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Expanding the Home Care Workforce National Global Perspectives III

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Expanding the Home Care Workforce National  Global Perspectives III Powered By Docstoc
					         AcademyHealth – Annual Research Meeting 2006
               Seattle, 25-27 June 2006, Seattle




Migrant Care Workers in Long-Term Care:

      Lessons from the Italian Case


       Giovanni Lamura, Francesca Polverini
          & Maria Gabriella Melchiorre


     I.N.R.C.A., Department of Gerontological Research, Ancona, Italy
                        E-mail: g.lamura@inrca.it
     Home care workers in Italy by nationality

                        with foreign
                Total   nationality    %
1991           181.096     35.740      16,5
1995           192.942     67.697      35,1
2000           256.803   136.619       53,2
2001           261.390   142.196       54,4
2002           224.243   147.328       65,7
2003           588.701   490.678       83,3
2005           700.000*  600.000*      86,0*
*: estimates
           Contents of presentation


1. The context of LTC in Italy: demographic, socio-
   economic and legal background


2. The role of migrant care workers in Italy



3. Final remarks
                The Italian context (1/3)

growing demand of care due to rapid population ageing:
   oldest country in the world (after Japan);
   improved health does not compensate for worsening potential
    support ratio;

reduction of availability of informal care due to:
   increasing and longer female participation in the labor
    market (increase in female activity rate and raising retirement
    age limits);
   reduction of support from social networks available to OP
    (reduction in number of multigenerational families and
    increase in number of OP living alone)
        Over 65 population in the world's 10 oldest countries and
                          the USA (% values)
  Japan

    Italy

Germany

 Greece

  Spain

Sweden

Belgium

Bulgaria

Portugal

 Estonia



   USA

            12   13    14      15      16      17      18     19    20
              Countries with the lowest
               potential support ratio
          1999                          2050
1. Sweden         3.7       1. Spain              1.4
2. Italy          3.8       2. Italy              1.5
3. Greece         3.8       3. Greece             1.6
4. Belgium        4.0       4. China              1.6
5. UK             4.1       5. Tschec. Republic   1.6
6. Spain          4.1       6. Japan              1.7
7. Japan          4.1       7. Slovenia           1.7
8. France         4.1       8. Portugal           1.8
9. Norway         4.2       9. Rumania            1.9
10. Germany       4.2       10. Austria           1.9
Average (world)   9.2       Average (world)       3.9
     Female activity rate (1994-2004)

80

75
                                        Sweden
70
                                        U.K.
65
                                        Germany
60
                                        Poland
55
                                        Greece
50
                                        Italy
45
                                        US
40
         1994                   2004
         Proportion of elderly living alone
     in some European countries 1955-1995
                                                       US women 75 +
45
                                              Sweden
40
                                              UK
35
                                              Italy
                                                      US women 65-74
30
                                              France
25
                                                        US men 75 +
20
                                                        US men 65-74
15

10
     1955-60          1975-80           1990-95        2003
        Over 65 persons living with children
                (% of total elderly population)
40

35

30

25                                                          Italy

20
                                                            France
15
                                                            U.K.
10

5                                                           Sweden

0
     1950-60   1970-75           1980-85          1990-95
     Over 65 year old persons living with children (2002)
               0   10   20    30     40     50     60       70

     Japan
       Italy
    Austria
    France
        UK
        US
    Finland
  Germany
    Norway
Netherlands
   Sweden
  Denmark
                                                            %
                 The Italian context (2/3)

 “chronic” shortage of nursing staff: 50.000-100.000 nurses
  are needed yearly to face the care demand from hospitals,
  home and residential care sectors (but only 6.000 complete
  training yearly);

 insufficient supply of public home care, despite high
  preference granted by Italian families to this form of care;

 still strong orientation towards a familistic approach to
  elder care (“families should pay for care”, and “children
  should care for parents”)
                   Nurses and practising physicians per 1,000 inhabitants
                                in selected OECD countries
           Italy

        France

         Japan
                                                              Practising physicians
                                                              Nurses
  United States

United Kingdom

      Germany

       Canada

       Norway

   Switzerland

   Netherlands

        Ireland

        Finland


                   0      2       4      6       8      10      12           14           16
                                                                                      %
      Percentage of elderly in institutions or
      receiving home care in some countries
20


15                               Residential care
                                 Home care

10


5


0
     Sweden France    UK      Italy   Poland Greece
                            Preference for home care services
                             over residential care in Europe
      Denmark
       Portugal
       Slovenia
        Austria
Czech Republik
       Sweden
      Germany
   Netherlands
       Belgium
            UK
        France
         Spain
       Slovakia
            Italy
      Romania


                  70                   75                      80                      85                     90            %    95
*: EUROBAROMETER: Which comes closest to your opinion: elderly people needing personal care should go into residential/nursing
homes OR the social services should help the elderly to remain in their homes for as long as possible? (Alber & Köhler 2004)
       Who should pay for taking care of elderly parents?*

    Sweden

     Finland

Netherlands

          UK

     France

   Germany

        Italy

     Poland                                                                   Parents
                                                                              Children
      Spain
                                                                              State
     Austria


                0         10            20           30        40   50   60   70         %80
*: EUROBAROMETER 2002, as elaborated by Alber & Köhler 2004.
                          Yes, working adults should look after
                                 their elderly parents*
    Sweden

Netherlands

     Finland

      France

   Germany

           UK

       Spain

      Ireland

      Poland

         Italy

     Greece

                 20             30                40               50                60               70                80 %   90
*: EUROBAROMETER: If, in the future, working adults would have to look after their elderly parents more than nowadays, would
you say that this would be rather a good thing or rather a bad thing? (Alber & Köhler 2004)
              The Italian context (3/3)
According to the law, any person requiring LTC in Italy can
 count on following public support:
• right to free health care from the National Health System
• right to receive means tested social care from Municipality
  (depending however on available funds)
• right to care allowances (up to 1.250-1.500 $/month) by:
  – the State: disability pensions (means tested) & payments
  – some local authorities (Regions/Municipalities), generally
    means tested
• individual right to alimony from relatives up to second
  degree (often abused by Municipalities to repay support)
          The Italian context (3/3 contd.)

… but the rationalisation of hospital system (introduction
 of DRG system in the early 90s) has caused:

⇒ a sharp decrease in average length of hospital stays

⇒ an increase in number of not appropriate admissions
  of dependent elderly in “older people”’s homes
  (historically born for poor elderly, thus not equipped to
  provide adequate care), due to lack of rehabilitation and
  nursing residential facilities (now requesting also a co-
  payment by users of 40-50 Euros/day after 45th day)
     Average length of stay in Italian hospitals
             (mean number of days)
14

12

10

8

6

4

2

0
     1985     1990    1995    1997    2000    2003
Appropriateness of admissions in old people’s
    residential care in Central Italy (2004)
                                       … rehabilitation
                                            (3%)
                                       ... intensive
                                        care (6%)




                          Not
       Appropriate    appropriate,
          57%        should go to...
                         43%            … nursing
                                       home (33%)
           Migrant care workers (1/3):
        … or: the “do it yourself” solution!
- More and more Italian families resort to migrant care
  workers, often cohabiting with the elderly persons;

- to keep costs low, this often occurs on an undeclared
  basis, by hiring illegal immigrants (who are particularly
  cheap), or legal immigrants without a legal contract;

- this situation was “institutionalised” in 2002, when
  almost 350.000 home care workers were legalised (in
  2006 further 45.000, & current plans for further 100.000)
- this caused a further decrease in the use of residential
  care
         Migrant care workers (2/3):
    Home care workers in Italy by nationality
                         with foreign
                 Total   nationality    %
1991            181.096     35.740      16,5
1995            192.942     67.697      35,1
2000            256.803   136.619       53,2
2001            261.390   142.196       54,4
2002            224.243   147.328       65,7
2003            588.701   490.678       83,3
2005            700.000*  600.000*      86,0*
*: own estimates based on CISL 2006
          Over 85 year old persons in residential care
           in some countries (1990-91 vs 2000-2001)
40
      %




35
                       1990/91      2000/01
30

25

20

15

10

 5

 0
      Women




                    Women




                                  Women




                                                Women




                                                              Women




                                                                            Women




                                                                                          Women
              Men




                            Men




                                          Men




                                                        Men




                                                                      Men




                                                                                    Men




                                                                                                  Men
                                                 GB




                                                                             NL
                                                               US
                                    A
                      P




                                                                                            S
        I




     Source: Tomassini 2004
               Migrant care workers (3/3):
                   Wage differentials

- Moldavia: average monthly wage: 75 $

- Romania: average monthly wage for:
   - medical doctor: 175 $
   - registered nurse: 110 $

- Italy: average monthly wage for:
   - full time (live-in) care worker: 850 $ (net/month)
   - non live-in care workers: 6-8 $ (net/hour)
Families’ motivations to employ migrant care workers
                Guarantee of constant care

                       Keep elder at home

                       Keep same life style

                      Safeguard own family

Unable to provide necessary amount of care

                       Lack of alternatives

             To be able to keep on working

            Cheaper than other alternatives


                                              20 30   40 50   60 70 80   90 100
Source: Spano 2006                                                          %
                 Families with migrant care workers
          by degree of dependency of cared for older person

      Severely
     dependent

     Moderately
     dependent

Light dependent

       Almost
    independent
                  0,0   5,0   10,0   15,0   20,0   25,0   30,0   35,0   40,0
     Families with migrant care workers by income level

25
     %

20


15


10


5


0
          < 500 $             500-1000 $        1000 $ & over

          Income of elderly                Income of carer
     Families with migrant care workers by received care
                         allowances
25
     %

20




15




10




 5




 0
         Disability pension   State care allowance   Local care allowance
       Families that have hired privately paid personnel to provide
              night care during older person's hospital stay
                    0        5          10         15         20      25


       North East



      North West



          Centre



South and Islands
                 Final remarks / 1:
      migrant care workers as an opportunity?
Migrant care workers have de facto become a fundamental pillar
of the Italian LTC “system”, for following reasons:
  – economic convenience: a co-resident care worker costs 850 $
    / month (compared to 1.600-2.200 $ Euros minimum for
    residential care) and is fiscally deductible (public support!)
  – tailored care: able to respond timely to more personal needs
    of both dependent persons and family caregivers;
  – lower/delayed institutionalisation rates: residential care is
    delayed or even completely avoided;
  – convenient to migrant workers themselves:
       • high income differentials
       • low housing costs thanks to cohabitation
                    Final remarks / 2:
          migrant care workers as a “problem”?
The widespread employment of migrant care workers in Italy raises
however questions of:
  – quality of care: need to improve qualification and training of
    migrant care workers;
  – integration with existing formal care services: need to
    “redefine” their role to take account of the migrants’ presence;
  – labour market: recruitment procedures need to facilitate match
    demand-supply of care labour & to control undeclared work;
  – exploitation of migrant care workers: dignified working and
    living conditions have to be better granted (overlapping of gender
    and ratial dimensions of exploitation);
  – “care drain” in sending countries: process is creating a drain of
    young workers from sending to hosting countries
                     Final remarks / 3

On the long term existing care labor shortages need to be
tackled at their roots by:

 improving contents, modalities, resources and quality of
  care work in developed countries, to attract more national
  candidates and thus reduce lack of internal “vocations”;

 facilitating international cooperation programs between
  hosting and sending countries, to improve living conditions
  there and thus counteract brain drain phenomena.
                     “Caring is sharing”:

the way we take care of frail elderly is an indicator of our society’s
ability to share resources with equity within & across national borders



                        Thank you!
    Prevalence of privately paid care workers in
   some European countries (EUROFAMCARE study)
    ITALY

 GREECE

        UK


GERMANY

 POLAND

SWEDEN


             0        2   4   6   8   10   12   14
 Lamura et al. 2005                                  %

				
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