Social Inequality under a New Social Contract: Long-term Care in Japan

The 1990s saw the beginning of new developments in the social policy agenda of Japan. A combination of further cuts in social expenditure and increases in financial resources through various means has become inevitable in response to the increasing cost burden of an ageing society, the prolonged recession and changes in the Japanese family. In this context, “kaigo hoken” (long‐term care insurance) was introduced in 2000 to increase revenue and fill the gap vacated by the family. The scheme introduced a different concept to the public: that long‐term care was no longer “expected’’ from the family or “allocated” by the state, but has become part of a “social contract” based upon a system of mandatory contributions, uniform entitlements and consumer choice. This paper first explores the role of the new scheme in creating social inequalities among individuals (and families). A panel survey is used to highlight different patterns of care provision and the varying degree of financial pressure among different income groups. Second, based on qualitative research, the paper examines how the new scheme has transformed the relationship between older people and their families who have played a central role in this arena. The scheme has consequently divided “traditional” families and their liberal counterparts, as a result of care work being “commodified”. It is apparent that this scheme has not only responded to fill the existing care gap but may also help accelerate the changes that have been taking place for the last two decades.     

Managing in the Trenches of Consumer Care: The Challenges of Understanding and Initiating the Advance Care Planning Process

To better understand how community-based long-term care providers define advance care planning and their role in the process, we conducted 8 focus groups with 62 care managers (social workers and registered nurses) providing care for Ohio's Medicaid waiver program. Care managers shared that most consumers had little understanding of advance care planning. The care managers defined it broadly, including legal documentation, social aspects, medical considerations, ongoing communication, and consumer education. Care managers saw their roles as information providers, healthcare team members, and educators/coaches. Better education, resources, and coordination are needed to ensure that consumer preferences are realized.     

Chapter 18. The Aging Network and the Future of Long-Term Care

SUMMARY

Federal and state governments face a significant challenge in meeting the long-term care needs of an older population that will double in size between 2000 and 2020 and continue to increase through 2050. States have made significant improvements in their long-term care systems for the elderly. However, they are still spending a significant proportion of their long-term care funds on nursing homes. Any effort to improve long-term care for the elderly qualitatively, and not just on the margins, must be focused on developing a more flexible and balanced long-term care system that is responsive to consumer choice.

The Aging Services Network is poised to play a significant role in this transformation process. The strengths of the Network include the ability to develop and manage consumer-driven community-based programs; to assess the needs and resources of individual older persons and provide cost-effective community supports; to operate within fixed, capped budgets; and to identify and maintain roles for informal caregivers. Now is the time for national aging organizations, state units on aging, and area agencies on aging to use existing opportunities to move towards the establishment of a balanced system of long-term care.     

Solidarity in Italy's policies towards the frail elderly: a value at stake

The Italian public policies towards the frail elderly are underdeveloped by both quantitative and qualitative standards. The bulk of care responsibilities lies on the family and the private provision of paid care is flourishing. The last decade was characterised by significant signs of improvement – an increase in the public resources committed to long-term care and the rising interest of politicians and scholars towards this issue – but the situation is still highly critical. In such a context several questions on solidarity arise regarding the degree to which this value is actually embedded in the public policies, what are the most relevant issues and how the main actors involved are concerned. The article aims to answer some of these questions, taking into consideration the points of view of the main actors: elderly people, carers and professionals.
In doing so, the article discusses the targets of the public services, differences in their provision across the country, the rise of the care allowance and the private provision of paid care. The article shows the problems regarding solidarity in the Italian policies towards the frail elderly and sets an agenda of issues to deal with in the next decade. How policy-makers will be able to manage these issues will determine whether and how the value of solidarity will shape Italy's long-term care policies in the future.     

Caregiving in Transition in Southern Europe: Neither Complete Altruists nor Free-riders

In the framework of the SOCCARE Project, focusing on families dealing with a double front of care for children and frail elderly people, similarities can be found in Italy, France and Portugal beyond their different welfare regimes. The comparison of family histories and caregiving strategies, by the methodology of case‐matching, gives an interesting overview of the relationship between the debate on social care and that on the intergenerational contract. The paper aims to understand which are the available combinations of family, informal and institutional resources making a heavy burden of care “acceptable and still normal”: this focuses both typical situations of each country and common features through the countries. The results show how changes in the representations of obligation and duty in the intergenerational pact produce different outcomes and demands in welfare systems. The analysis of shifting boundaries between the public and private spheres in care provides useful policy recommendations, aimed at improving choices and “sustainable” responsibilities of individuals, families and social networks. Sustainable policies seem to be more dependent on family and structural types and resources of networks than on different welfare and services support.     

构建老人福利机构危险管理机制——日本经验之启示

"养儿防老"是中国传统的养老模式,长期以来老人的养老主要依靠子女来解决,但是随着生活方式的改变、家庭规模的日趋小型化,老人的长期照顾问题受到了社会的广泛关注。近年来国家制定了相关的政策、制度以及服务来满足老人及其家人的需求,然而老人福利机构及所提供的照顾服务,其服务质量离人性化照顾服务仍有一段距离。就现阶段而言,老人福利机构所提供照顾服务的质与量,均有提升与改善的空间。日本是亚洲第一个施行公共性长期照顾保险的国家,其施行之初也面临着一些与我国同样的问题,为提升长期照顾机构的服务质量,日本厚生劳动省在介护保险制度施行后的2002年,就开始倡导老人福利机构应建立危险管理机制的理念,并于2006年修订老人长期照顾福利机构管理规则,规定老人福利机构应建立危险管理机制,以提升照顾服务质量。有鉴于此,本文将对日本老人长期照顾福利机构建立危险管理机制的过程、基本架构,以及相关课题做系统说明,为我国老人福利机构经营管理提供参考,也可为我国未来在探讨老人长期照顾问题之际,提供必要的配套依据。     

Exploring Social Care: Applying a New Construct to Young Carers and Grandparent Carers

Mainstream literature on paid care for children, frail elderly people and people with chronic illness or disability, and unpaid care provided usually by family members within households and kin networks tends to establish dichotomies: formal/informal, commodified/non‐commodified. Recent feminist literature rejects these dichotomies, developing models of social care in which the interconnections of paid and unpaid care are mapped within policy frameworks. This paper uses theoretical frameworks of ‘social care‘: care as labour; care as a relationship embedded in obligation; care incurring a range of costs; to explore two case‐studies: young carers aged up to 24 years who are most often caring for a co‐resident parent; and grandparents who are the primary carers of their grandchildren. The latter may occur under the aegis of child protection authorities, or Family Court orders, or in informal arrangements, not licensed by state authorities. This analysis of the international literature and Australian research data affirms the power of the social care framework, and also shows the influence of social policy settings on informal care provision.     

Admission to Nursing Homes in Taiwan

The population of Taiwan is facing a radical ageing process. A proportion of the growing number of people aged 65 and over is expected to need nursing home care. This research concerns the family context of decision‐making in the process of admission to a nursing home in Taiwan. Employing survey data from interviews with elderly people in nursing homes (235 interviews) and their carers/key families (265 interviews), the factors affecting their views about admission were explored. Bivariate analysis and a logistic regression model were also used to examine perceptions of alternatives to nursing home care among family members with elderly relatives in nursing homes. Most elderly people in Taiwan are cared for in their own homes by their families but, in some circumstances, entry to a nursing home seemed inevitable. This research found that the decisions were taken mainly within a family context. The adult children of the elderly people, carers/key families’ preferences and the availability of carers influenced the decision. Apart from the important need factors of elders, families’ views about alternatives to nursing homes were significantly influenced by their preferences. This study has important implications for long‐term care in Taiwan. It is hoped that this will be needs‐led, both by elderly people and their families.     

The residential home – what difference does it make?: Comparing the public systems of care for the elderly and disabled in two Swedish municipalities

Two municipalities in Sweden – Solna and Sigtuna – have taken part in a project (the ASIM project) aimed at developing a system for monitoring and analysing the public system of long-term care and assistance for elderly and disabled people. The two municipalities have chosen different alternatives in the question of residential homes. In Solna they have been retained and in Sigtuna they have been converted into sheltered housing. By separating the clients into different classes of dependence using the ASIM assessment, it is shown that in Solna, compared with Sigtuna, fewer of the most dependent clients are in long-term hospital care and fewer of the high-medium category are in domiciliary care. The data were used to calculate the distribution of the clients and the average dependence on the different levels of care if Solna were to apply the care pattern of Sigtuna and vice versa.     

Aging and Elder Care in Japan: A Call for Empowerment-Oriented Community Development

This article provides a brief overview of the situation of the elderly and their caregivers in Japan, including demographic changes in Japan, development and changes in long-term care policy that have targeted the poorly integrated community care system, and other challenges that the elderly and family caregivers face. Policy direction designed to address these issues is increasingly targeting care by the community versus support care by society (which was initially the main strategy). The potential of empowerment-oriented community development intervention strategies to decrease the gap between available institutional and formal community-based services and the needs of the elderly and their families in their efforts to meet late life challenges is described. The need for an increased role of social workers in community development interventions is explored and strategies are suggested.     

市场化、社会转型与城市郊区农村老人的“轮养”——来自子女口述史的分析

通过对河北省保定市郊区农村的深入访谈和问卷调查，本文研究了有两个以上已婚儿子的老年夫妻去世前的生活状况。研究发现，儿子成年之后的独立门户，是这类老年夫妇“宁巢”的前提，而“空巢”又是“轮养”契约得以建立的条件。市场化、社会结构转型、儿媳妇在家庭决策中作用的增强等，使老年人失去了家庭决策权。故“轮养”在生命过程中，实际是被安排的结果，而不是老年父母自己的选择。     

Allowing Family to be Family: End-of-Life Care in Veterans Affairs Medical Foster Homes

The Medical Foster Home program is a unique long-term care program coordinated by the Veterans Health Administration. The program pairs Veterans with private, 24-hour a day community-based caregivers who often care for Veterans until the end of life. This qualitative study explored the experiences of care coordination for Medical Foster Home Veterans at the end of life with eight Veterans’ family members, five Medical Foster Home caregivers, and seven Veterans Health Administration Home-Based Primary Care team members. A case study, qualitative content analysis identified these themes addressing care coordination and impact of the Medical Foster Home model on those involved: (a) Medical Foster Home program supports Veterans’ families; (b) Medical Foster Home program supports the caregiver as family; (c) Veterans’ needs are met socially and culturally at the end of life; and (d) the changing needs of Veterans, families, and caregivers at Veterans’ end of life are addressed. Insights into how to best support Medical Foster Home caregivers caring for Veterans at the end of life were gained including the need for more and better respite options and how caregivers are compensated in the month of the Veteran’s death, as well as suggestions to navigate end-of-life care coordination with multiple stakeholders involved.     

A Qualitative Exploratory Study on the Service Delivery System for the New Long-Term Care Insurance System in Korea

ABSTRACT

To cope with the rapid growth in its aging population, the Korean government introduced a new social long-term care insurance (LTCI) system for elderly people beginning in July 2008. This study aims to understand how National Health Insurance Corporation (NHIC) staff and home-visiting service providers experienced and evaluated the new service delivery system. A total of 26 semistructured in-depth interviews were conducted with NHIC staff primarily responsible for the functional assessment of the elderly and the home-visiting service providers responsible for providing direct services to elderly clients. In summary, interviewees had negative experiences with the new service delivery system such as difficulties in carrying out their roles. The findings suggest that Korea's new LTCI service delivery system faces challenges and that a more active role for the Korean government, especially regarding the introduction of a proper care management system, is needed to address the issues. Future research with larger sample sizes is needed to examine and understand the issues in detail.     

A Comparative Case Study of Care Systems for Frail Elderly People: Germany, Spain, France, Italy, United Kingdom and Sweden

Comparative studies of European social policies towards frail elderly people typically focus on the systems and their implementation. The study presented in this article, conducted in 2001 in six European countries (Germany, Spain, Italy, France, the United Kingdom and Sweden) aims at comparing the rights of the individuals within the different care systems. The methodology used is a case study approach, which draws on a series of situations of dependent elderly people. Therefore, the analysis focuses on the public authorities’ responses – the care packages, which determine the type of care required and the financial contribution of the user – in each of the six countries, in relation to the concrete situations of frail elderly people. As local variations are important, in all the countries studied, local authorities have been chosen in each of the countries. This approach gives us interesting concrete elements on the services and financial help which can be given to frail elderly people, but it also enables us to understand precisely the national care systems organized in the different countries and the main difficulties encountered by public authorities in facing this problem of frail elderly people.     

Eldercare Service Redesign in Finland: Deinstitutionalization of Long-Term Care

ABSTRACT

Deinstitutionalization is an important trend in the redesign of long-term eldercare in Finland. It refers to a process where traditional institutional care is partly replaced by home care services and the creation of homelike housing units. The first part of this article provides an overview of eldercare service redesign by using national statistics. The second part consists of qualitative analysis of the deinstitutionalization of eldercare. The data consist of 27 interviews conducted among municipal care administrators and is analyzed using thematic and discourse analysis. Main findings show a deep policy change taking place in eldercare deinstitutionalization discourse lying at its center. A distinction between explicit and implicit deinstitutionalization discourse is made. The former clearly states that institutional care needs to be cut back making it possible for all older people to live at home or in homelike housing facilities. Implicit deinstitutionalization discourse is underpinned by comments of a different type, more critical and problem-centered. Within intensive service housing, for instance, fee policy is reformed. The main results include the observation that explicit deinstitutionalization discourse is in line with the national policy aims of putting home first, while implicit discourse deals with hidden or unexpected consequences. The article discusses future research in the conclusion.     

Caring while living apart

In recent years, researchers have paid increasing attention to the issue of care in the new types of family and partner relationships. The aim of this study is to examine expectations and attitudes concerning care among elderly people in LAT (Living Apart Together)- relationships in Sweden, that is, people who have a long-term intimate relationship, but who do not share a common home. Questionnaires were completed by 116 elderly people in LAT-relationships. Partners are ranked as the main providers of care, especially by men, but there is considerable variation in the answers. This seems to be principally related to the degree of flexibility in this type of relationship. Some individuals see a LAT-relationship as a marriage-like relationship, while others see it primarily as a type of relationship that guarantees them the possibility of maintaining their own independent way of life.     

Choice and control in social care: Experiences of older self-funders in England

This paper considers the experiences of older self-funders in England in the context of policies promoting choice and control. Self-funders are people who are not state-funded; they pay for social care from their own resources. Choice and control have been operationalized through personal budgets, based on the assumption that managing resources enhances ability to access appropriate care and support. This paper uses data from 40 qualitative interviews with self-funders and their relatives, and 19 with professionals. It explores the impact of the financial and social capital that self-funders are assumed to have and asks how older self-funders experience choice and control. The study found that older self-funders drew on personal experiences, family, and friends for information; were reluctant to spend their wealth on care due to competing priorities; and felt they had more control over the timing of decisions than people who were state-funded. Personal wealth appears to be perceived differently to funds “gifted” to people through cash for care schemes.     

Focused participation in social work and social action

Focused participation proposes that total participation by clients of social work and communities involved in social action is no participation if it neglects the severe blocks on capacity to participate imposed by oppressed life experience and poverty. Workers should take on the responsibility for including a planned program of participation in every intervention focused on what is most important to the client or community members. Case examples in residential care for elderly people, a child advocacy service concerned with the closure of children's homes, cutting a voluntary organization's budget and family social work illustrate the main points of focused participation.     

To Coordinate Information in Practice: Dilemmas and Strategies in Care Management for Citizens with Dementia

ABSTRACT

This qualitative study, based on 19 interviews with care managers, explores the experiences of care-managers involved in assessing the need for social services for people with dementia. The study shows that social workers, as care managers, face several dilemmas in their practice concerning people with dementia, in relation to the exchange of information and in regards to conflicting interests between different actors involved in the assessment of the need for support for people with dementia. Strategies used to handle problematic situations that arise in their work are using other sources for information (e.g., relatives and actors from other professions), persuading, and pursuing creative forms of consent. However, the study shows that dilemmas and strategies used generate other, prominently moral, dilemmas for care managers in their practice, which relate to participation and self-determination by the person with dementia. The study shed light on the problematic situation for care managers in their work to coordinate information and further the new “realities“ that they encounter as well as on how to handle these new situations. This study suggests possible ways to improve the everyday work of care managers, as well as how policies concerning social work and people with dementia can be improved.