Elderly people in care

homes

(EHPAD)

2022 Annual Public Report

2

_____________________________ PRESENTATION _____________________________

Just over 600,000 people live in one of the 7,500 care homes for dependent elderly

people (EHPAD)

1

. Although these are accessible from the age of 60, they in fact accommodate

a much older population suffering from multiple pathologies: one person in ten over the age of

75 lives in a care home, one in three being over 90

2

.

The health crisis has therefore particularly affected their residents: nearly 34,000 of these

residents died as a result of the pandemic between March 2020 and March 2021. This

particular vulnerability cannot be explained solely by the fragility of the residents. It also results

from the structural difficulties of care homes.

Following a survey focusing more broadly on the quality of medical care in care homes

3

and based in particular on 57 detailed studies of homes carried out by the regional courts of

accounts and the Court of Accounts, it seemed useful to the Court to report on the impact of

the health crisis on these homes and the vulnerability factors explaining said impact (I). This

crisis was an opportunity for new forms of organisation with, first, considerable financial

support decided by the Government, whether short-term, in order to deal with the immediate

consequences for homes of the health crisis, or long-

term, within the framework of the “Ségur

de la santé” plan and, second, the emergence of good practices from players in th

e healthcare

and welfare sector. However, these developments have not been accompanied by the far-

reaching structural reforms that seem necessary (II).

1

According to the Drees (

Studies and results no. 1196

, July 2021), at the start of the pandemic, there were 7,547

care homes accommodating 606,400 elderly people.

2

Drees,

728,000 residents in residential homes for the elderly in 2015

,

Studies and results no. 1015

, July 2017.

3

Survey carried out at the request of Parliament (Senate Social Affairs Committee), in the context of which the

financial courts audited 57 homes throughout the territory, including overseas, as well as the main public players.

An additional investigation covering the period from August 2020 to July 2021 has been produced for the purposes

of this publication.

3

I - The severe impact of the crisis on the elderly, amplified by

the structural deficiencies of care nursing homes

The covid-19 pandemic has caused a high number of deaths among care home residents

(A). The developments of the epidemic, to which care homes have tried to adapt (B), have

highlighted their structural weaknesses (C).

A - A high cost in human terms

In general, management of the pandemic improved very strongly between the first wave

- during which, despite drastic measures, sometimes experienced as too uniform and brutal,

care homes were particularly hit -, and the third wave, which, for the most part, spared them,

thanks to the vaccination campaign.

All in all, the human toll of the epidemic can be considered heavy, even if international

comparisons show that other countries have revealed weaknesses similar to or even greater

than those observed in France.

1 - Significant mortality during the first two waves, affecting different territories and

homes

Reliability of statistical sources listing the number of deaths in care homes and the

number of cases

The Court of Accounts worked on data for the period from March 2020 to March 2021,

consolidated by Public Health France and forwarded by the Department of Research, Studies,

Evaluation and Statistics (Drees). Data concerning deaths are coherent with those published by a

consortium of research organisations in September 2020.

The

number of deaths corresponds to care home residents who died as a result of covid-19, in

a hospital or in the care home itself.

Hospital deaths were recorded using the Si-Vic information system, set up after the November

2015 attacks to identify deaths occurring in exceptional conditions.

Deaths in care homes were recorded using ad hoc computer-based systems set up during the

pandemic: a system developed by the Paris hospitals, specific to Île-de-France and used until July

2020, and a system rolled out throughout the territory, developed by Public Health France, called

“Voozanoo” and making it possible to trace not only the number of deaths but also the cases and how

these developed. Since July 2020, Voozanoo has been the only information system used to identify

cases and deaths in care homes.

The data entered in Voozanoo dates back to 1

st

March 2020. However, according to the Drees,

they can only be considered reliable and exhaustive from the end of April 2020.

Data relating to cases are also subject to caution, up until implementation of systematic PCR

tests in care homes, which started in May 2020.

Wave 1 data should therefore be considered with caution.

4

According to Public Health France and the Drees, over the period from March 2020 to

March 2021, 34,000 elderly people in care homes died as a result of covid-19

4

. Of these,

14,700 died between March and 1

st

July 2020, 14,600 between July and 1

st

January 2021 and

4,700 in the first quarter of 2021. However, preliminary epidemiological studies concluded that

the death rate was actually a little higher

5

.

During the first wave, in the 3,497 care homes affected, 80,100 residents were infected

and 14,700 of them lost their lives (which represents 50% of the deaths recorded during the

first wave of the epidemic

6

). During the second wave, 144,400 residents were infected

7

. The

number of deaths (14,600) was almost identical to the number of deaths in the first wave. The

presence of personal protective equipment

8

(PPE) and testing, knowledge of protocols and

health partnerships were not enough to reduce the number of deaths. However, this wave was

longer and affected almost all regions. As a result, the number of cases was higher. However,

these figures should be interpreted with caution, the absence of tests at the start of the first

wave not making it possible to determine with certainty the number of elderly people infected.

Care homes were very variously affected depending on their geographical location.

During the first wave, 4,436 deaths

9

were recorded in Île-de-France, 1,809 in Grand Est, 1,339

in Auvergne-Rhône-Alpes, 1,244 in Hauts-de-France, compared to only 225 in Nouvelle-

Aquitaine, for example. The second wave lasted longer and was more widespread in

geographical terms than the first, but territorial disparities remained significant: the regions and

homes most affected during the second wave had been only slightly affected during the first.

Over the period from March 2020 to March 2021, 80% of care homes were affected, but only

37% were hit over several episodes

10

.

4

Source: Drees databases, based on figures from the French Public Health Agency

5

A study conducted by the COMONH consortium, bringing together several researchers belonging in particular to

the AP-HP, the CNAM, the INED, SPF, the INSERM and various universities, gives a death rate linked to covid-19

of 15,114 deaths, while SPF data identifies 14,054 deaths over the period from 1

st

March to 1

st

June. The COMONH

Consortium,

Magnitude, change over time, demographic characteristics and geographic distribution of excess

deaths among care home residents during the first wave of covid 19 in France: a nationwide cohort study

, Age and

Ageing, 2021.

6

Drees,

In 2020, three out of four care homes had at least one resident infected with Covid-19

,

Studies and results

no. 1196

, July 2021.

7

Compared to 80,100 during the first wave: but due to a very different testing policy between the two periods,

comparison remains problematic.

8

In care homes, personal protective equipment includes masks, gloves, gowns, aprons, headgear and eye

protection.

9

Whether the resident died in the care home or in hospital.

10

Source: analysis by the Court of Accounts.

5

Map n°1: the most affected regions (wave 1 and wave 2)

Source: Drees

International comparisons made by the European Centre for Disease Prevention and

Control

11

should be considered with caution. In fact, the concept of

“

nursing

homes”,

on which

they are based, brings together very disparate realities. Within the same private group

established in several countries, comparison of its various entities subject to the same

reporting rules due in particular to common medical management, can, to a certain extent,

eliminate certain biases and allow a better approach. It thus emerges from the summaries of

the Colisée group, relating to the period from 1

st

March 2020 to 1

st

February 2021, that the

proportion of residents affected by covid-

19 in the group’s French homes (44.4%) was lower

than that observed in its homes located in Belgium (46.5%), Italy (64.7 %) and Spain (53.2%).

The proportion of residents who died was also lower in France (5.1%) than in these three

countries, where it reached 6.8%, 7% and 6% respectively.

There is not much epidemiological work yet to help explain why, in the same

geographical area, some care homes were more affected than others. A study carried out in

June 2021 by Public Health France and the Regional Health Agency (ARS) of Nouvelle-

Aquitaine with around fifty care homes

12

collected data on the characteristics of the homes

affected. The lack of human resources, the unsuitability of the premises, the late introduction

of preventive and control measures stand out among the risk factors in the spread of the virus.

In particular, the care homes most affected are those whose proportion of full-time equivalents

(FTE) of paramedical staff, nurses or coordinating doctors was lower.

11

12

6

Other factors of improved resistance to the pandemic, highlighted by the Drees in a study

in July 2021

13

, relate to the size of the care homes, their location in the catchment area of an

urban area of more than 700,000 people and their legal status. It shows in particular that private

sector commercial care homes, where the resident supervision rate is lower, were significantly

more affected than other structures during the second wave. Nevertheless, they are also those

which accommodate, on average, residents with the most serious pathologies requiring more

care. Conversely, care homes attached to public sector hospitals were less exposed to the

virus than others, probably thanks to their link backing to a healthcare establishment.

2 - A poorly documented psychological impact

Few care homes, at the end of the first wave, carried out systematic psychological and

physical assessments of their elderly residents, because of lack of resources or because of

other priorities, resulting from the continuation of the pandemic. However, four of the five

Korian group homes audited as part of the survey had done so. A psychological assessment

of residents was conducted in these homes in June 2021, usually by the psychologists,

supported by the physical therapists and the nurse coordinators (IDEC) for these homes. The

assessment showed that the physical and psychological consequences of the crisis on the

elderly had been significant: increased anxiety, appearance or accentuation of behavioural

disorders, pain, loss of autonomy, food deficit, etc.

Some measures were particularly difficult for the families and teams of care homes, such

as measures relating to end-of-life and the immediate placing of bodies in coffins without

personal care after death. The audits carried out showed that some managers had not followed

these instructions strictly, considering them too hard to bear for families. Consideration of

ethical concerns in care homes also increased during the waves of the epidemic: activation of

regional ethical forums (ERER)

14

, ARS initiatives, forums within groups of care homes, a

charter drawn up at the request of the Ministry of Health

15

.

The freedom to come and go within care homes also changed over the course of the

epidemic. In a report dated 1

st

April 2020, the National Ethics Advisory Committee (CCNE)

drew attention to several fundamental guarantees and issued recommendations, relating to

the temporary and proportionate nature of the measures, the need to involve families and

external third parties in decision-making or the importance of the fight against the isolation of

residents. Individual lockdown thus became exceptional during the second wave. In its report

in May 2021 on

The fundamental rights of elderly people in care homes

, the Defender of Rights

co

nsidered that “

the health crisis [had] highlighted the difficulties, for public authorities, in

reconciling public health issues with the need for an appropriate response to the specific needs

of the elderly in care homes in order to protect not only their health, but also their rights and

freedoms

”. The Directorate

-General for Social Cohesion (DGCS) of the Ministry of Solidarity

and Health and the Directorate for Civil Affairs and the Seal (DACS) of the Ministry of Justice

were tasked in 2021 with redefining a policy concerning respect for the fundamental rights of

people care for in healthcare and welfare establishments and departments (ESMS).

13

Drees,

Studies and results

no. 1196, July 2021.

14

ERER were created by the Law on Bioethics of 6 August 2004. Since the Law of 4 March 2002 on patient rights,

healthcare establishments have been entrusted with the task of organising a forum on the ethics associated with

medical care.

15

Fabrice Gzil,

Ethical Charter and Support for Old Age

, September 2021.

7

The psychological impact of the crisis was also significant for staff, faced with the

management of complex situations. In the Occitania region, specific support for ESMS staff

has been set up and a study on stress has been carried out by the University Hospitals of

Montpellier, Nîmes and Toulouse to help maintain employment in care homes.

B - Adaptive management of problems

The health and regulatory context changed considerably as the different “waves” of the

epidemic progressed. Care homes tried to adapt to these changes.

1 -

The “first wave”

The health crisis, which broke out in the spring of 2020, first resulted in measures that

were gradually tightened from February to July 2020.

Management of the crisis was based first on marked intervention by services in care

homes and hospitals, with the support of the ARS, themselves coordinated at a national level.

Many care homes therefore took early measures to protect themselves from the epidemic. For

example, on 24 February, the Le Manoir care home, part of the Colisée group, located in Val-

d’Oise set up an entrance porch for visitors, with temperature measurement, hydroalcoholic

gel and compulsory mask-wearing. At the beginning of March, it extended the requirement to

wear a mask to all staff and, like other homes, banned all visits. The Les Opalines care home

in La Ciotat (Bouches-du-Rhône) decided to completely close the home to outside visitors on

6 March. Similarly, the care home attached to the hospital on the Crozon peninsula (Finistère)

suspended visits on 7 March.

Care homes were more or less well-equipped in the face of a pandemic of

unprecedented intensity. Almost all the care homes audited had a Blue Plan

16

. However, none

had anticipated such an impact or built up sufficient stocks of personal protective equipment

(PPE).

The period was thus marked by a shortage of PPE and of tests, logistics proving more

difficult to organise at a national level given the dispersion of establishments across the

country, particularly in rural areas. Admittedly, care homes did receive PPE, but this was

limited. Delivery, handled through regional hospital groups (GHT), began in the week of 24

March 2020. Severe pressure on supplies prompted many care homes audited as part of the

survey, to resort to makeshift measures: masks worn all day, with the addition of a gauze pad,

making fabric masks and protective clothing out of rubbish bags, and so on.

16

Developed under the responsibility of the director of the healthcare and welfare establishment, the “Blue Plan” is

nature. “Blue Plans” were created following the heat wave of summer 2003. The Les monts

organisation of the establishment’s various sites, and also to the resident population.

8

To a certain extent, for-profit private sector groups were able to make up this shortfall by

placing group orders in February. Associative groups also tried to promote networking. Thus,

the SOS Séniors group set up a central support team for its care homes, which are very well-

established in the Grand Est region. On a lesser scale, the Association pour le développement

et la gestion des équipements sociaux, médico-sociaux et sanitaires (Association for the

development and management of social, healthcare and welfare and healthcare facilities,

ADGESSA) also provided real support to the 21 establishments, including 11 care homes,

which it manages in New Aquitaine.

For their part, regional health agencies

17

organised crisis cells, both at a regional level

and in their departmental branches

18

. They helped supply PPE, were involved in setting up

platforms for additional staffing, organised contact tracing campaigns, promoted cooperation

between care homes and healthcare establishments and set up, with care homes, regular

exchanges accompanied by instructions (incidentally considered rather cumbersome by many

establishments).

ARS demonstrated responsiveness: the ARS in Grand Est and Hauts-de-France were

the first to draw up a protocol for care homes, then taken up at national level for all

establishments. All ARS organised their own PPE collection network, based on donations, in

order to supplement the national distributions made by Public Health France. The ARS in

Occitania implemented a testing policy which was more effective than required by national

instructions. The ARS in New Aquitaine set up special entry porches at all its care homes.

Despite these initiatives, the system remained highly centralised. Although the first alerts

were not relayed immediately, the timeline of the measures taken during the first wave of the

epidemic shows that at a national level, stakeholders were guided by a constant concern for

the protection of the elderly.

17

The action taken by departmental councils should also be highlighted, even though this was not assessed in the

context of the survey. The indirect observations collected seem to reflect a certain dispersion in the intensity of their

mobilisation.

18

At a regional office level, these are the Regional Health Support and Steering Units (Craps), which used to include

the business departments, the support departments, including communication and information systems, as well as

other units set up specifically for managing the pandemic (supply of equipment, for example). At a departmental

level, these are the departmental support cells (CDA).

9

Schema n°1: timeline of measures taken during the first wave in care homes

Source: Court of Accounts

2 -

The next two “waves”

During the second wave, which began in certain regions as early as August 2020 and

ended in January 2021, care protocols were operational, protective equipment was available

and tests were more accessible (notably with the arrival of antigen tests

19

) along with systems

19

The arrival of antigen tests in care homes, firstly, on an experimental basis as from the Decree of 10 July 2020

and then systematically as from the Decree of 16 October 2020, made it possible to reduce testing completion

times.

10

of support to healthcare establishments well-established (geriatric on-call healthcare, home

hospitalisation, palliative care, etc.).

In the light of accumulated experience, regulatory requirements were relaxed. While

maintaining a certain national uniformity, the task of deciding on the measures applicable

locally was explicitly left to care home managers, after collegial consultation, according to the

health situation of the establishment and in compliance with the local recommendations of the

ARS. Some ARS therefore implemented different protocols depending on department, such

as the region of Occitania, which classified the region’s thirteen departments according to three

zones (green, orange or red) and adapted the measures to be taken according to the intensity

of the pandemic recorded.

Schema n° 2: measures concerning care homes during the second and third waves

Source: Court of Accounts

The ramp-up in vaccinations was rapid: according to data from Public Health France

20

,

on 2 February 2021, 57% of residents (358,000) had received a first dose. This rate rose to

more than 72% on 2 March. As of 16 June, nearly 80% of residents had received two doses.

20

Vaccination data come from Public Health France.

11

The process was slower for professionals: at the end of June 2021, only 50% of them were

fully vaccinated

21

.

This marked increase in vaccinations meant care homes almost completely escaped the

third and fourth waves of the pandemic. From February 2021, there was a drop in the number

of new episodes, particularly severe or critical episodes

22

.

Graph n° 1: number of severe or critical episodes in care homes between

January and May 2021

Source: Drees

C - Pre-existing weaknesses

Identifying the structural causes of the high human cost of the epidemic in care homes

is not an easy task. The increasing weight of pathologies of care home residents is one of

these causes; but this was only insufficiently reflected in the resources made available to care

homes (1). Care homes also suffered from significant structural difficulties in managing their

staff (2) and sometimes also from the unsuitability of their premises (3).

1 - Insufficient medical resources in the face of changing resident profiles

According to the Drees, the average age of care home residents was 86 years and six

months in 2015. In four years, the proportion of those aged 90 or over has risen from 29% to

35%

23

.

The level of dependence of the people concerned is on the rise, as are their medical

needs

24

. In 2015, 260,000 elderly people residing in care homes (i.e., more than 40% of all

residents of these homes

25

) were identified as suffering from Alzheimer’s disease or a related

disease. According to France Alzheimer, 70% to 80% of care home residents suffer from

21

According to Public Health France, this rate stood at 88% on 7 September 2021.

22

An episode is

when at least one third or 30 residents are affected. An episode is

when it leads

to the death of 10% of residents or of at least 10 people.

23 Drees, The accommodation of elderly people in homes, September 2017.

24 The proportion of elderly people with loss of autonomy within the meaning of the AGGIR scale (classified in GIR

categories 1 to 4), rose from 81% in 2011 to 83% in 2015. Care homes were more affected by this increase: their

GMP (weighted average GIR) rose from 689 on average in 2011 to 723 in 2018. More than half of the residents

(54%) are very dependent (GIR 1 and GIR 2). Medical care needs measured by the PMP (weighted average

PATHOS) have also risen sharply, from 180 in 2010 to 209 in 2018.

25 Drees, Studies and results no. 1015, July 2017.

12

cognitive disorders. These data are similar to those presented in a report recently submitted

by Professors Jeandel and Guérin

26

, according to which 80% of residents have coherence

disorders and 57% are suffering from neurodegenerative diseases.

Residents’ healthcare is based on car

e provided in the care homes, on primary care

structures and on partnerships with healthcare establishments. These three aspects however,

mean it has significant weaknesses. All care homes must have a coordinating doctor

(Medec)

27

. This position, the quota of which is regulated, has established itself as a structural

role in the running of a care home, alongside the position of the manager. However, 32% of

care homes did not declare any FTE Medec in 2015

28

. Among the care homes audited as part

of the survey, one third had, or had recently had, a vacancy for a coordinating doctor position

29

.

A quarter of them were working on the basis of a coordinating doctor’s hours below the

regulatory thresholds.

Consultations with general practitioners in care homes, covered by health insurance,

were declining before the health crisis. The corresponding expenses

30

rose from €30 to €34

per month per resident between 2014 and 2016 to €27 in 2017 and €24 in 2018. The shortage

of attending physicians going in to care homes is a widespread phenomenon in the territory.

And lastly, in all the care homes audited, partnerships had admittedly been entered into

with healthcare establishments, but their application was not always effective.

2 - Significant pressure on staff which is detrimental to the quality of care

Of the 377,000

31

FTE in care homes, doctors represent fewer than 1%, nurses 11% and

carers

32

33%. Care homes are therefore not, strictly speaking, medicalised places, but places

for living where a certain level of care must be accessible. A comparison of staffing structures

with a healthcare establishment makes this clear

33

.

In addition, most care homes are plagued by more or less acute difficulties in terms of

human resources. The absenteeism rate is high

34

, with a national median of 10% according to

the National Performance Support Agency (ANAP)

35

. In the facilities audited, in 2019, this rate

was at a significantly higher level (around 20%)

36

.

26 USLD and Care Homes, mission report by Professors Jeandel and Guérin, June 2021.

27 Decree No. 2005-560 of 27 May 2005 on the qualifications, tasks and method of remuneration of the coordinating

doctor practising in a residential home for the elderly. This position, the quota of which is standardised by Article D.

312-156 of the Code of Social Action and Families (CASF), has established itself as one of the structural roles in

the running of a care home, alongside the manager. The tasks of this position mainly relate to admission of residents

and organisation of care quality and safety, plus staff training and technical support. The coordinating doctor also

has a geriatric coordination role, in particular with external stakeholders, and a role in checking drug prescriptions.

Their remit does not include the individual follow-up of residents, except in special circumstances.

28

Source Drees,

Recruitment difficulties in care homes

, Studies and Results No. 1067, June 2018.

29 For example, the associative Saint-Antoine de Desvres care home (Pas-de-Calais) has been without medical

supervision for more than three years. This home is not taking shouldering all its responsibilities in the area of care.

30

For care homes having opted for the partial rates arrangement without a pharmacy for internal use (PUI). The

trend is similar for care homes having opted for the partial rates arrangement with a PUI, to a lesser extent.

31 Representing 433,250 people, 2015 figure, Drees care home survey.

32 Carers handle personal care but are not authorised to distribute medication unless delegated to do so.

33 By way of comparison, according to the Drees 2020 edition, healthcare establishments comprise 210,000

medical staff, 767,000 non-medical caregivers (nurses, carers, physiotherapists, etc.) and 336,000 non-caregivers.

34 In 2019, according to the barometer of absenteeism and hiring, France had an absenteeism rate of 5.11%.

35

Anap, Dashboard for performance in the healthcare and welfare sector, early lessons, June 2018.

36 18% for the Saint-Joseph care home in Saint-Jean-de-Bassel (Moselle), 20% for the Gournay-en-Bray care

home (Seine-Maritime), over 25% for the Les Opalines care home in Saint-Chamond (Loire).

13

Care staff turnover rates are also high. The instability of the teams makes it difficult to

train and improve staff skills. In this regard, the survey revealed particularly worrying situations.

Thus, the annual turnover of nurses had risen to 83% in 2017 in the La Filature care home in

Mulhouse, in particular due to a competitive environment. At the Maison bleue care home in

Villeneuve-lès-Avignon, during 2019, there were nearly 159 different people working the day

shift, for a theoretical workforce of 40, with a staff turnover rate of 50% for nurses and 38% for

carers.

The accumulation of difficulties (insufficient supervision rate, poor organisation of rotas,

absenteeism, lack of training, etc.) can cause real problems in the quality of care, outside of a

crisis situation. Given the difficulties that homes are experiencing in recruiting carers, many of

them are replaced by staff “standing in” as carers, although they do not have the necessary

qualifications. So staff who were themselves vulnerable were the ones having to support the

elderly during the pandemic period, usually with a particularly high level of involvement. During

the crisis, many exemptions were put in place to make staff working conditions easier

(provision of taxis, payment of rent to allow some employees to stay near care homes,

childcare, etc.), improve hiring conditions and promote the new collaborations initiated

between care homes, ARS and organisations responsible for employment (Employment

Centre, etc.).

3 - Buildings which are sometimes unsuitable

Care homes are community spaces. Most have a capacity of 60 to 99 spaces (average

range, all statuses combined). A minority of them (18%, or 1,361 care homes, often attached

to healthcare establishments) offer a capacity of more than 100 spaces

37

. Their premises are

sometimes unsuitable, even dilapidated: 15% of care homes are set up in buildings over thirty

years old and their architectural configuration did not always allow separate covid-19 zones to

be set up, or the isolation of residents affected by the disease. Only 45% of care homes are

able to offer only single rooms. And lastly, with the exception of those care homes attached to

healthcare establishments, they are not equipped with systems for the distribution of medical

gases (particularly oxygen).

II - The organisational and financial response to the crisis

should not delay structural reforms

Since the start of the health crisis, new responses have been provided to the age-old

difficulties faced by the sector: on a national level, the economic effort made in times of crisis

followed a considerable long-term financial effort (A

)

; on a l

ocal level, “good practices” have

emerged (B). However, structural reforms are progressing too slowly (C).

A - An unprecedented public financial effort, short-term then permanent,

without significant returns

The healthcare and welfare sector and care homes in particular, have benefited, during

the pandemic, from unprecedented short-term support, decided by the Government and

37

14

funded by health insurance38. Beyond that, very significant additional funding, mainly of a

long-term nature, has been committed within the framework of the Ségur de la santé plan and

the France Relance plan. This latter funding could have been the Government’s opportunity to

initiate structural reforms that have been delayed for too long. But this was not the case.

1 - Compensation for loss of revenue and additional costs during the crisis

If we consider expenditure associated with the covid-19 epidemic on its own

39

, care

homes benefited from threefold support: compensation for loss of revenue

40

, coverage of

expenses caused by the pandemic (additional staffing to compensate for increased

absenteeism, logistical costs, small items of equipment, masks, cost of covid-19 units, etc.)

and full coverage by health insurance of the “

c

ovid bonus” allocated to staff, announced in

June 2020. Overall, this repr

esented €1.7 billion in 2020, at the expense of health insurance.

Graph n°2: financial support allocated to care homes to offset expenses related

to covid-

19 (2020, amounts in €M)

41

Source: CNSA

These measures were partially renewed for the first phase of the 2021 budget campaign.

The budgetary instruction of 8 June 2021 thus provided for a total of €324 million for the sector

looking after the elderly, including €151 million in compensation for loss of revenue, €141

38

41

15

million in compensation for additional costs and €24 million for reimbursement of deductibles

applicable to contact tracing.

2 - Long-term costs as a result of the Ségur de la santé plan

a) Pay rises

Even before the health crisis, pay in care homes had started to go up in early 2020, as

part of the “My Health 2022” ministerial plan. Following the El Khomri report on attracting

people to jobs in care for the elderly

42

, an “old age bonus” of €100 net per month was allocated,

from 1

st

January 2020, to carers in the public sector hospital sector

43

and working in a care

home.

Then, as part of the Ségur de la santé agreements signed in July 2020, an increase of

€

183 net per month was allocated to public sector hospital and care home staff, with effect

from 1

st

December 2020, and also to the staff of private sector non-profit care homes. Staff in

private sector for-

profit care homes benefited from an increase of €160 net per month.

This increase is exceptional on two counts. First, because of its size. For carers and

educational and social support workers, it represents an increase of between 10 and 15%

44

.

Second, because of its scope. It concerns not only the medical professions, but also all the

non-medical professions in care homes, whether they relate to care, dependency or

accommodation. The social security system is therefore paying, on an unprecedented basis,

pay rises for non-caregivers, who do not come within its remit

45

.

It is still too early to measure the impact of the Ségur de la santé plan on attracting people

to care home jobs. However, according to all stakeholders interviewed, the pressure caused

by the lack of staff is very significant.

In total, for 2020, the “old age” bonus represented a cost of €134 million and the entry

into force on 1

st

December 2020 of the basic measure for the Ségur de la santé plan increase

resulted in an expenditure of €351 million. The full

-year amount of this additional expense is

€1,867 million.

Other expenses, on a smaller scale, have also been decided in order to attract more

people to the profession, to generate interest among care homes and their staff in the quality

of care for the elderly, and to extend the pay rises under the Ségur de la santé plan to other

staff working in healthcare and welfare establishments and services

46

.

In 2022, the pay-related measures of the Ségur de la santé plan will have a long-term

cost of more than €2.2 billion for establishments and healthcare and welfare services for the

42

National mobilisation plan in favour attracting people to jobs in care for the elderly, 2020-2024

, October 2019.

43

Decree No. 2020-66

establishments mentioned in Article 2 of Law no. 86-33 of 9 January 1986.

44

According to the CNSA, Economic and financial situation of care homes in May 2017 and 2018, May 2020, the

45

The funding of care homes is based on three sections: care, dependency and accommodation. 90% of the care

component is funded by the CNAM, 10% by the CNSA. The accommodation component is funded on the basis of

a third by the departmental councils, a third by the CNSA and a third by households. The accommodation

component is primarily funded by households. In 2019, the CNAM financed 28% of the overall care home budget

(Source: Social Security Accounts Committee,

Social security accounts

, June 2020).

46

Permanent and contractual public sector employees working as carers, medical-psychological assistants (AMP),

care assistants (AVS) and health and social care assistants (AES) in public sector healthcare and welfare

establishments not attached to a healthcare establishment or care home and funded by health insurance, will also

sector healthcare and welfare establishments funded by care homes.

16

elderly. The chart below details the increase in this additional pay expenditure between 2020

and 2022.

Graph n°3: additional expenditure associated with pay rises paid to staff working in

care homes

Source: Court of Accounts, based on information provided by the social security department

b) Significant investments in digital tools and real estate

In addition to pay rises, grants amounting to €1.5 billion over four years have been set

up to fund the renewal or creation of places in care homes, plus a budget of €600 million for

the development of digital tools in healthcare and welfare establishments and services. The

total expenditure planned for these two items is therefore €2.1 billion over the period from 2021

to 2025. The CNSA is responsible for allocating this financial support, which comes under the

France Relance plan, through calls for projects, the first of which were launched in 2021.

The projects of the “Digital ESMS” programme are part of the national roadmap

“Accelerating the digital shift in health”

47

.

However, the circular of 24 September 2021 on the mobilisation of investment credits

from the Ségur de la santé and France Relance plans

48

does not provide a sufficiently precise

national framework for the allocation of financial support for making real estate investments in

care homes. In partnership with the departmental councils, ARS need to identify the

investments to be made, without having defined beforehand the care home model that the

public authorities wish to favour: simple upgrading of existing establishments, opening up to

the outside, a

long the lines of the project on “alternative spaces” in care homes, or even

47

In particular, roll-out of the computerised user file (DUI) needs to be incorporated into other modules, such as

secure messaging for health professionals (MSanté), shared medical records, the on-line prescription project (e-

prescription) and the coordination tool for health pathways (e-parcours).

48

Circular no. DGCS/SD5C/CNSA/2021/210 of 24 September 2021 on the mobilisation of investment credits from

the Ségur de la santé and France Relance plans in support of the residential shift in the support offer for the elderly

in a society of elderly people.

17

enhancing support in the home. The CNSA admittedly set up, in early 2021, “research into

tomorrow’s solutions”, but this does not constitute a strategic framework.

In total, for 2

022, the overall spending target for the elderly is €14.3 billion

49

, i.e., an

increase of €3.6 billion (+33.6%) in the space of four years, including €2.2 billion in the pay

increases of the Ségur de la santé plan and nearly €0.6 billion in funding of real

estate and

digital tools.

Apart from this considerable financial effort, a certain number of measures have been

taken in response to the emergency, which should be continued.

B - The emergence of good practices to be consolidated

1 - Better integration into healthcare networks

Despite the heterogeneity of organisations according to region, activation of geriatric

sectors has made it possible to set up specific on-call care set-ups from the end of March

2020

50

. In particular, these have helped provide hotlines for geriatric care and palliative care,

so as to get a multidisciplinary opinion before each hospitalization and to facilitate direct

admission without going through the emergency services.

These geriatric care on-call set-ups have been enhanced with, in particular, an increase

in opening times, the introduction of mobile teams or the creation of new systems. So, in

Auvergne-Rhône-Alpes, 97% of care homes have benefited from a dedicated hotline. In

Meurthe-et-

Moselle, where an “elderly person” healthcare on

-call service, with a dedicated

number, has been set up, the Nancy CHRU has made several mobile teams available to care

homes: a mobile palliative care team (EMSP) and a mobile geriatric liaison team (EMLG).

In 2019, home hospital care (HAD) of patients living in care homes represented 8.1% of

total HAD admissions (i.e., 14,300 patients). During the pandemic, admission requirements

were relaxed

51

and home hospital care increased significantly. In 2020, for care home

residents, the number of HAD admissions thus increased by 69%, i.e.,nearly 12,000 stays.

This development is almost entirely due to the care of patients with covid-19.

These new partnerships between care homes and hospitals are being consolidated,

which is positive. The 2021-2026 strategy roadmap for HAD provides for its development in

care homes as a strategic objective. The roadmap of the 2021-2024 national plan

“Development of palliative care and end

-of-

life support” includes the strengthening of

partnerships with care homes. The roll-out of mobile geriatric care teams (EMG) is being

accelerated to care homes. In 2021, 55 EMGs were created or enhanced. The mobile health

teams and support centres for the prevention of healthcare-associated infections (CPIAS),

which have proven their usefulness during the crisis, should also be maintained.

Several measures have also been taken to allow for additional staffing in terms of

independent doctors and nurses: possibility of applying to patient visits in care homes, the

extra emergency rate (with a cap of

€57.60 per visit), introducing a fixed rate of €420 per half

-

49

Source: 2022 social security funding bill.

50

Healthcare establishment record,

Instructions and recommendations concerning the support by healthcare

establishments to care homes for the elderly

, Ministry of Health and Solidarity, March 31, 2020.

51

The Decree of 1

st

April 2020 supplementing the Decree of 23 March 2020 establishing the organisational and

operational measures of the healthcare system necessary to deal with the covid-19 pandemic within the framework

of the state of health emergency, authorised a very large number of exemptions for the use of HAD in care homes.

18

day under a contract between the establishment and the doctor. These provisions were partly

consolidated in Amendment 9 of the 2016 Medical Agreement, signed on 30 July 2020

52

.

2 - A digital contribution which should be extended

The roll-out of digital tools in ESMS is lagging behind compared to healthcare

establishments

53

. In care homes, the pandemic has favoured the rapid development of digital

technology in three areas: relationships with families, remote consultations and provision of

information.

All the establishments audited have relied on social networks and have set up video calls

to allow residents to communicate with their families. However, the Court and the regional

courts of accounts have observed, on site, that these tools on their own are not enough:

support is essential, because many residents are unable to master the IT tools made available

to them. This was the case for 30% of residents of the Saint-Charles care home in Bayon

(Meurthe-et-Moselle).

Remote consultations conducted in care homes have increased, but to a lesser extent

than for the population as a whole. According to the Digital Health Agency (ANS)

54

, 71% of

doctors had provided at least one remote consultation at the end of September 2020,

compared to 13% at the end of September 2019. However, remote consultations did not

exceed 3% of the work of geriatricians over the same period. Only 9% of doctors doing remote

consultations provided remote consultations for patients hospitalised or residing in care

homes.

And lastly, digital tools for collecting and aggregating data, such as Voozanoo

55

, set up

by Public Health France and used to monitor the pandemic in care homes, need to be

consolidated on the basis of feedback.

C - Measures to be supplemented by structural reforms, very recently

begun with the PLFSS 2022

These measures, necessary as they were, would not be enough to remedy the structural

weaknesses of care homes. These weaknesses are known to the public authorities and have

been the subject of several recent reports

56

, as well as Court publications. These reports are

convergent in their findings and similar in their recommendations.

Two of the main weaknesses highlighted by this work called for structural responses,

implementation of which has been postponed. They relate first, to staff working conditions,

which need to be improved, and second, to the organisation of establishments, excessive

dispersion of which means the elderly cannot be offered a satisfactory level of medical care.

Firstly, the support provided to caregivers and non-caregivers within the framework of

the Ségur de la santé plan, justified as it was, only related to pay rises. However, training,

52

Thus a home visit for a patient over 80 years of age with a long-term illness (ALD) may be listed as a long-term

visit up to €70 (compared to €35 currently),

four times a year

for an estimated annual cost of €145 million.

53

ANAP,

Use of digital tools in ESMS

, March 2019.

54

Odoxa, The ANS remote medicine barometer, Wave 2, October 2020.

55

The Voozanoo application was developed by SPF in March 2020 to identify cases of covid-19 in ESMS and

ensure epidemiological monitoring, pre-existing tools proving unsuitable.

56

Report entitled

Old age and autonomy

submitted by Dominique Libault on 28 March 2019, report entitled

National

mobilisation plan in favour of attracting people to jobs in care for the elderly

, presented by Myriam El Khomri on 29

October 2019, Mission report on ULSDs and care homes by Professors Jeandel and Guérin in June 2021.

19

career development and the prevention of accidents at work and occupational diseases, which

are particularly high in the healthcare and welfare sector, have been identified for several years

as priorities, calling for a long-term national action plan from the public authorities. The national

mobilisation plan in favour of attracting people to jobs in caring for the elderly, 2020-2024,

resulting from the El Khomri report, proposed several measures regarding these issues. Many

of these, although less expensive, did not experience the same momentum

57

.

Secondly, the crisis has highlighted the particular difficulties faced by isolated

establishments and, conversely, the benefit for a care home of being part of a network, which

can take several forms: a broad partnership with a healthcare establishment, the pooling of

support functions and medical and health resources between several establishments or

membership of a group of establishments. Being attached to a hospital or a group in particular,

allows a more efficient organisation of medical resources and, ultimately, better continuity of

care between the healthcare and welfare and health sectors.

The funding budgets planned for investment could however, have been an opportunity

to redefine the organisational model of care homes, firstly, by directing funding, as a priority,

to care homes committing to signing up for a pooling initiative, and secondly, by reforming the

authorisations system, to shift from organic authorisations (granted by ARS to establishments)

to functional authorisations (granted for services adapted to the patient’s

journey, whether they

are in care homes or at home). It is clear that ARS have great difficulty in implementing real

territorial strategies, allowing better integration of care homes into geriatric services networks.

The long-term agreements on targets and resources signed by ARS with care homes are not

strategic documents and, usually, their content is too descriptive and essentially administrative.

The social security funding bill for 2022 admittedly includes measures on medicalisation.

It also provides

that certain care homes can become “territorial resource centres”, responsible

for organising and bringing together the various stakeholders in the old age sector.

However, these measures do not constitute developments in the overall operating

framework of care homes. Reforms had however been announced and initiated, such as the

merger of the “care” and “dependency” allocations, which was to constitute a significant

simplification of the financial framework applicable to care homes. If these more structural

initiatives are not taken into account, the funding effort at an exceptional level decided within

the framework of the Ségur de la santé plan may well fail to allow care homes to overcome

their deepest organisational and operational weaknesses.

57

The mobilisation plan included 16 targets covering an estimated annual cost of €825 million. The pay rise

component was only planned for

€170 million and focused on the upgrading of pay below the minimum wage. It

also included a national programme to improve the accident rate and improve the quality of life at work, simplification

of training and the possibility of career progression. These measures have made little progress.