed. Large databases also have to be built. One study, based on MDS data from Denmark, Italy, Iceland, Japan and the US, shows that no one country excels in all the indicators used, even when assessing subgroups of patients and after adjusting for physical dependency and cognitive impairedness.

Five indicators were used for evaluating quality: falls by patients during the previous month; the presence of pressure ulcers; faecal incontinence, restraint use and social engagement and interaction with others. The US ranked first or second in prevalence of falls and restraint use in all sub-groups assessed, but it presented the lowest percentage of residents with little or no social engagement. Italy has a higher prevalence of faecal incontinence. Iceland and Japan had virtually no pressure ulcers.

More sophisticated quality indicators for institutional care and home care have recently been completed. For home care, the provisional results coming from Ontario Community Care Access Centres (CCACs), which act as single-point entry agencies providing access to community and institutional services, show that there are wide variations in practice patterns. For instance, there is a 2.6-fold difference in the rates of inadequate pain control among existing CCAC clients, with prevalence rates reaching a high of almost 47% of clients.

The methodology for evaluating quality in long-term care is now ready for use. If quality measures could be combined with reimbursement on a case-mix payment basis, the system would be even more effective. For example, the presence of pressure ulcers will lead to a higher payment to a nursing home because of the higher costs of care, but it would also lead to the facility being flagged for poor quality. In other words, using MDS data in such counter-balancing ways would help to provide more accurate assessments. Such systems are used in Ontario and have been validated in Sweden, Japan, UK, Finland and Spain, following the US experience, where Medicare uses it to calculate its per diem rate to nursing homes.

Policymakers have to be aware that the initial investment must be made to adequately train clinicians who will be actually using these instruments and administrators whose job it will be to analyse the databases. Long-term care deserves greater attention and the gap that divides health and human service professionals has yet to be bridged.


• Carpenter, G.I., Hirdes, J.P., Ribbe, M.W., Ikegami, N., Challis, D., Steel, K., Bernabei, R., Fries, B., "Targeting and quality of nursing home care. A five nation study", Aging Clinical and Experimental Research, 11(2), 1999.

• Ikegami, N., "Population ageing and impact on the organisation, delivery and financing of long-term care: An innovative approach from Japan", 2001, http://www.chera.ca/program.html

• Morris, J.N., Murphy, K., Nonemaker, S., "Long Term Care Facility Resident Assessment Instrument (RAI)", Health Care Financing Administration, 1995.

• A Caring World- The New Social Agenda, OECD, 1999.

• Zimmerman, D., Karon, S., Arling, G., Clark, B., Collins, E., Ross, R., Sainfort, F., "The development and testing of nursing home quality indicators", Health Care Financing Review, Vol. 16, 1995.

©OECD Observer No 229, November 2001 

Economic data

GDP growth: +0.7% Q2 2017
Consumer price inflation: 2.2% Aug 2017 annual
Trade: +1.4% exp, +1.7% imp, Q2 2017
Unemployment: 5.8% Aug 2017
Last update: 20 Oct 2017


Stay up-to-date with the latest news from the OECD by signing up for our e-newsletter :

Twitter feed

Suscribe now

<b>Subscribe now!</b>

To receive your exclusive paper editions delivered to you directly

Online edition
Previous editions

Don't miss

  • The annual OECD Eurasia Week takes place in Almaty, Kazakhstan 23-25 October. Writing in The Astana Times, OECD Secretary-General Angel Gurría urges Eurasia countries to stay the course on openness and international integration, which has brought prosperity but also disillusionment, notably regarding inequality. The OECD is working with this key region, and Mr Gurría urges Eurasia to focus on human capital and innovation to enhance productivity and people’s well-being. Read more.
  • When someone asks me to describe an ideal girl, in my head, she is a person who is physically and mentally independent, brave to speak her mind, treated with respect just like she treats others, and inspiring to herself and others. But I know that the reality is still so much different. By Alda, 18, on International Day of the Girl. Read more.
  • Globalisation’s many benefits have been unequally shared, and public policy has struggled to keep up with a rapidly-shifting world. The OECD is working alongside governments and international organisations to help improve and harness the gains while tackling the root causes of inequality, and ensuring a level playing field globally. Please watch.
  • Read some of the insightful remarks made at OECD Forum 2017, held on 6-7 June. OECD Forum kick-started events with a focus on inclusive growth, digitalisation, and trust, under the overall theme of Bridging Divides.
  • Checking out the job situation with the OECD scoreboard of labour market performances: do you want to know how your country compares with neighbours and competitors on income levels or employment?
  • Trade is an important point of focus in today’s international economy. This video presents facts and statistics from OECD’s most recent publications on this topic.
  • How do the largest community of British expats living in Spain feel about Brexit? Britons living in Orihuela Costa, Alicante give their views.
  • Brexit is taking up Europe's energy and focus, according to OECD Secretary-General Angel Gurría. Watch video.
  • OECD Chief Economist Catherine Mann and former Bank of England Governor Mervyn King discuss the economic merits of a US border adjustment tax and the outlook for US economic growth.
  • Africa's cities at the forefront of progress: Africa is urbanising at a historically rapid pace coupled with an unprecedented demographic boom. By 2050, about 56% of Africans are expected to live in cities. This poses major policy challenges, but make no mistake: Africa’s cities and towns are engines of progress that, if harnessed correctly, can fuel the entire continent’s sustainable development.
  • OECD Observer i-Sheet Series: OECD Observer i-Sheets are smart contents pages on major issues and events. Use them to find current or recent articles, video, books and working papers. To browse on paper and read on line, or simply download.
  • How sustainable is the ocean as a source of economic development? The Ocean Economy in 2030 examines the risks and uncertainties surrounding the future development of ocean industries, the innovations required in science and technology to support their progress, their potential contribution to green growth and some of the implications for ocean management.
  • The OECD Gender Initiative examines existing barriers to gender equality in education, employment, and entrepreneurship. The gender portal monitors the progress made by governments to promote gender equality in both OECD and non-OECD countries and provides good practices based on analytical tools and reliable data.
  • They are green and local --It’s a new generation of entrepreneurs in Kenya with big dreams of sustainable energy and the drive to see their innovative technologies throughout Africa. blogs.worldbank.org
  • Interested in a career in Paris at the OECD? The OECD is a major international organisation, with a mission to build better policies for better lives. With our hub based in one of the world's global cities and offices across continents, find out more at www.oecd.org/careers .

Most Popular Articles

OECD Insights Blog

NOTE: All signed articles in the OECD Observer express the opinions of the authors
and do not necessarily represent the official views of OECD member countries.

All rights reserved. OECD 2017