A Good Life in Old Age? Monitoring and Improving Quality in Long-Term Care While the number of elderly people in need of care is projected to at least double, governments are struggling to deliver high-quality care to people facing reduced functional and cognitive capabilities. Based on a recent OECD and EC report, this policy brief looks at data and policies to measure quality in long-term care and drive standards of care up What measures of long-term care quality are collected?..........................................................................2 What are the main regulatory approaches to encourage quality of long-term care.................................4 How can care processes be better standardised for better quality...........................................................6 Can market and transparency incentives be better leveraged for quality improvement? ……..................7 Delivering quality long-term care services Figure 1. Rapidly increasing share must be a priority of the population aged over 80 years Japan There will be more than Spain twice as many old people aged Germany Korea over 80 years old in 2050 than Italy Switzerland there are now (Figure 1). The Austria share in the population will Netherlands Finland rise from 3.9% in 2010 to 10% EU in 2050 across OECD countries; France Portugal and from 4.7%to 11.3% across 27 EU Member Slovenia New Zealand States. Between one quarter and one half of Greece them will need help in their daily lives. Yet OECD Czech Republic governments are struggling to deliver high- United Kingdom quality care to those facing reduced functional Canada Sweden and cognitive capabilities. Belgium Poland Denmark Quality of long-term care (see definitions in Norway Iceland Box 1) is important for three reasons. First, users Luxembourg of care services demand more voice and control Slovak Republic % 80+ 2010 Ireland % 80+ 2050 over their lives. Second, as the cost of care Australia United States services keeps on growing from 1.6% of GDP Hungary across the OECD (Figure 2) to at least double this Chile Estonia figure by 2050, LTC services are under pressure Israel to improve their accountability. Third, Mexico governments have the responsibility to protect 0% 5% 10% 15% 20% vulnerable older people from potential abuse. Source: OECD Labour Force and Demographic Database, 2013 Policy Brief A Good Life in Old Age © OECD/European Commission June 2013 1 Figure 2. Long-term care expenditure, LTC quality measurement lags behind as a share of GDP (2010 or nearest year) comparable efforts in heath Health LTC Social LTC Indicators of LTC quality are useful for government regulatory oversight, help providers Mexico Slovak Republic … identify problems and point to adverse events in Australia the provision of care, and can help users make Portugal Estonia informed choices. Yet, whereas all countries are Czech Republic keen to measure indicators such as 30-days case Hungary (2008) fatality for stroke and heart attack, few Poland Korea countries systematically measure whether LTC is United States safe, effective, and centred around the needs of Spain care recipients. Luxembourg Slovenia (2008) Germany Lessons from the development of quality of Japan health care indicators suggest that indicators Austria Canada should focus on quality outcomes, not processes; New Zealand be constructed from administrative data using Switzerland (2009) standardised coding systems; and be built on a OECD Iceland single item, not on a multi-item scale. See Box 3 France for examples of monitoring and improving Belgium Finland quality in a few OECD and EU countries. Norway Denmark Clinical quality Sweden Netherlands Measures of elderly falls and related 0.0 1.0 2.0 3.0 4.0 fractures are only collected in about a third of Source: OECD Health Data 2012. % of GDP OECD countries. Even fewer have indicators on bed-sores, medication use, or weight loss, and only a minority such as Finland, Iceland, the Box 1. What is long-term care quality? Netherlands and the United States have Good quality of LTC maintains or, when measures of depression among old dependent feasible, improves the functional and health people, despite this being a very common outcomes of frail, the chronically ill and the condition. physically disabled old people. Three aspects are generally accepted as critical to quality of care: Standardised need-assessment tools used effectiveness and safety, patient-centredness by providers to monitor quality have sometimes and responsiveness, and care co-ordination. LTC been employed to generate quality indicators, includes a range personal care services to help and provide useful indication of trends (see disabled people with basic activities of daily Figure 3 which shows big differences in the use living (ADL), as well as basic medical services, of physical restraints in nursing homes both nursing care, prevention, rehabilitation or across Canadian provinces and over time). Yet palliative care. It can also include domestic help more national level data are needed before they and help with administrative tasks. can be used for cross-country comparisons. Policy Brief A Good Life in Old Age © OECD/European Commission June 2013 2 Figure 3. Restraint use in nursing home Figure 4. Hospital admission rates for in different provinces in Canada, 1996-2010 uncontrolled diabetes, people aged 80 and over 35% 30% Australia 25% Spain New Zealand 20% CCC Israel 15% BC Latvia LTC Canada 10% MB Switzerland United Kingdom 5% NL Portugal 0% NS Slovenia Ireland 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 1998 Czech Republic Iceland Source: Canadian data set available from InterRAI.org. Denmark Poland Responsiveness and care co-ordination Malta Norway Germany While various policies seek to make care Sweden services more attuned with individual wants and Hungary needs (for example by increasing the scope for Finland choice of service provider), few measures exist: Mexico Austria Korea England, Korea, Germany, Portugal and the 0 100 200 300 400 500 600 Netherlands assess user experience in LTC. Male Uncontrolled diabetes hospital admission rates, Only half of the countries that are worried population aged 80 and over, 2009 (or nearest year) about waiting times for LTC services actually Female Uncontrolled diabetes hospital admission rates, collect relevant data (such as hospitalised population aged 80 and over, 2009 (or nearest year) patients experiencing a delay in transfer to Source: OECD Health Data 2011. LTC services, as collected in England). Avoidable hospital admissions for chronic Figure 5. QoL by health status, England conditions for elderly people (uncontrolled diabetes, chronic obstructive pulmonary So bad, it could not be worse or very bad Bad disease, asthma) point to how well primary Alright Good care and LTC systems manage these 100% conditions (Figure 4). 80% Quality of life (QoL) 60% “Quality of life” relates to LTC recipients’ 40% ability to live at their highest physical, mental, 20% emotional and social potential. Denmark, Spain, the Netherlands, and England (Figure 5) survey 0% patient and user experience around issues such Very good Good Fair Bad Very bad Health Status as consumer choice, autonomy, dignity, comfort, Source: NHS Information Centre, 2012. security, relationships and social activity. Policy Brief A Good Life in Old Age © OECD/European Commission June 2013 3 Three main approaches have been adopted care (e.g., management of medication, record to drive LTC quality improvement keeping, infection control), and, more recently, A review of approaches in OECD and EU outcomes, quality of life, choice and human countries shows that a combination of policies dignity, as now used in Australia and the to drive LTC quality might be most effective: Netherlands. Regulatory standards, typically focused on Accreditation and standards for home care setting minimum standards on inputs and community-based care services are less (labour, infrastructure) and enforcing common, but can be found in France, Japan, compliance. Portugal, Spain and the United States. Standards to normalise care practice in desirable ways, and to monitor that quality Box 2. Protecting old people against abuses indicators match objectives. Legislation and regulations lay out the Market incentives for providers and users, means and procedures to protect against including financial incentives and the abuses, such as mandatory reporting of neglect grading of providers’ performance. or improper care (e.g., in Israel; Ireland; Alberta, Ontario and Nova Scotia, Canada; Germany; Most regulatory approaches have focused Japan; Korea; Norway), or mandatory criminal on institutions and minimum standards reference checks for care workers as in Canadian All countries have legislation setting provinces and the United States. National-level principles of adequate and safe care, or campaigns, including training for professionals protecting against abuse (Box 2). Decentralised and older people on responding to elder abuse bodies are often responsible for quality control. have been broadly successful in Ireland, Canada, Israel, and the United States. Ombudsmen to act Licensing, accreditation and minimum as advocates of old people exist in some standards in nursing homes provinces in Canada, Finland, and the United States, among others. Adult guardianship and In two-thirds of OECD countries, trusteeship arrangements have been established accreditation or certification of care facilities is in Australia, Canadian provinces, and the United