[Care planning for people with dementia on the margins of care between home care and nursing home: the balance of care approach in the RightTimePlaceCare project in Germany]. / Versorgungsplanung für Menschen mit Demenz am Übergang von der Häuslichkeit ins Pflegeheim: der "Balance-of-Care"-Ansatz im RightTimePlaceCare-Projekt in Deutschland.

BACKGROUND: The balance of care approach is a strategic planning framework that can be used to research the adequacy of care arrangements and the cost implications. It seeks to identify people who are on the margins of care, i. e. whose care and nursing needs could be met in more than one setting, and explores the relative costs of the possible alternatives. This article describes a balance of care application for people with dementia in a transitional phase between home and institutional care in Germany. METHODS: A sequential mixed-methods design was applied that combined empirical data, the decision of healthcare professionals (panels) and cost estimates in a structured way. Data were collected as part of the RightTimePlaceCare project from 235 people with dementia and their caregivers in 2 settings, in nursing homes and domestic care. RESULTS: Based on five key variables, case types of people with dementia with comparable needs were developed. In panels with healthcare professionals there was consensus that people represented by four of these case types could by cared for at home while the reference group of actual study participants was currently being cared for in nursing homes. For these four case types, exemplary home care arrangements were formulated, costs were estimated and compared to institutional care costs. CONCLUSION: There is a potential for home care for a significant group of people with dementia currently admitted to institutional care. Some of the alternative home care arrangements were cost-saving. Despite some limitations, the study demonstrated the utility of the balance of care approach to support the development of empirically based expert recommendations on care provision.

Informal and formal care: Substitutes or complements in care for people with dementia? Empirical evidence for 8 European countries.

BACKGROUND: In order to contain public health care spending, European countries attempt to promote informal caregiving. However, such a cost reducing strategy will only be successful if informal caregiving is a substitute for formal health care services. We therefore analyze the effect of informal caregiving for people with dementia on the use of several formal health care services. STUDY DESIGN: The empirical analysis is based on primary data generated by the EU-project 'RightTimePlaceCare' which is conducted in 8 European countries. 1223 people with dementia receiving informal care at home were included in the study. METHODS: Using a regression framework we analyze the relationship between informal care and three different formal health care services: the receipt of professional home care, the number of nurse visits and the number of outpatient visits. RESULTS: The relationship between formal and informal care depends on the specific type of formal care analyzed. For example, a higher amount of informal caregiving goes along with a lower demand for home care services and nurse visits but a higher number of outpatient visits. CONCLUSION: Increased informal caregiving effectively reduces public health care spending by reducing the amount of formal home care services. However, these effects differ between countries.

Informal dementia care: Consequences for caregivers' health and health care use in 8 European countries.

BACKGROUND: Informal (dementia) care has economic consequences throughout the health care system. Whilst the health and wellbeing of the care recipient might improve, the health of the caregiver might also change, typically for the worse. Therefore, this analysis aims to examine the association between caregiving intensity and caregivers' health and health care utilization. DATA AND METHODS: The empirical analysis is based on cross-sectional survey data generated by the European Project "RightTimePlaceCare" (RTPC). RTPC was a prospective cohort study conducted in eight European countries (Estonia, Finland, France, Germany, Netherlands, Sweden, Spain and the United Kingdom). The health status of 1029 informal caregivers was assessed by measures of psychological wellbeing (GHQ-12) and self-rated overall health (EQ-VAS). Health care utilization was measured by (i) the self-stated proportion of health care use influenced by caregiving and (ii) the probability of at least one visit to a general practitioner within in the last 30 days. The association between caregiving intensity and caregivers' health and health care utilization was assessed by descriptive analysis and multivariate OLS- and probit-models. RESULTS: A higher amount of informal care was significantly related to negative health outcomes for informal caregivers. On average, one additional hour of informal caregiving per day was associated with a decrease of psychological wellbeing and self-rated overall health by 0.16 and 0.42 index points respectively. Furthermore, one more hour of informal caregiving corresponded with increased self-stated proportion of health care use by 0.56 percentage points. However, the claim of increased health care demand due to caregiving as measured by GP visits was only partly confirmed. CONCLUSION: When evaluating the full economic effect of informal care, the impact of providing care on caregivers' health and health care utilization has to be taken into account.

Forgone care and financial burden due to out-of-pocket payments within the German health care system.

BACKGROUND: The amount of out-of-pocket (OOP) payments within the German health care system has risen steadily within the last years. OOP payments aim to strengthen patients' cost awareness and try to restrict the demand on medical necessary treatments. However, besides the intended decline of non-induced health care services there's a risk that people also forgo necessary treatments because the utilization of health care services depends not only on need-factors but also on the ability to pay for it. Therefore, this paper aims to analyze the determinants of the total amount of OOP payments, the financial burden caused by OOP payments and the relinquishment of health care services due to OOP payments. DATA AND METHODS: The empirical analysis is based on cross-sectional data of the German subsample (n = 2851) of the Survey of Health, Ageing and Retirement in Europe (SHARE). SHARE is a representative panel study among private households with persons above the age of 50 years and covers a wide range of topics, e.g. health behavior, health status and information about the socio-economic status. The analysis of the independent variables "total amount of OOP payments", "financial burden due to OOP payments" and "forgone care" is carried out by the means of descriptive as well as multivariate regression methods. RESULTS: Individuals with low income as well as people suffering from chronic illnesses face a higher financial burden and forgo health care services more frequently at the same time. E.g. the financial burden of people who belong to the lowest income quintile is about eight times higher compared to individuals who belong to the highest quintile. The probability of forgone care for this group is about 5.6 percentage points higher [95% CI: 5.2 - 6.0]. CONCLUSION: Especially for the group of people with chronic illnesses and low-income earners it cannot be ruled out that they also forgo necessary medical treatments due to the relatively high financial burden they face. Hence, it is required to facilitate the access to necessary care for these groups.