Abstract

Objectives: In order to assess the ability of the EFFA IHSD to act as a guide for policy-making it is important to understand whether it can be helpful to systematize and interpret available information from a variety of long-term care settings and to generate actionable insights. Furthermore, as the EFFA is intended to support integrated service delivery in the WHO European region it must be able to respond to the challenges faced in very different contexts and resource environments. Going beyond the geographical borders of Europe, the WHO European regions includes countries with vastly different cultural, political and economic traditions and with very different historical development paths for social services and support for older and dependent adults.

Methods: Six country case studies were selected for the application of the modified EFFA IHSD to integration of health and social services delivery in long-term care settings: Turkey, Germany, Romania, Portugal, Denmark and Croatia. The selection was purposive and aimed to ensure that all major care regimes in Europe were represented in the sample, while at the same time attempting to obtain a good coverage of the integration continuum (from countries in the early stages of long-term care development and low levels of integration, to front-runner countries that have achieved high levels of integration). Each country case study included a desk research phase (review of relevant statistical and policy documents; and of the grey and academic literature) and a country visit (site visits and group and individual interviews with a variety of stakeholders from policy-makers to care providers and user representatives).

Results: The case study analysis reveals a generalized focus on re-centering long-term care systems around people and populations and on promoting community based care solutions. However, most systems remain predominantly re-active in their approach to care, while prevention and rehabilitation play secondary roles. The analyzed countries vary greatly in the extent to which they support and incentivize family and other unpaid care provision, although in each country households provide the overwhelming majority of care. Efforts to improve and re-align care services to emerging population needs are on the way in all studied countries, although in certain contexts the severe capacity and resource limitations frustrate most efforts to modernization and quality improvement (RO, TK). Fragmentation of funding and governance structures are also common realities to all studied cases, although initiatives to overcome these barriers are becoming increasingly more common (PT, DK, DE). Similarly, workforce migration, high turnover rates and low professionalization levels plague every country studied, with potentially serious consequences for system sustainability. While the challenges they face are numerous, all the analyzed long-term system have been undergoing reform and modernization processes. Some have shown remarkable ability to manage change processes and mobilize broad support for innovation (PT, DK), whereas others are progressing at a slower rate (TK, RO).

Conclusions: While many European long-term care systems have been and are still undergoing reform process, the achieved level of integration between health and social care remains limited. Most countries have started to establish linkages while some have already reached levels of coordination in some of the dimensions considered in our framework. However, much remains to be changed in order for the goal of integration to be achieved.