User need and resource allocation in public long-term care. The use of disability and impairment instruments: Application on a large Norwegian municipality

Summary: In the coming decades, the European countries will witness great demographic changes. Within the next 25 years, the number of people aged 80 years or older will double. The elderly’s overall use of resources will increase considerably. Disability is the most important cause of the amount of care needed. The overall aim of this thesis is to assess the relationship between factors describing disability and impairment and the use of long-term care services both in a nursing home setting and at home. Since 2006, all Norwegian municipalities have been required to assess user needs using a standardised national registration system (IPLOS) that contains variables describing physical disability and cognitive impairment. This is the only instrument used across all Norwegian municipalities. Here, we utilised the same variables as those used in the national registration system and combined them with detailed time studies with recipients in the municipality of Trondheim. Our findings from study 3 show that the Norwegian instrument had difficulties in differentiating the need of the least disabled elderly individuals. However, this is a wellknown problem of disability instruments due to the trade-off between administrative burden and an “ideal” instrument. Introducing new variables to close these gaps should be considered. In study 1, we found that the amount of individual care received depends on both individual disability and differences between nursing homes. Approximately ¼ of individual differences could be explained by differences between nursing homes. Furthermore, we found that within a financial reimbursement model with no adjustment for case-mix, the amount of care that patients receive depends not only on the patients’ own needs but also on the needs of all the other residents. Thus, if one lives with less disabled patients, one receives more care than an individual who lives with more heavily disabled patients. In study 2, we found that home-dwelling elderly’s public use of care could largely be explained by disability and cognitive impairment. IPLOS seems to explain use of public care to the same extent as other indices. Those with comorbidity received 21 percent more public care than others. Those living alone received more public care than those living with others. Cohabiting women received approximately 30 percent less care than those living alone, while cohabiting men received approximately 50 percent less care. Furthermore, we found that behaviour is the most important predictor of the amount of public care for intellectually disabled persons but that help in performing everyday activities is also important for these persons, as it is for elderly individuals. Care from relatives or other private care is complementary and does not affect the amount of public care. Thus care from relatives or others act as a substitute for public care for home-dwelling elderly while it is complementary to public care for intellectually disabled persons. The results from this study could be used in overall administrative planning of public long-term care. The municipality of Trondheim has changed its reimbursement model for nursing homes and home-dwelling elderly since these results were found. Furthermore, the municipality is now changing its reimbursement system for intellectually disabled persons according to the results of this study