Margit Grilz-Wolf Charlotte Strümpel Kai Leichsenring Kathrin Komp
European Centre for Social Welfare Policy and Research
1 Introduction 3
2 Legal and structural framework - the general discourse on (integrated) care provision 5
2.1 Legal framework on health care and social welfare services 5
2.2 Financing health care and social welfare services 7
2.2.1 Financing health care 7
2.2.2 Financing long-term care: The Long-Term Care Allowance 7
2.3 Process of care provision 10
2.3.1 Institutional Care 10
2.3.2 Community Care 11
2.3.3 Personnel in old age care 12
2.3.4 Family Care 12
2.3.5 Managing pluralism in Vienna 13
2.3.6 Health Care Provision 14
2.4 Stakeholders 15
2.5 Demands and plans for improvement 16
3 Model ways of working 18
3.1 The understanding of integrated care in Austria 18
3.1.1 The terminology used in Austria 18
3.2 Approaching model ways of working in Austria 19
3.3 Theoretical model concepts of working 20
3.3.1 Integrated Health and Social Care Districts 20
3.3.2 The Virtual Hospital at Home 21
3.4 The practical model ways of working 21
4 Conclusions: Lessons to learn 24 5 References 26
Annex:Selected model ways of working 30
A1 Social Care and Health District Hartberg 30
A2 Organization of patients’ care between the Donau hospital and the
Health and Social Centre Donaufeld 32
A3 Discharge-Management in the hospital "Hartmann" - a cooperation
project between Viennese Red Cross and the "Hartmann" hospital 33
A4 Patient oriented integrated care in Vienna, district 14-17 35
A5 “MedTogether – Management between outpatient care and hospital
Traditionally, there has been a distinct division of “cure” and “care” in Austria, leading to enormous differences between the areas of health care and social care provision: Health care has been regulated mainly by federal government (exception: hospital system) whereas social care has been the responsibility of the nine provincial governments. Health care was and is financed by contributions of the social health insurance, by taxes and by patients’ co-payments. Social care was financed through a variety of individual measures in the context of social assistance schemes, many of them different from province to province. Also, health care has always been legally well regulated, whereas many areas of social care still are not subject to specific legislation (Barta/Ganner, 1998; Rubisch et al., 2001: 8).
The Austrian Constitution stipulates that, unless competencies are covered by the social insurance system, all matters concerning social care, e.g. services and institutions for frail older persons, for people with disabilities or children, are a matter to be dealt with by the regional governments (prov-inces/Länder). As a federal framework law on social assistance has never been agreed upon, there are nine different Social Welfare Acts with various differences concerning the extent of benefits, eligibility criteria and means-testing (Leichsenring, 1999: 1).
Thus it can be stated that, for a long time, policies for persons in need of care, i.e. all matters concerning institutional housing, the regional governments have shaped community care and related financial benefits, exclusively. These policies were characterized by an extension of institutional housing and care in nursing homes until the beginning of the 1980s. Since that time, policies were developed to increase the extension of community care services and to look for additional and/or alternative ways of financing measures to cope with social problems related to long-term care (Leichsenring, 1999: 2). Also, there has always been a large proportion of informal, family care provision in Austria (estimation: 80% of all care is informal, family care, mainly by women).
During the past ten years, political debates on necessary reforms but also concrete measures to improve social care in Austria are quite in line with general reform trends in Europe (Leichsen-ring/Pruckner, 1993):
• Firstly, persons with help and care needs are increasingly considered as self-confident clients of social services and persons who – depending on their individual potentials – are able to decide on their care arrangements (see 3.3.1). Especially younger persons with physical impairments acted as forerunners with respect to equal rights legislation and claims for “personal assistance”. Issues of user satisfaction, users’ choice of services and users’/clients’ rights have become increasingly important in the last few years.
• Secondly, the broad consensus is that care in the community is preferable to institutional care. The slogan “care should be provided at home as long as possible, rather than in an institution” can be found in most policy documents concerning social care. In the last few years care in the community has been developed, which reacts to but also poses new challenges for the interface between health and social care.
• Thirdly, it has become clear that services have to be developed to support informal or family carers to ensure that care at home is more adequate, and less expensive than institutional care.
Support services and provisions for family carers are being developed increasingly, but there is still a lot to be done in this area.
An important step in social care provision was taken in 1993 when the Federal Long-Term Care Allowance Act (“Bundespflegegeldgesetz”) was put into effect. The above mentioned issues were debated during the preparation of the Federal Long-Term Care Allowance Act, which allots a cashbenefit to individuals according to their levels of help and care needs, through the whole of Austria. This is one of the first laws regulating social care on the federal level (see below).
Another development to harmonize the area of social care that went together with the implementation of the Long-Term Care Allowance Scheme was the state treaty between the federal state and the federal provinces concerning the development plans for social care facilities. Such development plans were compiled in each region, in order to set objectives in relation to a minimum standard of community care services, institutional care facilities and intermediary structures in terms of quantity, quality, working conditions and co-ordination (Rubisch, 1998).
In the same way as progress was made towards improved coordination within the sector of social services, policies in the health care field have also been focusing on coordinating and harmonizing health provision during the last few years. A health care reform has been implemented since 1997, with the aims to improve transparency regarding costs and services and to support hospitals with regard to optimal resource allocation in order to provide a basis for performance-oriented budget flows from the federal state. Also in this case an agreement between the federal and provincial governments was necessary (Hofmarcher/Rack, 2001: 107-116).
A further agreement on health care reforms has come into effect for the time span 2001-2004 with a focus on uniform planning of the Austrian health care system, including the primary, secondary and tertiary sector with the aim of regionally coordinated planning. Another focus is on improving the management of the interface between different levels and types of health provision.
This paper will give an overview on the legal and structural framework of the varied and fragmented health and social care provision and the ensuing issues on financing health and long-term care. After a short description of the process of care provision with respect to institutional care, community, family and health care there will be a short section on the stakeholders involved in these processes as well as suggestions for the improvement of the integration of health and social care. In order to introduce the model ways of working in Austria, we will provide a comparison between the understanding of integrated care in an international perspective and in Austria. Furthermore, a theoretical model of integrated care provision will introduce the presentation of practical examples. Finally, conclusions will be made concerning lessons learned from the existing situation and from model projects that have been carried out.
2 Legal and structural framework -the general discourse on (integrated) care provision
2.1 Legal framework on health care and social welfare services
The legal framework of health and social care services is characterized by the fact that health and social services are strictly divided concerning legislation and competencies. Whereas health care and its financing is subject to the logic of social insurance, social care functions according to the logic of social assistance. A large variety of provincial laws lead to differing regulations in health care and especially in social care between the provinces. For example, old persons’ homes as well as education for staff in these homes are part of the social services and thus legislated by the provinces. Hospitals and the education of nurses are subject to basic regulation by federal laws.
This same rationale is true for the division between health insurance and social assistance: Only strictly medical services are the responsibility of the health insurance, long-term care is partly regulated by the Long-Term Care Allowance Act as well as by provincial laws (in particular provincial social assistance laws)1. In Europe, this distinction between health provision and long-term care provision is particularly strict in Austria and Germany (Barta/Ganner, 1998: 6-7).
A sound legal framework has a long tradition in health care in Austria but not so in social care. Whereas some provinces have had social care provisions legislation since the late 1970s others did not have such legislation until as late as 1990 (Barta/Ganner, 1999: 7-8). There has been an especially poor legal framework for training and education of staff in long-term care services for the elderly. The first law in Austria regulating the professional framework and education of staff working in help and care for the elderly and people with a disability was passed in 1992 in Upper Austria. Since then other provinces have followed this example. However, there is hardly any standardized provision in Austria, as the provincial laws differ quite substantially (Leichsenring/Badelt, 1999; Wild, 2002).
On federal level the Ministry for Women and Health is responsible for health care and the Ministry for Social Security and Generations has the social care agenda. Many of the responsibilities for the provision of health and social care lie with different departments of the provincial governments. Also, 26 Social Insurance Agencies2 are responsible for the provision of social insurance (health insurance, pension insurance, unemployment insurance). The Ministry for Education, Science and Culture is responsible for academic education and thus – as there is neither an academic education for Social Work nor for Nursing Sciences – only for medical doctors (Hofmarcher/Rack, 2001).
Concerning the legal framework, social insurance (including health insurance) is regulated by the General Social Insurance Law (Allgemeines Sozialversicherungsgesetz).
A specific problem with regard to split competencies in health and social care concerns the hospitals for the chronically ill (Chronische Krankenanstalten). They belong to the area of social care but partly offer the same medical provisions as hospitals. This leads to the phenomenon that persons receiving a certain medical provision in a chronic hospital has to pay for this themselves, while another person receiving the same provision in a regular hospital will have this covered by the health insurance.
The social insurance agencies are autonomous bodies. However, in this area federal legislation regulates their functions and governmental agencies are represented on their boards.
The basic legal framework for hospitals is set in Article 12 of the Austrian Constitution and in the Federal Hospital Law (Bundeskrankenanstaltengesetz). Details on hospital provision in the individual provinces can be found in the Provincial Hospital Laws (Landeskrankenanstaltengesetze).
On federal level there has been a law especially on the education and professional profile of staff in nursing since 1967 which was revised in 1997 as the Health and Nursing Law 1997 (Gesundheitsund Krankenpflegegesetz 1997). This regulates the education of registered nurses and nurses aids (“PflegehelferInnen”). However, it does not include provisions for other staff involved in the care of older people e.g. in old person’ homes. For this group of professionals, the laws of the provincial governments apply. This leads to quite varied educational and professional standards between the different Austrian provinces (Barta/Ganner, 1998; Kalousek/Scholta, 1999:13 ff).
The provision of long-term care is regulated in provincial laws, among others in the provincial Social Assistance Laws.
Since 1993 a federal law was passed to standardize provision for long-term care allowances throughout the country. Since then the Federal Long-Term Care Allowance Act (Bundespflegegeldgesetz) has been the main instrument to regulate and finance long-term care on federal level (see 2.3. for details).
Another development to harmonize and improve the area of social care that went hand in hand with the implementation of the Long-Term Care Allowance Scheme was the state treaty between the federal state and the federal provinces3 concerning “Needs and development plans for social care facilities”. Such plans had to be compiled in each province, in order to set objectives in relation to a minimum standard of community care services, institutional care facilities and intermediary structures in terms of quantity, quality, working conditions and co-ordination (Rubisch, 1998). These needs and development plans had to include the legal framework in each province, a structural analysis of demographic and sociological data, personnel needs in the social care sector, minimum standards for provision, development aims with cost assessment as well as an implementation plan (Eiersebner, 2002: 46).4 In addition, provincial governments bound themselves to implement these plans until the year 2011.
In summary, it should be underlined that not only a legal framework for integrated care in Austria is missing, but that the existing legal framework leads to a lack of coordination within the individual fields (especially long-term care), which results in fundamental barriers to integrating health and social care. Nevertheless, there have been some improvements over the last few years such as the implementation of the Long-Term Care Allowance Scheme as well as the “Needs and development plans for social care facilities”.
The article 15a of the Austrian Constitution allows for special coordination agreements between the federal state and the provincial governments in a specific field (such as health care) that both territorial authorities have competencies in. The aim of these agreements are to harmonize provisions throughout the country and to improve policy efficiency (BMSG, 2001).
As the general framework provided for these plans was quite vague and different institutes or consultants compiled them for each single provincial government, they are hardly comparable as they lack in comparative data sets and common criteria (Schaffenberger et al., 1999).