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Introduction
There are times at which an individual needs special care in our daily lives in order to live as long as he can. People reach a stage when they become old and require special care. These individuals also include people suffering from cognitive impairment either in their early age or at their older age. For people as such there are different programs being followed in the United States and Europe. Recently a new modernism is being followed in the long-term care of the elderly persons which is known as consumer directed home care. These are basically governmental programs which help elderly people, providing them with different sort of services, which includes who will provide them with the services and also how to deliver these services. Such programs usually allow the customer to manually control the home care workers. This enables the customers to receive services in their desired form and upgrades the quality of care as well. If we compare these programs to those with traditional ones, which rely on public or private agencies providing customers with services which were controlled by these agencies, to serve program beneficiaries. Consumer directed home care services program have been rather slow to work on as there are concerns, whether older people are capable enough to direct these services and actually want to direct these services. These concerns were more severe for those who were suffering from cognitive impairment as they could not manage their affairs of daily lives by taking their own decisions as compared to those who were at their older age but were not suffering from any injury. These people mainly could not control the workers, as they could not hire and train them to their needs rather these people required agency services. These private agencies could examine all their needs and appoint some employee to take care of such people and make decisions for them rather they making their own decisions. There are also concerns on the quality of care private agencies provide without been monitorized by higher authorities. All these concerns were majorly to provide the elder people with quality that satisfy their needs. Older people need these services not only to get services which provide them with care, but services which provide care with quality. This provides them with a better quality of life in their older age, without having to work and getting services in what so ever task they feel difficult to accomplish. Private agencies provide them with services but there is a need to supervise these agencies by higher authorities so that the services provided by them have quality to help elderly people in all sorts of problems. (Tilly, 1, 2000)
Long-term Care for Older People
Long-term care for older people is a plan or matter that is aimed to bring many different services and techniques for the help of the older people who are not able to take care of them selves completely and depend on others for helping them in carrying out their daily activities. It is estimated that in the next coming 30 years the demand and need of the long-term care for the older people will also get increased. Nineteen countries that are the members of Organization of Economic Cooperation and Development (OECD) are working really hard in order to give response to the growing demand of older people care. These countries include Australia, Austria, Canada, Germany, Hungary, Ireland, Japan, Korea, Luxembourg, The Netherlands, New Zealand, Norway, Mexico, Poland, Spain, Sweden, Switzerland, the United Kingdom and the United States. All these countries want to enhance the level at which the older people can have access to these services that are being provided for the long-term care and these countries also wants to enhance the quality of services that are being provided. Another objective of these countries in regard of long-term care for the older people is to provide them the services at the reasonable and affordable ranges. The plans for providing the caring services at home to the older people are also being planned. These 19 OEC countries are analyzing the past expenditures, costs and the people that have received these long-term care services in order to find out that what improvements can be made. The care taking services should also eliminate every kind of differences like religious, country and other such differences. The programs and services that are being given to the older people for providing them the long-term care services are being observed by these 19 countries in order to add more options for providing better care. (Long-term care for older people, 1, n.d)
Private Home Care Agencies
The traditional programs to provide older people with care rely on public and private dealings. They provide elderly with facilities or services to help them in their daily needs. Their basic task is to provide the people of old age or disabled clients to provide services so that they remain in their own homes by getting private home care at their doorsteps. The people at their old age are of the point of view that there only option is to remain at their residents or at a care centre. This enables them to live a life as long as possible for them when they are being taken care by provincial care. Private agencies carefully assign their workers to different old age people on the basis of their work experiences and also by taking in notice different personalities of their customers. These private agencies are fully aware of the problems which are being faced by the people at their older age. The workers working under these agencies undergo training at different stages so as to learn different circumstances which can be faced by customers of these agencies. Every individual is allotted with different tasks by the manager of these agencies so to provide care to the elderly in the best possible way. Private agencies at the best of their knowledge provide elderly with care so that the elderly can be assisted in their daily lives. (Private Home Care Agency, 1, n.d)
Private Duty Home Care Workers
There are different sort of workers that can provide older people health care. One of the basic needs for the older people is to be taken care of them at their own homes. The workers which help the old people in providing them with custodial care are often referred to as home health aides, certified nursing assistants and care workers. Mainly these workers stay all the time with the old people in order to provide them with all the services in their daily routine and take care of them in all their activities. These health care workers mingle with their beneficiaries by staying with them in their environment and making it comfortable for them as well as for the older people in maintaining a familiar environment. Such environment helps both, worker as well as the beneficiary, to interact with the each other and achieve a state of understanding. This worker provides them daily routine tasks such as bathing, dressing, feeding, and all other basic activities which are necessary for living. Not only this worker provides their beneficiary with basic needs but also provides them with help which has been quoted as instrumental activities such as shopping, transportation, making medical arrangement and many more. As it is true that persons usually prefer services within their residential address but there are certain individuals which require round the clock services. Such individuals are required to remain in a nursing facility so that they can be kept under view. This not only gives them full time nursing facility but also it is cost effective rather than appointing a worker at their residential address, which can be expensive for the older people. (Hiring Private Duty Home Care Workers, 1, 2009)
Consumer Directed Programs
Consumer direction is the indicator of future and in upcoming years aging individuals will be very much aware of heath care and long-term care services has trained staff for long-term care, mental health to train the consumers for their long-term health care. There is an office for training and studying the age individual for the leading role of promoting consumer directed in South Carolina. The training involves the evaluation of an agencys current climate/trend and to know how they can encourage consumer direction and promote the culture change. The purpose of this training is to empower consumers to direct their own care. This training provides opportunities for trainees to implement person-centered planning skills to develop competency prior to application in the field. Consumer directed programs not only provide caregivers with education but also consumers with education and due to such programs elderly people will be more educated in future years. This will enable them to direct all their problems to the best of their knowledge and get help from people by desiring more input from the health care people and control them in the long-term in providing them with best services. In these programs the workers are trained by emphasizing philosophical assumptions. Also these trainings provide the workers with opportunity to demonstrate their skills. (Consumer directed care, 1, n.d)
Structure of the Consumer Directed Program
The countries that are interested in the analysis, development and designing of consumer directed home care programs include Austria, Germany, France, the Netherlands and the United States. Many of the US states were involved in this analysis like California, Colorado, Kansas, Maine, Michigan, Oregon, Washington and Wisconsin. All these countries wanted to make older people to take part in the programs. These countries wanted to establish the program for the long-term consumer directed programs and for this these countries analyzed, designed and experienced the consumer directed home care programs. For such programs all of these countries that are involved had to observe and then take decisions over the major areas like administration, management, ability, allocation of resources, budget, cost containment and services that have to be provided. In most of the countries the agency directed programs are followed but in Austria the consumer directed programs are being used. The long-term care systems are very much dominant in the Netherlands and the United States. On the other hand in France and Germany the consumer directed care programs are in much use. The administration of these consumer directed programs are being done by the countries that are sub national insurance funds countries like Austria, Germany and the Netherlands and also can be administered by the local governments or the states like France and Germany. The national government does not administer the complete program by itself. But the situation is entirely different in the United States because the states do not need to provide consumer directed programs for long-term care. Each of the country that is involved in the establishment of such programs should analyze and use the methods and measures for finding out that can assess and judge the performance of the applicants that are involved in this program; the performance can be observed by analyzing their daily activities. This analysis is required to find out that whether the applicants are eligible for this work or not? German critics argue on the point that their eligibility criteria does not include people with cognitive or brain injuries where as in France critics say that the implementation of their assessment in partially towards those who have medical needs. The people that are having any problems in regard of cognitive approaches are definitely allowed to take part in such programs as an applicant but in the few of the US states it is not allowed to hire a cognitively impaired person. It is recommended and allowed by most of the programs that they hire cognitively impaired applicants but allow them to hire decision makers with them so that they can take good decisions. All the countries that are establishing and using these programs are provided with the cash payments as a benefit by their governments or states. These cash payments are basically used to introduce or buy new services for the old people in order to take care of them or these payments can also be used for supporting the caregivers that are informal. These cash payments can also be used for buying the services that are being used by the independent workers. All the benefits that have been provided by the government to the countries that are working for implementing such programs can be used in different ways and different kinds of benefits can be attained by these benefits. In many of the countries the government does not take care and look after that how the money or cash has been used and such countries use the beneficiaries without any limitations. Austria and Germany are two such countries and these countries use the majority amount of their benefits over the individual and independent caregivers instead of using it over the programs that are being established for providing quality care to the older people. In France the cash payments are given by the government and it is recommended that this amount should be spent over the workers for providing them more facilities in order to take more work from them. In the Netherlands, the vouchers are given which are then used for buying the services from the individual caregivers or from other different agencies that are working for the same purpose. The countries like France and the Netherlands preserves some of the benefits and then use it for any other kind of service that is needed or for any tool or equipment. In most of the US programs it is usually allowed to employ and fire the workers. These services are sometimes provided in large quantity to the countries which are not very strong in terms of financial conditions and some of these services are provided on the universal basis which means that the services are provided to all the countries. Austria, Germany and the Netherlands do not pay their attention over the financial status of the countries. Where as in the US and France most of the services are provided to the countries who are not very strong financially. General revenues and insurance premiums are being given to the countries for spending over these programs. Another major area of concern is that, obviously the need and demand for the services to enhance the program for providing are to the older people will continue to increase and would not be able to get controlled. This need can definitely make the expenses to get increased so much. So every country that is implementing these programs should set a limit for them that to what extent they have to utilize over providing the services. The limits and restrictions should be put over the criteria for the selection of employees, benefits that has been provided to the countries for the programs, services that are being implemented in the programs for the care takers and also the other beneficiaries. The amounts of the benefits should not exceed that much that it comes under the category of inflation. The eligibility criteria for the workers should be so strict that only the eligible people should be selected and not any other. The budget for the consumer directed programs should be limited so that other facilities can also be provided to the workers. All the factors that have been discussed above are very much essential to take care when it is being planned to establish the customer directed programs for the long-term care of the old people. (Tilly, 1, 2000)
Consumer-Directed Programs and Beneficiary Experiences
In a consumer directed program the beneficiaries and the caregivers have different experiences. In these programs the beneficiaries mainly hire the people from whom they want to be cared by and then train them in order to make them experienced enough to help their beneficiaries in every situation.
People requiring Consumer Direction
The most important influences rather than age are the personality of the human being, which requires services to help them in their daily routine. Also their circumstances count towards the sort of service they need from their caregivers. Mostly people with broad point of view and having a network of people hire workers which are being directed by them. Other people which are younger having some disabilities are quite vocal and express their point of view in referring their need for consumer direction. Also people who are older and have some sort of a disability mostly refer caregivers to be from the agencies rather than selecting them and controlling all the functions. There have been surveys in the United States to verify how many percentages of older people refer to consumer directed programs, which was quite moderate. In all it was observed that the mostly people with old age and having some sort of injury or disability prefer private agency workers to help them in their daily life schedule. While, young people prefer to control their caregivers, in order to live a life independent from their families. Regardless of these concerns found in the people with cognitive impairment, they contribute to consumer directed programs in at least one country. (Tilly, 1, 2000)
Beneficiary Experiences from Consumer Direction
Consumer directed programs mostly help their beneficiaries to become independent, by living their lives as they want to and making choices to how they want their services. There are some beneficiaries which are of the point that agencies does not respond to them due to their scheduling and staffing practices. They could not interact with the consumers specifically early in the morning, and on the weekends. They should rather schedule their employees properly so as to provide beneficiaries with the best possible service. Also due to these scheduling mistakes beneficiaries have to deal with different workers in a week. The private agencies and union representation are of the point of that services offered to beneficiaries are equivalent, in case of consumer directed services or agency directed services. But, universally it was observed that consumer directed services were more preferred by the beneficiaries to avail all the benefits for their health care. (Tilly, 1, 2000)
Experiences of Workers in Consumer-Directed Programs
Workers in traditional home care programs where they are liable to work under the rules and regulations and take their salaries from agencies. Where as in consumer directed services the workers are directly answerable to the people who are able to get the benefits, so how do their experiences differ from each other.
Role of Family Caregivers
In consumer directed programs the family caregivers play a very important and essential role. The family caregivers do care for the older people by working along with the consumer directed programs informally or formally. In the Netherland more than half of the workers caring for the people who were their family, friend or any other acquaintance. But in France this statistics was some how low as compared to the Netherland. The 30% of the total workers in the consumer directed programs are also the family members of the people to which the care is being given. In California again the statistics showed that more than 50 percent of the total workers were from the family and friends of the caretaker and the accurate figure was 75%. The reason for this observation that the caregivers are mostly from the friends and family members is that in very rare cases the beneficiaries or the care takers go to the agencies and companies that do provide the care givers. The beneficiaries mostly give priority to find out the person for taking care of them from their own family or friend circle. If the observations are made in the countries of Austria and Germany then again this assumption proved to be the right one, although no proper statistics is available for these countries but it is strongly assumed that the people of these countries also prefer to depend on the informal caregivers. The representatives from the government have observed that in four of the states of the US majority of the beneficiaries are using the care givers that are informal. Many of the people that have been using the services of the consumer directed programs for the long-term care of the older people were asked the reason for this high ratio of family care giver during the survey. The reason that was agreed by majority of the people was that it is better to spend money over their family members or their friends by appointing them as the caregivers. Another reason for this can be because people want to promote the informal ways of providing care to the older people instead of gathering new workers and employees and extending the circle of the labor for providing the services. May be this entire trend begun due to the shortage in the labor when it was needed or maybe there is some other reason but this reason is unknown and the people can just make their observations by taking interviews and conducting surveys. In many countries it is believed that the financial assistance that has been provided by the government like vouchers and cash payments should not be used for hiring new employees but instead by appointing the workers from the family and friends that money can be used for paying the workers and also for introducing new services. In countries like Germany, the cash payments and vouchers are used for finding and appointing new workers as care givers. Very small number of agencies, countries, unions and companies are not in favor of hiring the people from the family and friends as the care givers. This opposition is because these countries think that if the people from the family or friends are being hired then this customer directed program just becomes a way for facilitating the family and friends and the aim of providing the services for the care of older people cannot get completed. But the countries that are in favor of informal care givers do suggest that if the family and friends are being hired then these people should also be necessarily provided with the trainings, benefits, workshops and guidance and all other stuff that is given to the formal workers. It has been proved from many studies that a very small number of care givers from family and friends do change their working behaviors if they are being paid by cash allowances and funds. It has also been observed that the informal care givers some times do not take their work seriously and do not work for full time, they minimize their working hours but it is also believed by some people that if the allowances are given to the informal caregivers then they take care of the beneficiary in the more proper ways. Obviously if some one is giving his services for any reason then he or she must be paid and this cash payment or any other allowance will make him or her to work harder. Another fact that is really believed by majority of the people that if the caretaker is informal and some one from the family or friend then there exists some emotional stress over the care giver but if the person is a formal worker then there will be no emotional stress over the worker. The emotional stress sometimes makes it difficult to perform the task easily as it is not easy to see your loved ones in pain. It has been surveyed that the caregivers from the family and friend obviously do provide very much care but they also get very much emotionally stressed and feel a lot of emotional burden while seeing their loved ones in pain. So having the informal care givers are having both the positive as well as negative aspects but it is recommended that the informal caregivers should also be provided with the proper training stuff. (Tilly, 1, 2000)
Relationship of Workers with Beneficiaries
According to the analysis, estimations, observations and surveys made, this fact is quite clear that the workers that are working individually or the informal workers are having strong, close, frank, comfortable and good relationships with the beneficiaries as compared to the formal workers. The strong relationships among the informal workers and the beneficiaries is due to the fact that the informal workers are among the family and friends and they do have sound relations with the beneficiaries before working for them as the care givers. The informal care givers obviously do give much time to their relatives and friends whom they are serving and do not take many clients because they are seriously concerned with their care takers. The informal care givers obviously do spend long time periods with their family members or friends whose care is being taken by them. In a survey it was observed that in the Netherland, 90% of the individual or informal caregivers were having the sound relationship with their care takers or beneficiaries. 75% of the workers in California are also individual workers and are having good relationships with their clients. So in short it can be said that the workers who are informal do have good relationships with their clients as they already know each other before providing services. Although the formal workers can also have good relations but they obviously need some time to get close to their clients and make them feel comfortable. (Tilly, 1, 2000)
Ensuring Quality Long-term Care for Older People
The need of long-term care for older people is growing day by day in countries related with OECD such as United States, Austria, Canada, France, Italy etc and with the growing number of older people a question arises that can these people be provided with proper care at a price that is affordable for them. With the aging process as people grow old and weak they tend to become choosier about things like care, environment, medical facilities etc. They would demand a high quality care and the differences in the availability of these services show that some people are not even getting it. The Government of these countries should look into this matter and provide proper facilities and care to older people. Among many issues in which the government must look into is one important matter that whether the old people who need assistance in their daily routine activities like walking, bathing, dressing etc should be given help in their homes or they should be accommodated somewhere else, if they are accommodated in some other place can facilitate a large number of people or not and besides that an important question that if these people are given a separate accommodation who is going to pay or provide them care. As number of weak old people is increasing its high time that the Government should keep aside more money for the long-term care of such people through public and private both sources.
OECD has made a careful analysis by examining countries that have made major reforms to improve their long-term care system over the past few years. In this policy a detailed analysis related to different issues such as cost and expenditure and with the answer to most crucial and important question that who is going to pay for these care services. It also puts light on the program that these countries initiated to provide a choice for care options including cash to family.
First of all the major issue to be addressed is the cost of long-term care for elderly people. Normally people are living a healthy life in a normal budget but the long-term care can have a major effect on the budget. This is on top of the care that a family member or a friend voluntarily provides to these older age people. Several countries have made a remarkable progress over the past few years in rising above the fragmentation or division of service deliverance and financing across civic programs, districts or groups of people. Mainly in most of the countries the major source of financing is through taxation but a number of countries including Germany, Japan, Luxembourg and Netherlands have now chosen a new way which a social-insurance-type solution to provide resources and funds for long-term care facilities. Countries where public funding for long-term care for older people is still comparatively low enlists Hungary, Korea and Mexico due to which the care provided in institutions is in a quite limited quantity. The range of total expenditure on long-term care in OECD countries ranges from 0.3% to 2% of the Gross Domestic Product but most of the countries spend even less than 1.5% of their gross domestic product (GDP). The only countries spending more than 2% are Norway and Sweden; in OECD they have the highest distribution of people of and above the age of 80 years. They provide offer services which are broadly funded by public finances for those who are in need of serious care mainly in nursing homes but besides that they also provide services for home care. Even in these countries that are providing so much of long-term care light care is also provided to older people by their family members and friends. Differences that are observed in the spending levels of countries for long-term care services depend on the public funds and or how much widespread is the provision of public services. The services offered by nursing homes differ widely between countries depending on many factors for example how many people are accommodated in a single room and the facilities available to them. This is the reason why the distribution of older people in the population on its own only counts for just little more than 50 % of the variations in seen in expenditure of different countries long-term care spending. On the other hand in future when the number of older age people will increase suddenly more and better resources will be needed for long-term care services through public and private both funds.
Providing such care to older people at their home which can provide them with the facility to stay at home longer can help a lot in improving their health conditions and this is the thing which most of the people want. The main advantage of keeping old people n their homes and care for them is that it costs much less than keeping them in a nursing home or some other type of housing care. An important factor which can help achieve this goal is to make available a wide range of care services available which may include breather care and specialized guidance to family members. Today home care counts in the 30% of the public funds are being used up on the long-term care services in the countries related with the OECD. So now older people are in need for care now prefer to stay at their homes. Care at homes is made easier because when an older person needs care his or her partner is likely to remain in good health longer. Other than this nowadays pensioners have high incomes as compared to earlier groups hence they can afford to pay more for their care and similarly standards of living have also been raised. Besides the development in services such as the respite care or breather services there have been other services that have been initiated to promote informal caring. These services may include giving pension cards for the amount of time spent on caring and compensatory money given to the person taking in compensation of the loss of earnings. Due to these policies a question arises about the future outcomes of giving incentive money to the curers who leave their market jobs and start to provide care to older people, specially females, it will get difficult for them to get back into market later on. Long-term care policies can face a number of challenges in accomplishing their goals for example when they overlie with other social and health services including care provided by family members and friends. As an example a problem in managing sensitive health care, treatments and long-term care can cause inadequate results for patients and can result in substandard use of health care resources. To overcome these coordination problems new policies have been set up in many countries through a variety of ways. These types of coordination policies are put into practice by multidisciplinary care evaluation teams. These teams provide guidelines to families and end users or customers about the care substitutes that are accessible and what way should they opt for as an individual.
Within the past 10 years the Government
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