Background information about dementia and home care services

Prior to 1994, the German health and social services system did not cover the risk of dependency. Although the service for public assistance was responsible for this, it was not under any obligation to provide social services to dependent people (Ylieff, 2005). Since the introduction of the long-term care insurance, the number of home-based care providers has risen from about 6,000 to 12,500 in 2003 (Theobald, 2004). However, according to Theobald (2004), the long-term care insurance is orientated towards the performance of basic daily activities and as such neglects other aspects of care which are particularly important when caring for people with dementia e.g. general supervision and attention, and social and emotional support. It has also been argued that this orientation presupposes family support or a stable social network which in turn hinders the development of more comprehensive, complex care arrangements (e.g. which might enable people with dementia living alone to continue to do so for longer).

Legislation relating to the provision of home care services

The Social Dependency Insurance Act of 26 May 1994 relating to Care Insurance radically changed this situation. It made it compulsory for people to subscribe to the Long-Term Care Insurance (LTCI). People on a higher income, who are consequently not subject to statutory health insurance, are not obliged to subscribe to the long-term care insurance. However, they must prove that they have a private long-term care insurance policy.

Various diseases or disabilities are listed in the care legislation. These include psychiatric illnesses and psychological, physical and mental disabilities such as dementia or other forms of age-related mental decline. In order to be eligible for support or care under the LTCI, a person must have a recognised disease or disability as well as a recognised need for care (Meyer, 2004).

The Act was implemented in two stages: first for home care in April 1995 and then for institutional care in July 1996 (Brodsky et al., 2000). The Complementary Nursing Act was passed in 2002. The aim of this Act was to grant a yearly amount to carers or people with dementia in order to purchase additional services.

Organisation and financing of home care services

The LTCI is financed through a tax of 1.7% of the gross wage which is shared equally between the employer and the employee. The LTCI is obligatory for every person who has a health insurance and also for people who are privately insured. The employer is compensated through the designation of one day’s holiday as a working day (Brodsky et al., 2000). A person’s financial situation and the availability of assistance from the family are not taken into account when judging eligibility. Since 1 April 2004, pensioners have been obliged to pay full contributions to the LTCI. Prior to 2004, pension insurance funds paid half of the cost.

The LTCI covers personal hygiene, nutrition, mobility and housekeeping. There are four levels (I, II, III and special hardship) and a person must need substantial help for at least 6 months to qualify. Within each category, a specific amount is payable for each kind of assistance needed and this differs according to the person providing the assistance/service. For this reason, the allowance can be paid either to the person with dementia so that they can pay carers in cash or directly for services (“Sachleistung”). The following table provides an overview of the payments in Euro for services according to each category:

Source: Bundesministerium für Gesundheit (2006)

The allowance granted under the Complementary Nursing Act of 2002 amounts to a maximum of EUR 460 per year and is especially for people who have a significant need for care and supervision beyond that already covered by care insurance provisions. This includes people with dementia. The care allowance can only be used to pay for “day or night-nurses, short-term care, special services of general supervision and care from recognized care providers, and for services from low-level care providers” (Bundesministerium für Gesundheit, 2006).

Non medical home care services are often provided by home health assistants and housekeepers who provide assistance with household chores. Certain services such as shopping and simple household help may also be provided by young men who decide to do community service instead of military service (Payne et al. 1999).

Domestic careworkers from Eastern Europe, taken on to carry out household tasks, sometimes become unofficial carers even though they do not necessarily have the right to work (Meyer, 2004).

Kinds of home care services available

The kinds of services covered by the LTCI are:

• Personal hygiene: washing, showering and bathing, dental hygiene, combing, shaving and assistance going to the toilet.
• Nutrition: assistance with eating
• Mobility: assistance getting into and out of bed, standing up, going up and down stairs, leaving and returning to one’s home
• Care of the home: shopping, cooking, cleaning, washing pots, changing and washing clothes, heating the home
• Organised care: respite care, day care and night care
• Various aids: nursing aids and technical aids

Consultation with people with dementia and carers

According to Brodsky et al. (2000), the Social Dependency Insurance Act of 26 May 1994 included provisions for quality assessments. Service providers have to undergo external assessment of the quality of the services they provide. People who choose a cash allowance instead of services have three inspection visits per year from formal service providers who ensure the quality of the services provided, give information on available services and advise informal carers (Brodsky et al., 2000).

Sources

• Brodsky, J., Habib, J. and Mizrahi, I. (2000), A review of long-term care laws in five developed countries, http://www.wu-wien.ac.at/wwwu/institute/Sozialpolitik/LTC.pdf#search='A%20review%20of%20longterm%20care%20laws
• Bundesgesetzblatt (14.11.2003) extracted from: Leistungen und Rechengrössen der Kranken- und Pflegeversicherung im Jahr 2004, http://www.pflege.de/html/pflegeversicherung.html
• Bundesministerium für Gesundheit (2006), Long-term care insurance, http://www.bmg.bund.de/cln_041/nn_617004/EN/Long-term-care-insurance/info-long-term.html (accessed on 8 August 2006)
• Meyer, M. (2004), National Background Report for Germany, EUROFAMCARE, http://www.uke.uni-hamburg.de/extern/eurofamcare/documents/nabare_germany_rc1_a4.pdf
• Payne, K. A. et al. (1999), Resource use by dementia patients and caregivers: an international survey of medical and social services and processes of long-term care, Annals of Long Term Care, Volume 7, Issue 7
• Theobald, H. (2004), Care services for the elderly in Germany - infrastructure, access and utilization from the perspective of different user groups, Arbeitsgruppe Public Health
• Forschungsschwerpunkt Arbeit, Sozialstruktur und Sozialstaat, (WZB), http://skylla.wz-berlin.de/pdf/2004/i04-302.pdf#search='Pflegeversicherung'
• Tschainer, S. (2002), Das Wichtigste 8. Die Pflegeversicherung, Deutsche Alzheimer Gesellschaft, http://www.deutsche-alzheimer.de/index.php?id=37&no_cache=1&file=14&uid=224
• Ylieff, M. et al. (2005), Rapport international – les aides et les soins aux personnes démentes dans les pays de la communauté européenne, Qualidem, Universities of Liège and Leuven