DRAFT GUIDELINES TO IMPROVE LONG-TERM CARE EXPENDITURE IN OECD HEALTH DATA 2006/2007

1. DRAFT GUIDELINES TO IMPROVE LONG-TERM CARE EXPENDITURE IN OECD HEALTH DATA 2006/2007 7th Meeting of Health Accounts Experts and Correspondents for Health Expenditure Data Paris, 29 - 30 September 2005

2. Components of OECD work on LTC expenditure • Long-term Care Study – provided the definition for HC.3 • Follow-up on the Long-term Care Study: data collection on recipients of LTC • Data collection complementary to OECD Health Data 2005 on expenditure on health and social care for the elderly and people with physical and mental impairments – pointed out the need for reporting Total LTC expenditure (HC.3+HC.R.6) • Preparation of guidelines on LTC expenditure for OECD Health Data 2006 and SHA data collection

3. Requirements for LTC expenditure data • Availability of data • Reliability of data • Timeliness • Comprehensiveness of estimating total spending • Consistency of hierarchy of sub-aggregates • Comparability across countries and over time • Transparency (estimation methods and deviations) • Policy-relevant indicators

5. Proposed way of presenting categories of LTC in OECD Health Data 2006

6. Policy relevance of different categories of LTC expenditure • From the point of view of public budgets, it is desirable to provide information concerning the total spending on services provided to the elderly and people with physical and mental impairments (with ADL and/or IADL restrictions). • Expenditure on LTC services provided to persons with ADL restrictions distinguish between severe and minor disabilities

7. Requirement of comprehensiveness • SHA Manual: “In accordance to the functional approach, all programmes designed to provide health care … should be included, whether labelled “health care” or not in national statistics.” • It is desirable to apply this requirement for health and social care for people who are limited in their ability to function independently on a daily basis over a relatively long period of time – regardless whether it is labelled “health” or “social” in national statistics

8. HC.3 Services of long-term nursing and personal care Definition – developed by the LTC Study Long-term nursing and personal care comprises a range of services required by persons with a reduced degree of functional capacity, either physical or cognitive, who are consequently dependent on help with basic activities of daily living (ADL), such as bathing, dressing, eating, getting in and out of bed or chair, moving, around and using the bathroom. This physical or mental disability can be the consequence of chronic illness, frailty in old age, mental retardation or other limitations of mental functioning and/or cognitive capacity. In addition, help with monitoring status of patients in order to avoid further worsening of ADL status

9. HC.R.6. Health-related LTC social services (Long term care other than HC.3) • This item comprises services of home help and residential care services: care assistance which are predominantly aimed at providing help with IADL restrictions to persons with functional limitations and a limited ability to perform these tasks on their own without substantial assistance, including supporting residential services (in assisted living facilities and the like).

10. Total long term care (including HC.R.6) • The term ‘long-term care services’ encompasses the organisation and delivery of a broad range of services and assistance to people who are limited in their ability to function independently on a daily basis over an extended period of time. Functional dependency can result from either physical or mental limitations and is defined in terms of the inability to perform essential activities of daily living (ADLs), such as eating, bathing, dressing, using the toilet, getting into and out of bed, and moving about the house, or activities necessary to remain independent, known as instrumental activities of daily living (IADLs) such as shopping, cooking, doing laundry, managing household finances, and housekeeping.

11. Components of LTC spending • Palliative care (end-of-life care) • Long-term nursing care • Personal care services (assistance with ADL restrictions) • Services in support of informal (family) care • Care allowances • Support to informal care givers • Home help; care assistance (help with IADL restrictions) • Supported living arrangements: residential (care) services • Other social services provided in a long-term care context • Special types of transportation • Case management / coordination

12. Initial comments on LTC Guidelines Alternative proposals • Home care • Home help; care assistance (help with IADL restrictions) • Meals on wheels • Services in support of informal (family) care • Care allowances • Support to informal care givers

13. HOME CARE: alternative proposals Option A HC.3.3 Long-term nursing and personal care: home care • Includes: personal services, nursing services delivered at home; lower-care services (home help), if provided by the same person that also provides help with ADL restrictions at the same time. Option B HC.3.3 Long-term nursing and personal care: home care • Includes: nursing and personal care services delivered at home; and services in support of informal (family) care related to ADL restrictions • Excludes: all other types of LTC services

14. HOME HELP: alternative proposals Option A Recommendation:Home help and other help with IADL restrictions - where delivered as separately identifiable services should be included only in HC.R.6: Health-related social services of LTC • Include expenditure on help with IADL restrictions in HC.3, if provided as part of nursing or personal care services provided by the same care giver Option B Home help, care assistance and other help with IADL restrictions should be included only in HC.R.6: social services of LTC (Long-term care other than HC.3). If home help provided together with HC.3.3. LTC home care, these services should be separately accounted under HC.3.3 (home care) and HC.R.6 (home help). If the separation is not possible, all expenditure should be reported under HC.R.6.

15. Meals on wheels: alternative proposals • Option A • Meals on wheels included in HC.R.6 • Option B • Meals on wheels is excluded from all types of LTC

16. Programmes of personal budgets and consumer-choice, care-allowances etc. Option A • All expenditure on programmes of care allowances and other direct payment schemes should be included in health accounts Option B • If it is possible to distinguish whether the eligibility is due to ADL restrictions or IADL restrictions, the expenditure should be accounted as HC.3 or HC.R.6, respectively. If it is not possible to make this distinction, all payments should be reported under HC.R.6 financed by HF.1 • Note: special attention should be paid to avoid double counting (not to report the expenditure as financed by households).

17. Further comments (not included in alternative proposals) Personal care services (assistance with ADL restrictions) should be excluded from HC.3 and only included in HC.R.6 HC.3Long-term nursing care • Palliative care (end-of-life care) • Long-term nursing care HC.R.6. Health-related LTC social services • Personal care services (assistance with ADL restrictions) • Services in support of informal (family) care • Home help; care assistance (help with IADL restrictions) • Supported living arrangements: residential (care) services • Other social services provided in a long-term care context

18. Treatment of complex provider organisations Recommendation on estimating the boundary between HC.3 and HC.R.6 (when data on actual spending is not available separately) To estimate the number of three types of persons: • (i) those who receive nursing and personal care (HC.3) • (ii) those who receive only social support services due to IADL restrictions (HC.R.6); and • (iii) those who basically live in mixed institutions to avoid social isolation

19. Treatment of complex provider organisations (cont.) Estimation methods • surveys • expert opinions • dominant profile of the institution Proposed general rules • Account as HC.R.6, if not possible to decide between HC.3. and HC.R.6 • Exclude if not possible to decide between HC.R.6 and other non-LTC

20. Alternative labels for HC.R.6.1 • Health-related LTC social services • Social services of LTC • LTC other than HC.3

21. Categories for health-related expenditure (relevant to LTC) in the joint OECD- Eurostat and WHO SHA questionnaire

22. Next steps • Decision about the alternative proposals • Assessment of the discussion at the Meeting of Health Accounts Experts • Discussion with experts at EUROSTAT and WHO • Finalising the LTC Guidelines for OECD Health Data 2006/2007 (and joint SHA data collection) • Establishing SHA Electronic Discussion Group Issues beyond 2006-07 • Starting a wider discussion about rationality and feasibility of Health and Long-term Care Accounts and harmonisation with ISIC Rev4

23. ISIC Rev4 86 Human health activities 861 Hospital activities 862 Medical and dental practices 869 Other human health activities (includes paramedic activities and medical testing) 87 Residential care services 871 Nursing care facilities 872 Residential care activities for mental retardation, mental health and substance abuse 873 Residential care activities for the elderly and disabled 879 Other Residential care activities 88 Social work activities without accommodation 881 Social work activities without accommodation for the elderly and disabled 889 Other Social work activities without accommodation

24. Issues for discussion • Alternative proposals based on comments received on the Draft LTC Guidelines • Appropriateness and feasibility of the proposed guidelines • Possible difficulties in implementation in 2006 and 2007