1. Long Term Care: Pragmatic Reform Ideas from Europe Richard B Saltman Department of Health Policy and Management Rollins School of Public Health Emory University European Observatory on Health Systems and Policies Systems and PoliciesBrussels www.observatory.dk

2. In Western Europe: Broad range of system-wide, social strategies - Funding - Funding - Delivery - Delivery

3. Funding Ideas I MACRO LEVEL : SHI Separate Social Health Insurance Fund for long term care: -national-universal-mandatory -50% employer/50% employee -in-kind services, and/or -cash payments to informal carers (Germany, Austria, Netherlands)

4. Funding Ideas II: MICRO LEVEL: CLIENT CONTRACTING FOR HOME CARE: MICRO LEVEL: CLIENT CONTRACTING FOR HOME CARE: Contract-based bidding to provide services to each client -based on IADLs -pre-qualified bidders -client budgets -municipal monitoring/regulation (Netherlands) (Netherlands)

5. Delivery Ideas I MESO LEVEL: ELDERLY HEALTH CENTERS MESO LEVEL: ELDERLY HEALTH CENTERS Modeled on well-child centersModeled on well-child centers(“pram-distance”) (center of town) Basic medical supportBasic medical support - Nurse staffing to take blood pressure; - Nurse staffing to take blood pressure; give medications give medications Several observation beds (2-3 hours)Several observation beds (2-3 hours) Paid for by municipalitiesPaid for by municipalities All elderly welcomed (Netherlands)All elderly welcomed (Netherlands) Minimum if any chargeMinimum if any charge

6. Delivery Ideas II MESO LEVEL: SYSTEMATIC SUPPORT TO INFORMAL CARERS Dedicated Municipal Budget Dedicated Municipal Budget Telephone Advice Telephone Advice Respite care (if carer gets sick) Respite care (if carer gets sick) Drop off day centers Drop off day centers Training (e.g. moving a heavy patient, etc) Training (e.g. moving a heavy patient, etc) Pension Points towards retirement Pension Points towards retirement (resembles “dagmama”/ Swedish child care) (resembles “dagmama”/ Swedish child care) (Netherlands/Sweden/Germany) (Netherlands/Sweden/Germany)

7. Observation #1 Key Characteristics of European Long Term Care Strategies: Social not individualSocial not individual Systematic not piecemealSystematic not piecemeal Mandatory funding sourcesMandatory funding sources (taxes or SHI contributions) Universal services (open to all)Universal services (open to all)

8. Observation #2: Contrast w/ current U.S. strategies for home care: Mostly self-funded/ well-to-doMostly self-funded/ well-to-do Home/ individual basedHome/ individual based Private Insurer drivenPrivate Insurer driven Technology / IT orientedTechnology / IT oriented

9. From Modern Physicians, April 2, 2007 “Aging Population Spurs Innovation” John Dannher, M.D. “connected personal health and fitness products and services” “home-based technologies”: - motion sensers - video cameras - telemonitoring - functional clothing with on- body sensors - personal wireless networks - radio frequency identification (to track movement)

10. The Core Challenge: 1) Designing Systemic, Social, Culturally Appropriate Adaptations 2) Overcoming Public Sector Paralysis Paralysis