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Determining eligibility for long-term care-lessons from Germany.

Objectives This paper addresses recent steps for reforming the eligibility criteria of the German long-term care insurance that have been initiated to overcome shortcomings in the current system. Methods Based on findings of a survey of international long-term care systems, assessment tools and the relevant literature on care needs a new tool for determining eligibility in the German long-term care insurance was developed. Results The new tool for determining long-term care eligibility broadens the understanding of what ‘dependency on nursing care’ implies for the person affected. The assessment results in a degree of dependency from personal help provided by formal or informal caregivers. This degree of dependency can be used for determining eligibility for and the amount of long-term care benefits. Discussion The broader understanding of ‘dependency on nursing care’ and the new tool are important steps to adapt the German long-term care insurance to the challenges of the demographic and societal changes in the future.


Introduction
The development and design of long-term care (LTC) systems receive increasingly more attention in health care policy, particularly in Northern America and Western Europe with their rapidly aging populations. This is reflected by the growing discourse on long-term care principles and challenges that has been initiated by international organizations, such as WHO, OECD, and EU [1][2][3] and is supported by calls for preventing the demand for long-term care services in the elderly population [4,5].
International Journal of Integrated Care -Volume 11, 31 May -URN:NBN:NL:UI:10-1-101447/ijic 2011-19 -http://www.ijic.org/ One of the key questions in any long-term care system is the definition of eligibility for LTC benefits and services. It is one of the most important aspects for steering LTC systems in terms of regulating the number of beneficiaries and, by doing so, having a baseline for calculating costs and resources necessary to run the system. But eligibility criteria not only determine the costs of LTC systems, they also reflect which individual circumstances related to health, ill-health or disability are considered to be serious enough to be covered by a national or regional LTC system. In this respect the eligibility criteria have a function in terms of fair distribution of services and benefits to people in need and in terms of granting access to services.
Both aspects, the costs and the degree of population coverage, have been discussed in the German LTC insurance system from its implementation in 1995 until now. Recently, important steps have been undertaken to reform the eligibility criteria of the LTC insurance and to adapt it to the challenges of the future [6,7]. This paper provides an overview of these steps and addresses important aspects for developing eligibility criteria in LTC and the approaches for its assessment. In the beginning some key aspects of the German LTC system will be highlighted that are needed for understanding the reform discussion addressed in this paper. Finally, some implications for long-term care systems in general will be discussed.

Background: the German long-term care insurance system
The German long-term care insurance was implemented to cover individual needs for nursing care that can be addressed by formal and/or informal caregivers. It is part of the overall national social insurance scheme that includes sickness, pension, accidental, unemployment and long-term care insurance. This social insurance scheme is an obligatory insurance system that ensures coverage against several life risks for the entire population [8]. The general principle of this scheme is the shared contribution of insurance fees by employers and employees who pay 50% of the contribution each. The insurance fee for long-term care is 1.95% of the employee's gross salary (2.2% for adults without children).
From its implementation in 1995 the LTC insurance was intended to cover only parts and not all of the longterm care needs of the population. The eligibility criteria, which introduced a 'Concept of dependency on nursing care' (Begriff der Pflegebedürftigkeit), reflected this intention by defining the parts of long-term care needs that are covered. According to this a person is considered to be eligible for long-term care benefits, if she or he is unable to perform regular activities of daily living in the areas of personal hygiene, nutrition, mobility and domestic care due to physical or mental illness/disability for at least six months. The severity of dependency is defined on three levels: Level 1: substantial need of care, which means that • assistance in at least two of the activities personal hygiene, nutrition or mobility is needed once a day and in addition domestic care several times a week. The amount of time required by an informal caregiver to spend on the care of the person is at least 90 minutes a day (out of which 45 minutes need to be spend on hygiene, nutrition, mobility). This definition indicates that in the current system not the degree of dependency on nursing care, but the estimated time for the performance of selected care activities is assessed [9]. This assessment is undertaken by the Medical Board of the sickness insurances (MDK), an official independent consultancy jointly financed by the sickness insurance funds. Within the MDK doctors and nurses are employed and responsible for the assessment that takes place in the claimant's or a nursing home. People who have been found eligible for benefits from the LTC insurance can receive benefits for nursing home care, care-in-kind-services in their homes (i.e. services provided by professional home care nursing services) or cash payments. The amount of benefits is determined by the level of dependency and is always limited to the legally defined level (see Table 1).
In addition, people may be eligible for benefits and services from other parts of the social security system, such as home care nursing with regard to medical aspects that is covered by the sickness insurance or additional social assistance. An overview of the LTC beneficiaries in 2009 [10] is provided in Table 2.

Shortcomings of the existing system
The eligibility criteria mentioned above have been criticized since their implementation [11]. The critique was focused on the narrow concept of 'dependency on nursing care' that only includes somatic and neglects other aspects, such as consequences from cognitive impairments, mental and behavioural health problems, communication ability or various challenges in the management of chronic illness. Given the increasing number of people suffering from dementia and chronic illness this narrow definition of eligibility for services excludes obvious needs of a large part of the population [12].
Less discussed, but equally important in the evaluation of the existing system is the use of time as a measure for determining eligibility. It seems a reliable measure at first glance, but when considered from a scientific point of view it poses severe methodological problems [13]. The time that is needed for performing activities of daily living is actually not a suitable objective measure, because it is highly individualized and depends on a range of influencing factors, such as: the aims of the caregiver when performing a par-• ticular activity the person who is providing the care in terms of • motivation and skills The problems with measuring time became obvious right after the implementation of the LTC insurance. Huge regional differences in the distribution of eligibility levels across Germany have been identified that could not be explained by any epidemiological or demographic factors [14,15], but purely because of the inherent methodological problems of the system. In the German context this is particularly problematic, because equality is one of the core principles of the whole health and social care system. Accordingly the assessment process has to be performed in a way that ensures equal chances for the population to be assessed for eligibility in a reliable and comparable way. The regional differences in the distribution of eligibility levels due to methodological weaknesses therefore are not acceptable in the long-run.

Search for LTC eligibility criteria internationally
Despite the broad consensus on the weaknesses of the existing system it took some time, before the German Ministry of Health launched an initiative to evaluate and to reform the current eligibility criteria. For this purpose it established an Advisory Board to review the legal definitions in the long-term care insurance. The members of the Advisory Board represented all relevant stakeholders from the German LTC field, such as provider organization, insurers, professional representatives, consumer organizations, scientists and lawyers. To base the discussions of the Advisory Board on solid evidence a study was commissioned to search and analyze international LTC systems, their eligibility criteria and the assessment tools and procedures used. The idea was to learn from international experiences and make use of them for the reform of the German LTC system.
The results of this study [16] can be summarized by three aspects that are addressed in the following paragraphs:

Defining 'Dependency on nursing care' from different perspectives
From a nursing science perspective some 'need theorists' have focussed on activities and areas of life, because of which a person might become dependent on nursing care. These were conceptualized as 21 conditions for which a nurse can assist [17], a person's lack of knowledge, strength, or will to carry out activities [18] or as a deficit between a person's self-care capabilities and self-care demands [19]. The activities and areas of life that cause dependency are related to physical, mental and social aspects as well.
Unlike this rather person-centred approach the discussion within international LTC systems on eligibility criteria can be characterized as rather pragmatic. The following criteria have been found in different systems internationally [16]: Age: some LTC systems have been developed for • elderly people only (usually 65 years +). Exceptions from this principle, such as the Japanese regulation that people between 40 and 64 receive benefits only in case of the occurrence of legally defined illnesses [20,21], also fall under this principle. The German LTC insurance does not limit the beneficiaries to particular age groups. Financial situation of the person in need of care: • some countries use a means test to determine whether and to what extent people can pay for the services they need out of their own pocket, before public spending on these services begins. As mentioned above, the German LTC system is part of the overall social insurance scheme and therefore access to services is granted independently from the individual's financial situation.
Role of the family: similarly the role of the family • can be considered as a barrier for LTC eligibility, i.e. as long as family caregivers provide the services necessary no public money will be used. In fact, because informal caregivers are still, and always have been, the backbone of long-term care, the role of the family is more and more considered as a resource that needs to be maintained by means of granting benefits for caring family members [1].

Key elements to characterize 'Dependency on nursing care'
Despite the huge heterogenity in approaches for determining eligibility for long-term care the search revealed some key elements of what constitutes dependency on nursing care. According to this a person is dependent on nursing care who: due to a lack of personal resources for compen-• sating or managing functional limitations or healthrelated burdens and requirements permanently or temporarily • is not able to engage independently in activities, ill-• ness management or social participation and therefore in need of personal assistance in nursing care • activities [16].

Assessment tools for determining LTC eligibility
As heterogeneous as the definitions of 'dependency on nursing care' have been the findings on assessment tools that are used for determining LTC eligibility. A total of 40 different tools have been thoroughly investigated for their content, formal structure, methodological quality and the feasibility of their utilization. Despite positive ratings for some instruments according to these criteria, such as FACE (Functional Assessment of Care Environments) or the Resident Assessment Instrument (RAI), the study recommended to undertake the work of developing a new assessment tool for determining eligibility. This recommendation was based on the fact that none of the instruments was tailored to the formal requirements and structure of the German social security system in general and the long-term care system in particular. The Advisory Board of the Ministry of Health endorsed this recommendation and commissioned a study on the development and evaluation of a new assessment tool for determining eligibility in the German long-term care insurance.
Similar processes of searching and identifying suitable tools for determining eligibility for LTC have taken place in several other countries, such as Australia [22], Japan [20] and the UK [23] during the last years. In Japan, too, the decision was made to develop a new tool that is suitable for the Japanese situation instead of using and adapting an existing tool [20]. In the UK criteria for tools to be used in the Single Assessment Process (SAP) have been developed and six different tools have been accredited for utilization [23].

The new approach to determining eligibility for LTC in Germany
The process of developing a new assessment tool in Germany was guided by several requirements by the Advisory Board and the Ministry of Health. These concerned: the existing eligibility criteria were to be expanded • considerably, particularly in terms of including people with cognitive impairments, the tool was to ensure a valid and reliable assess-• ment of dependency from other persons, the procedure of the assessment process and its • results needed to be transparent and understandable for LTC users, the assessment process with the new tool needed • to be feasible for the Medical Boards of the insurances, the results of the assessment were to be used for • care planning purposes.
All these aspects were considered in the development process of the new tool that was labelled NBA (German for: Neues Begutachtungsassessment zur Feststellung der Pflegebedürftigkeit-new assessment tool for determining dependency on nursing care). It was first published in Germany in February 2008 [24] and afterwards tested and evaluated [25].
The first step in the development of the NBA was an outline of the different areas of relevance for determining dependency on nursing care. This was done with reference to established assessment tools, particularly those with positive results in the preceding analysis, and classification systems for nursing care. The different areas were organized in modules. By constantly evaluating and further refining the modules it was ensured that they have enough discriminatory power to be used for determining eligibility and granting benefits.
In total eight modules have been developed: mobility, cognitive and communication abilities, behaviour and psychological problems, self-care, ability to deal with illness-/therapy-related demands and stress, managing everyday life and social contacts, activities outside the house and household maintenance.
In a second step the items for each module have been identified. This was also done with reference to other assessment tools. In addition, focus group discussions with experienced assessors (physicians and nurses) from the Medical Board of the Insurances have been conducted. During the development process international experts on assessmemt tools from the UK and an expert of long-term care in Japan have been consulted to ensure the integration of as much expertise as possible. An overview of modules and items is provided in Table 3.
The Scoring system of the tool was first generated for each module separately. This step was necessary, because of the different contents of the items in each module. The actual assessment is done on a four-point scale. In Modules 1, 4, 6 and 8 the scale embraces the four points: independent, mainly independent, mainly dependent, fully dependent. Module 2 is related to abilities and therefore the scale contains the four points: existing/unaffected, existing to a larger degree, existing to overcome the narrow focus on physical aspects in the existing system without stressing the mental aspects too strongly and neglecting the physical ones at the same time.
Finally, module 5 reflects that the need for care • often arises from chronic illness that requires a range of activities for the person affected and that these activities have an influence on the person's degree of dependence. This justifies a 20% contribution to the overall score.
Using this algorithm the scores from the singular modules are transferred into a score matching the relative contribution of each module to the overall score. The pre-test of the NBA [24] and the evaluation [25] confirmed that the objectives of the NBA can be achieved with the weighting of the different modules.
One of the key features of the new tool is the underlying assumption that dependency can be assessed and measured in terms of a person-related characteristic that exists independently from any contextual factors. This implies a strong distinction between 'dependency on nursing care' as a person-related characteristic and the individual need for care. According to this individual dependency of a person will be the same in different settings and different life circumstances. It can be determined with regard to the person and without consideration of any contextual variables. On the other hand, the individual need may vary considerably due to the setting, general life circumstances, individual preferences and other aspects of the person. While dependency can be assessed by using a tool, a statement on the individual need always needs a negotiation and agreement between the persons involved. The individual need is determined jointly between the person affected and formal or informal caregivers. It is strongly influenced by the context in which it is placed.
Compared to the existing approach the NBA overcomes the shortcomings mentioned above: the narrow eligibility criteria have been considerably expanded and the reliance on the measure of time needed for activities of daily living has been replaced. The NBA instead is intended to assess and measure the degree of individual in/dependence in selected life areas and activities.

Five categories of need
The Advisory Board followed the suggestion of the NBA developers to distinguish five different categories of dependence/independence. These have not been defined arbitrarily as it is criticized in other tools [27], but according to dependency levels and mean values that have arisen from the pre-test and evaluation of to a minor degree, not existing. Unlike in the other areas modules 3 and 5 require the consideration of the frequency of occurrence of the particular items. While in all other modules an assessment on all items is made here usually only some items apply at the same time. Therefore, in module 3 the occurrence of the behavioural or psychological problems is assessed. Even more complex is the assessment in module 5. There it is assessed firstly, whether the item occurs at all. If so, it is assessed, whether the person performs an activity independently. If not, the frequency of the support needed is assessed.
For integrating the scores of the individual modules into an overall score between 0 and 100 an algorithm was developed. To calculate the overall score each module contributes to a different extent. The modules have been weighted as presented in Table 4.
The rationale behind this weighting is based on several considerations. One of the main objectives of the development process was to include people with dementia and other mental health problems in the long-term care insurance without, at the same time, excluding people with problems related to mobility and self-care. The weighting of the modules needs to reflect this objective. Other considerations were as follows: Modules 1 (mobility) and 4 (self-care) play a key • role when determining the degree of dependency on nursing care. Therefore, together their contribution to the overall dependency score should not be below 50%. Results from a previous study [26] indicate that the relation between supportive activities with regard to mobility compared to those with regard to self-care is approximately 1-4. Therefore, mobility is weighted with 10% and self-care with 40%.
The support needed for problems in modules 2 and • 3 is rather similar and includes aspects of observation, supervision, emotional support, de-escalating activities, motivation and the like. Also module 6 is related to problems with cognition and communication. The modules 2, 3 and 6 that are related to cognitive and behavioural aspects account for 30% of the overall score. This seemed reasonable of dependency on nursing care. It can be used for a strongly person-centred approach to granting access to long-term care services and benefits. The advantage of eligibility criteria that have been defined like in the NBA is their usability for various other purposes within a given long-term care system. This relates to the definition of criteria and indicators for measuring the quality of care, the appropriate allocation of funds and the development of staffing ratios. In addition, for service providers the results of the NBA assessment can be used as the starting point for individual care planning.
The options for using the NBA are not limited to long-term care systems only. The understanding of 'Dependency on nursing care also' is considered, as has been outlined above, as a personal characteristic that can be assessed without contextual variables. Therefore, it can also be used to determine dependency in acute hospital or rehabilitation care. The NBA offers an option of using one single assessment tool for different care settings and by doing so can be supportive in establishing integrated care pathways.
The implementation of the NBA in the German LTC will go along with some serious administrative and financial implications. A new understanding of dependency on nursing care challenges all prognosis about the future demand for long-term care in Germany that is based on the old understanding. Given that the new eligibility criteria reflect a much broader concept and embraces physical as well as mental aspects, it can be expected that the number of people in need of care will increase significantly. This would imply a need for more resources to ensure an appropriate amount and quality of services for more people in need of care.
Within the German LTC system the recommendation to use and implement the NBA confirms the approach that was actualized with the implementation of the LTC system in 1995: there is only one general conceptualization of eligibility that applies in institutional as well as home and community-based settings. The degree of dependence is considered to be a personal characteristic that is assessed for every applicant without taking her/his individual life situation into account.
The recommendations of the Advisory Board to the Ministry of Health can be considered as a strong statement of all relevant stakeholders in the German LTC system that a reform is overdue. A change of the existing system is a huge undertaking that needs careful considerations of the implications for the whole social security system. These discussions have been initiated and it can be expected that the recommendations of the new tool. The different levels and threshold values suggested are presented in Table 5.
In summary, the Advisory Board concluded that the NBA presents a suitable alternative to the current assessment procedure and eligibility criteria for LTC benefits in Germany [6]. The Board emphasized that the new tool not only overcomes problems and shortcomings of the existing system, but also creates a basis to address the future challenges in long-term care. In particular the new tool: takes all relevant aspects of dependency on nurs-• ing care into account and is not limited to particular ones, creates more equality, because it now embraces • people with dependency on care due to mental (particularly those with dementia) as well as physical health problems, uses the measure 'degree of in/dependence' for • determining LTC eligibility instead of the problematic measure of time, offers a new way for understanding long-term care • services that nowadays often are limited to the existing eligibility criteria only, which resulted in serious shortcomings of services related to cognitive and behavioral mental health problems, provides valuable and reliable information that can • be used in the various care arrangements for care planning, case management and other purposes.
Because of these many advantages compared to the current system the Advisory Board unanimously recommended to change the existing eligibility criteria within the long-term care insurance system and implement the NBA as the national tool to determine LTC eligibility.

Conclusions
The NBA is a tool for determining eligibility for long-term care based on a theoretically sound conceptualization