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Social and Health-Care Policy for the Elderly in Denmark


By: Mary E. Jarden and Jens Ole Jarden
Clinical Geriatrics

 

Ms. Jarden is a nurse development consultant, and Dr. Jarden is Chief Neurology Attending and Chairman, Stroke Department, Amager Hospital, Copenhagen, Denmark.

Trends in Denmark's aging population warrant a discussion of its mainly government-organized and -financed social service and health-care system, which is so closely associated with the well-being of its citizens. Over the last decade a more intensive and active engagement with this rapidly growing older age group has led to government-sponsored research and new standards in health law. In addition, new clinical and social service approaches, as well as the efforts of senior citizen special interest groups, have gained a strong influence on government decision making.

This article introduces the Nordic and, more specifically, Denmark's social service and health-care system and policy regarding the care of its elderly.  

The Nordic Countries
It is typical of Nordic tradition that the federal government assumes responsibility for the welfare of the elderly. This means that the state, regional council districts, and the municipalities are responsible for organizing efforts that cover the elderly's needs. The federal government establishes a budgetary limit for each district and municipality, while local leaders formulate policies and services within those constraints according to the special needs of the community. Generally this effort is organized through an "institutionalized" setting, whereby care is offered and given in either special institutions or at home. Current policy is aimed at providing conditions that allow elderly to stay in their homes for as long as possible. The trend is bringing the care to the patient instead of expecting the patient to seek out care. When assistance or specialized care is needed, a network of nurses and physicians employed by the municipality visits the elderly in their homes or senior living units. If an elderly person reaches a point at which they cannot remain at home, they are offered one of several residential options in senior care. 

The Nordic countries have successfully introduced a growing number of senior day care centers, at which a range of activities are available for all senior citizens. In addition, Sweden and Denmark have introduced social volunteer efforts whereby the elderly can help each other in a variety of ways. 

Geriatrics hospitals and departments specializing in dementia, orthopedics, general internal medicine, and terminal care have also evolved. The Nordic approach represents a system of care that focuses on the individual needs of the patient. 

Taking care of senior citizens is part of a greater Scandinavian tradition covering societal groups not active in the labor market, including children, the handicapped, etc. This tradition is based on equal rights legislation, which secures the aging population an overall, consistent access to health care and other needed services. At the same time, health-care providers are guaranteed equal employment conditions. 

The traditional Nordic social service and health-care model is now considering a more privately organized home-care approach. A few of Sweden's municipalities have allowed private businesses to take over the responsibility of home care, but in Denmark, privatization has been attempted in only a few selected areas such as meal and cleaning services. This trend is still the exception in the Nordic countries, however, and it seems that although many municipalities are interested in finding new ways to cut budgets through private means, others still cling to the more traditional public management of their elderly.1

Geriatrics in Scandinavia
A shared Nordic approach to comprehensive geriatric assessment has been established through the research efforts of academic geriatricians in Scandinavia. The Nordic version of a geriatric work-up is based on Scandinavia's common attitudes and comparable organization of the health-care system as well as the tradition for shared collaboration within geriatrics.2 The concept of Nordic geriatric assessment is based on a model, defining health and disease in old age in terms of functional limitations, pathology, impairments, and disability, modified by extra- and intraindividual factors. The model is founded on the American "Disablement Process" developed in 1994,3 and it is used as the common Nordic framework for evaluation and rehabilitation efforts. 

Geriatrics in Denmark
The present trend is that of establishing specialty units within county hospitals for the elderly, that is, geriatrics units with special departments for dementia, orthopedics, stroke, general internal medicine, and terminal care.

Of the total population over 65 years of age, 4 to 6% suffer from a socially isolating dementia.4 Dementia patients are no longer diagnosed and treated solely by psychiatrists, but are often also in the care of geriatric specialists or neurologists. Special hospital departments and nursing homes provide services for senile persons. This recent interest in patients with senile dementia has brought about multidisciplinary team approaches, using new strategies and treatment methods. Preventive and supportive measures are initiated in dementia cases to avoid, for example, the social collapse of a demented person's family. Other geriatric preventive strategies include programs to prevent cardiac disease, illness related to physical inactivity, spinal degeneration, and reduction of learning ability. Initiation of this preventive approach is developed to improve quality of life in the aging population, whether an older individual is defined as a healthy well-functioning senior citizen or a person suffering from dementia.4

Denmark's Senior Citizens
The average life expectancy in Denmark today is 76 years. Of Denmark's total population of 5.2 million persons, approximately 790,000 (16%) are 65 years or older. Those 80 years or older account for 189,000 persons (3.6%). It is estimated that over the next 19 years, the number of those over 80 years of age will rise by at least 20%, whereas the number of those 65 to 79 years of age will remain stable.

Denmark has for practical reasons adapted a classification system for individuals over 60 years of age, with those over 60 referred to as the third age group and those over 80 as the fourth age group. This age grouping is sustained by the fact that nearly all of the employed have retired by the age of 70 years; 50% retire by the age of 60,6 and the average retirement age is only 61.7 Of those older than 65 years of age, 20% require home health visits/care, whereas 50% of those older than 80 years require this support.8 Approximately 80% of the elderly live independently in the community, and 40% receive state-subsidized social and health services. However, the population over 65 years is responsible for one-third of all hospital admissions, which translates into over 50% of the total number of hospital days in Denmark.9 Because one-fifth of the population is over 60 years of age, one-third of all hospital admissions are persons over 60 years of age; in other words, every other hospital bed in Denmark is occupied by an elderly patient. It is believed that as much as 10 to 20% of all hospital admissions of those over 65 years are due to the side effects of medications, an example of which is the tendency to over treat with antihypertensive drugs, resulting in falls that causes fractures and other complications.10

Denmark's Social Service and Health-Care System
The Danish social service and health-care system is based on free comprehensive medical and social care benefits financed by the government through a relatively high personal tax of 50 to 70% and a tax on goods and services of 25%. Approximately 5.6% of Denmark's gross national product is spent on health-care costs as compared with 10.7% in the United States. This figure even includes expenses for day care, sick leave, hospitalization, and general health care. 

Caring for the Elderly
It was earlier believed that most social and health-care problems of the elderly should be solved through institutional care. Currently, however, the idea is to provide conditions allowing the older person to remain at home for as long as possible. This policy is reflected by the large shift in expenses from the secondary to the primary sector. For example, the number of patients that a public health nurse visited increased 52% between 1981 and 1993; the frequency of visits increased by 132%. These substantial increases in number of home health care patients and frequency of visits are explained by the increased number of citizens over 67 years in the same period.11 From 1981 to 1993, there was a concerted effort toward building communication and cooperation between the hospital, family practitioner, and the public health-care system. The Health Care Committee introduced a model that integrated nursing homes and public health nursing in 1989. In 1983, only 39 local communities offered 24-hour services, a number increasing to 269 in 1995. Over a 12-year period, a total of 230 communities completely revised their policy of care for the elderly.11 

Helping Elderly to Help Themselves
To accommodate the preference of senior citizens to remain in their own homes, the municipality has developed a wide range of services aimed at helping these elderly to help themselves. These includes assistance with cleaning, shopping, washing, preparation of meals, and personal hygiene and care. Home care can be used to assist or relieve family members caring for a sick or handicapped person. Two forms of home care are available, long term and temporary help. Long-term care is provided free of charge, whereas temporary home care visits may warrant individual payment depending on the income of the recipient. 

The public health nurse offers free around-the-clock services including patient education, care, and treatments, and help in filling out applications for various needs, change of residence, aid, and emergency help, as well as applications for senior centers and senior day-care facilities. 

All handicapped, sick, or infirm individuals can have an emergency or safety phone-calling system installed, with direct 24-hour contact to the public health nurse. 

Living Situation 
When elderly persons are in need of another living situation due to health reasons, a more suitable residence is offered.  An array of possibilities are available based on each individual's needs and desires. Senior citizen residences, gated communities, assisted living units, and nursing homes are designed especially for the elderly and handicapped when they no longer can take care of themselves, offering a one- or two-room apartment, elevator, and emergency/contact system as well as social activities. They often differ in their management and administration, and some residences are associated with nursing homes supplying health aides. Resident councils provide representation of the needs of the residents in these senior citizen units. 

A day-care center is offered as an option for those who do not wish to move permanently, but for a shorter or longer period require extra care. Transportation to and from the day-care center is arranged. There is also the option of using a nursing home for a shorter period, to provide a respite for the family. 
Senior citizens receive a full pension while being monetarily responsible for individual services received, such as meals, cleaning, care, and rent. However, no more than 15% of the pension is expected to go toward the rent.7

Pension and Aid 
At 67 years of age, all individuals automatically receive a state pension. In addition, another extension of the social safety net is a supplemental labor market pension, paid for by the employers and designed to supplement the state senior citizen pension.12
A retiree is entitled to a tax-free monetary supplement to their pension fund based on the person's or couple's total income. Therefore expenses such as heating bills and expenses related to illness, medications, dental procedures, and eyeglasses are often financed publicly. 

All retirees can apply for monetary supplements or loans for their housing rent whether they rent or own their residence. Seniors living in a collective housing community can also apply as long as five of the residents are at least 55 years of age.7 
Supplements for foot care and treatment for persons with diabetes, scar tissue, and ingrown toenails are provided.  The general practitioner's referral to training centers for rehabilitation purposes is free of cost, and physical therapy sessions are given at a 40% subsidized rate. Special dental home care visits can be arranged in many districts.

A food service is available, with meals being delivered to the home at a subsidized rate. Additional home and yard services are available to senior citizens through their municipality at a low rate.  

"Seniors Help Seniors" Program
Volunteer work is a new phenomena in Denmark. The Social Service Law of July 1998 administered 700,000 dollars yearly for developing and expanding social volunteer efforts in Denmark. In 1999, regional and municipal districts used as much as 46% of the funding. This project has reached 120 of 275 municipals. The intention is to fight loneliness by creating a network for senior citizens. The goal is to establish volunteer help in the remaining 155 municipalities over the next three years. The perspective is to broaden the volunteer profile by integrating volunteer work into the senior citizen's daily life regardless of the volunteer's age, profession, or ethnic background, thus developing a "shared social understanding" that hopefully will strengthen Denmark's social welfare profile.12

Home Support of the Elderly
In the last decade, societal developments have made it difficult for families to care for elderly family members. As a consequence, care taking of the aging population has become a societal responsibility. At least 80% of the women in Denmark are employed, and over 95% of children are enrolled in some form of day care. It is no longer typical for the younger family members to take care of the older family members, with only 5% of senior citizens living together with their families and 6 to 7% of those 70 years of age and 25% of those 80 years of age living in a senior home facility.6 However, 80% of the elderly see their families once a week, as 60% live within a half-hour drive from family members. Most families use resources available within the family structure, for example, two-thirds of all families help each other by caring for grandchildren, doing yard work or repairs, washing clothes, cleaning, and preparing meals.

Most of the elderly living in their own residence are self sufficient, albeit they have some degree of chronic illness and take multiple medications daily. Of those individuals 75 years of age, less than 5% have problems with making their own food and with personal hygiene, 15% have impaired vision, and 10% have impaired hearing.

Aging Minority Groups 
Aging immigrants in Denmark have traditionally been cared for by their children and family members. This tradition is expected to shift, however, and follow the Danish societal pattern. It is believed that younger immigrants, due to employment and educational responsibilities, will entrust the care of their elderly relatives to the municipality. The number of immigrants over 60 years of age will almost triple in the years to come. In 1997, there were 34,000 immigrants over 60 years of age in Denmark; the projection for the year 2020 is 86,000.13  
The language and cultural barriers that the immigrant senior citizen will potentially meet could cause great isolation, because this immigrant elderly population will probably not take advantage of the wide spectrum of opportunities available to them. As a result, immigrants are strongly encouraged to learn Danish and health-care workers are educated in the special aspects of immigrant elderly care. 

Political Goals and Trends in Policy
Political interest in the aging population has intensified, and great initiatives have been undertaken to improve quality and efficiency while controlling costs in the social service and health-care systems. Highlights of political goals and trends are as follows:9
 
In 1977 the Priority Committee suggested shifting the main responsibility of caring for the elderly from the hospital to the public health-care sector with special emphasis on health promotion and preventive efforts. This suggestion led in 1985 to improvements of conditions for elderly in their own homes, during hospital admission, discharge, and during follow-up care. 

In 1984 Denmark adopted the World Health Organization's goals for health in "Health for all in the year 2000," prioritizing prevention and supportive care. Goal 6 is about healthful aging adding years to life as well as life to years. Adequate care within an acceptable economical framework is enforced, and new programs and facilities for long-term care are introduced. The basic philosophy is to maintain the elderly's mental and physical capacities for as long as possible by offering the appropriate care and support. 

The Health Ministry's report in 1993 stated that a general demand for better planning and coordination of offered social and health-care system services would be prioritized. The elderly individual is guaranteed optimal treatment, care, and rehabilitation, with the goal of regaining their functional level prior to their illness and with the intention of helping that older person reach the highest level of independence possible. 

The "Roedovre project" from 1984 created the basis for the new law on Preventive Home Visits to the Aging (July 1996), documenting the effect of prevention on illness, weakness, and psychological and social problems. All persons over 75 years of age are entitled to receive at least two home visits annually. The goal of these visits is to secure safety and well-being by recognizing their own as well as the municipality's resources.14

Another change in social service and health-care practice in the 1990s at the national level was that all persons, 70 years or older, can receive a public health nurse visit no later than three days following discharge from a hospital. This nurse is responsible for follow-up and ensures that adequate help is available in the home. 

Conclusion
As a result of an active interest in the aging population at the governmental, health professional, and societal level, social service and health-care practices have evolved to directly protect and enhance the quality of life of the senior citizen. Whereas Denmark places a great emphasis on state provisions, a care system that allows for more flexibility in the living conditions and the social environment of older persons has developed. However, it is not without its share of challenges, facing a rise in health-care expenses while confronted by the question of how to provide universal service while containing costs. 

 


Copyright 2002 Global Action on Aging
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