Planning and Developing Integrated Services in Israel

1. Planning and Developing Integrated Services in Israel Responding to Ageing: Workshop to Exchange International Experience Hanoi, Viet Nam, 25-26 Sept. 2013 Prof. Ariela Lowenstein, President Max Stern Yezreel Academic College, Israel Gerontology Dept., Center for Research & Study of Aging, University of Haifa, Israel arielal@yvc.ac.il

2. Lecture Outline Factors impacting service planning The socio-demographic picture of Israel Policy and Legislation in Israel Continuum of Care Different Service Models Issues and Changes needed Implications for Policy

3. Factors Affecting Service Planning and Design Demographic Developments Composition of Various Aged Groups Global Views – Ageing in Place, Active Ageing Societal Norms and Culture, Religiosity Social and Political Fabric – Policy & Legislation

4. Elder Care Networks in Israel – Norms, Culture and Religiosity Israel is multi-cultural, pluralistic, and democratic,with diverse groups of national, religious, and ethnic backgrounds Israel an urbanized welfare state, relying on a mixture of govt. and market forces shaping its welfare policies and services

5. Demography In 2013 Israel’s population was 8million, 80% Jews, 20% non-Jews. Life expectancy - currently 79.6 years for men and 83.8 for women. The 65+ are 10%; 12% in Jewish sector, and 4.2% among non-Jews - due to higher fertility rates Close to 19% of Jewish elders are disabled in ADL. Among non-Jews – close to 31%

6. Family Status and Living Arrangements Most aged have an informal support network -spouses the main source, then children. Strong emphasis on family role in elder care, reflected in low institutionalization rate: 4.1%

7. Policy and the Service System • Basic objectives of service delivery: • Enable maximum self-sufficiency, continue living in the community as long as possible - Ageing in Place • (2) Enable active societal participation, relating to diversity and heterogeneity – Active Aging. • (3) Even LTC for frail elders focuses on lifestyle continuity,shifting from early institutionalization

8. Human Capital Society should use human capitalinherent in the growing “young-old” - activating political power. In Israel the Senior Citizens Party, created a Senior CitizensMinistry Raising retirement age, to prepare for societal aging; It was suggested in all OECD countries. in Israel it was raised 2 years ago to 67 for men, 62 for women The state and private sector should develop programs to provide incentives for older workers to stay in workforce

9. Policy and the Service Systems in Israel Four major sectors are involved in service provision: Government agencies Trade unions Voluntary organizations The private sector

10. Policy and the Service System The National Insurance Institute (Israel’s social security system) is the core policy instrument for social protection. Currently, the system includes the following programs for elders: Old age and survivor insurance, Disability insurance, Long-Term Care Insurance Law; Advisory Stations for elders.

11. Advisory Stations for EldersAdvisory Stations for EldersStations are activated by ‘Young-Old’, around the country.All volunteers get one year training course, at the various universities.They have different roles: visiting home bound elders, assisting them with contacts; providing information on elders rights; working with recently widowed elders. Each group is supervised by a senior social worker. They also form a self-help support group for the participants

12. Policy and the Service System Elders’ social and welfare services are covered by the General Welfare Services Law, 1958. In each local authority the local welfare office has to provide services to needy, including elders. Major community services: pensioner clubs; day care centers for frail and mentally frail elders; supportive neighborhoods and ‘warm homes’; meals on wheels; activating volunteers. Supportive neighborhoods - in communities around the country where a high rate of elders live - a ‘neighborhood father’ is elected to be afocal pointfor all elders to answer all needs: like fixing a bulb; bringing food and medications when home bound; looking after their social life; developing intergenerational programs

13. Policy and the Service System The Ministry of Health, through its Dept. of Geriatric Medicine, is in charge of communitypublic health services; family health and mental health clinics; institutional placement, surveillance and supervision of nursing and mentally frail elderly in institutions.

14. Policy and the Service System National Health Insurance Law, 1995 enacted to provide health coverage for all Israelis, no discrimination for age or disability. Primary & acute health care are provided by 5 HMO’s in primary clinics with home-visits in every neighborhood. Currently developing an Integrated Service Model – strong collaboration between: health clinics, day care centers, hospitals, social services & informal carers – creating One Point Entry System

15. In 1969 the Ass. for Planning & Development of Services for the Aged (ESHEL) was created: To coordinate activities of the various ministries; To promote national service planning; To develop partnershipsbetween public and voluntary sectors. In each community Local Associations for the Aged were created, with members of local service providers and elders, working on a 5 year program for service development Policy and the Service System

17. What Should be the Appropriate Balance ? Formal Service Care Informal Family Care

18. The Community Long Term Law The Law, 1988 - presents a unique model for service provision to community elders, with case manage-ment playing a central role. An important element is integration of all agencies operating in the area of LTC, particularly the Sick Funds and the Ministries that provide health care

19. The LTC Insurance Law It is characterized by : 1. It is a social insurance law recognizing elders right for personal services per assessed needs. 2. It has a community orientation to assist elders who live in their homes, to delay or even avoid institutionalization. 3. The benefits are for very dependent elders, to assist family carers and ease their burden. The family, however, does not receive payment. 4. Priority is in-kind services that are universal, egalitarian, and implemented according to uniform rules

20. 5. It is geared to use existing infrastructure,integrating it with additional services, thus incorporating the mutual responsibility of the government and the Sick Funds. 6. It transfers service provision to non-governmental organizations, both non-profit and commercial, allowing entry of the private sectorinto home-based services. 7. It sets standards and norms for the professionals, strengthening interdisciplinary treatment approaches 8. It provides more efficient service management by local service systems The LTC Insurance Law

21. The Israeli Community LTC Insurance Law, 1988 The Law has system-oriented and person-oriented goals. System-oriented goals: Development of a wide range of community-based services; Advancing quality and efficiency by service coordination; Contracting service delivery to voluntary non-profit and for-profit organizations Identifying populations 'at risk‘; Delaying institutionalization; Cutting costs

22. The Community LTC Insurance Law Person-oriented goals are: To provide intensive and systematic evaluation of clients' needs by local professional committees, headed by municipal social workers To develop an individualized care plan, which is dynamic. Personal home care is by paraprofessionals To pay more attention to severely dependent elders and their family caregivers

23. TheLTC Insurance Law The extensive contribution of the Long-Term Care Insurance Law is reflected in its expansion of the scope of needy population from a projected 10,000 in 1980 to close to 1,600,000 in 2012

24. An Elder Abuse example – Translating data into Policy & Practice Till a decade ago the phenomenon of elder abuse and neglect was thought to be ‘non-existent’ in Israel The ‘ideal’ picture was shattered by data from the First National Survey (Lowenstein et al., 2008), showing a high percentage – 18.4 among 65+ community elders Data was presented at the President’s of Israel House and at the Parliamentary Committee of Health and Welfare. Wide media coverage was received and public and professional awareness raised

25. Elder Abuse Service Developments Based on the survey ESHEL and relevant Ministries created in all local welfare offices special units on elder abuse, manned by trained social workers. They work in interdisciplinary teams, activate the community, identify and treat cases of abuse The Ministry of Health issued special directives, established Violence Committees in each acute hospital An Interministerial Committee withESHEL, Police reps. Legal NGO’s & Academics is working on ‘burning issues’ & coordination

26. Training of Professionals Till 15 years ago aging in Academia was taught mainly as a ‘stream‘ or a course in Social Work or Nursing Depts. In 1999 two MA Gerontology Programs were established: One at Haifa University which has now also a doctoral program and one at Ben-Gurion University ESHEL created a Training and Supervision Center to provide in-service training and different workshops Currently the study of aging is ‘on the agenda’.

27. Policy Implications In the future, elder care will dealt by a public-private mix, the exact ratio varying by country. Mix Specifics will depend on : (a) family culture that guides readiness to use public services; (b) availability, accessibility, quality, and cost of services. Thus, services must help families define their willingness; Families should be compensated for the care they provide.

28. Macro level - Health and Social Care Recommendations A wider use of more creative services like the supportive neighborhoods in Israel Access to services increase their use – updating elders and families about their rights – The Advisory Stations for elders More choice in care arrangements – LTC options More help to elders in high service countries indicates that a family dominant system is less able to cover needs Countries with legal family obligations, like Israel, need to reconsider as the older generations wish for independence

29. Meso level – the family Developing supportive and complimentary services in the workplace for working carers – flexible hours, working from home Integrating health & social care so families continue and support older members – A model of Integrated Care Technological developments to assist health care and welfare organizations to deliver services more efficiently

30. Micro Level: Older people To empower elders and allow service choice- Local Associations for the Aged Social policy to move from the notion of dependence – emphasis on Active Aging – volunteers – Advisory Stations for the Aged. To strengthen positive images of ageing Need to identify groups ‘at risk of dependency’ in order to develop adequate services for them

31. As David Ben Gurion, the first Israeli Prime Minister once said “He who does not believe in miracles in theMiddle East is not a realist.” So must we believe in miracles, but try to be realistic and work towards: improving quality of life of elders and older families and enhancing intergenerational family relations

32. Thank you "We must be the change we wish to see in the world" M. Gahandi