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MEDICAL CARE
OF THE ELDERLY
IN NURSING HOMES
(Ehpad):
a need for a new model
Communication to the Senate Social Affairs
Committee
February 2022
2
Executive summary
The number of dependent elderly people in France, estimated at 2.5 million people in
2015, could rise to 4 million by 2050. The question of their care will therefore become an
increasingly acute issue.
Despite the desire of French authorities to promote a “shift towards
the home”,
établissements d’hébergement pour personnes âgées dépendantes
(Ehapd
s, “
care homes
with nursing
for dependent elderly people”) play a central role in the provision of care, as they
now accommodate around 600,000 residents, i.e. 15% of the over-80 population living in
France. This proportion has remained stable for several years, although at a level that is slightly
lower than that observed in comparable countries.
Increased expenditure, yet a failure to meet the needs of an increasingly
fragile population
The overall volume of public expenditure devoted to care and dependency in Ehpad
nursing homes increased by 30% between 2011 and 2019
almost three times faster than
GDP
reaching €11.24 billion in 2019. Added to this amount a
re expenditure on care provided
to residents, financed by health insurance; 2018 estimates were €1.34 billion for city care and
€1.02 billion for hospital admissions and emergencies.
However, this significant increase in expenditure was not sufficient to meet the needs of
an increasingly fragile segment of society. In particular, while 42% of elderly people in Ehapds
suffered from Alzheimer’s disease in 2015, more than 57% today suffer from a
neurodegenerative disease.
When considering the challenges of adjusting services accordingly, there seems to be a
need for a better understanding of the prevalence and development of conditions linked to
dependency in the population, in order to anticipate future needs and design plans able to
meet the challenges.
Chronic shortages of qualified personnel
Although the ratio of staff per resident has increased in recent years, the number of
caregivers remains insufficient to ensure high-quality support. The Court recommends the
creation of benchmarks, making it possible to assess the minimum ratios required to
satisfactorily meet the various care functions.
In addition to changing the staff-to-staff ratio itself, improving the quality of care involves
improving the organisational structure of work and the distribution of tasks, as well as improving
the qualifications and training of personnel, in particular nursing auxiliaries.
It also takes the form of better professional recognition, which can be a means of
attracting and stabilising personnel, whose difficult working conditions result in high rates of
absenteeism and turnover.
Medical services appear to be in particular difficulty: in half of all Ehapds, there is either
no coordinating doctor, or the number of hours worked is insufficient. This lack of medical
personnel can have consequences that are aggravated by the fact that residents do not always
have access to a attending physician. The availability of standby night nursing assistance staff
also appears to be insufficient.
As for the nursing coordinators, who play an essential role, their functions are not defined
by regulations, and neither is there a minimum ratio of supervision.
3
Lastly, the care of residents in Ehpads suffers from insufficient levels of intervention by
occupational therapists, psychomotor therapists and psychologists, who are vitally important
for residents with cognitive disorders.
Preventive actions and quality improvement strategies remain
insufficient
In terms of prevention, programmes are conducted on topics such as hygiene, oral
health, depression and suicide risk. However, their scope is limited.
The issue of drug overuse is, for its part, insufficiently considered. Most establishments
are therefore not in a position to reduce the consumption of psychotropic drugs by people with
cognitive and psychic disorders. The data, produced by the National Health Insurance Fund
(Cnam) via the Resid-
ESMS information system, provides a “profile” of per
-establishment
healthcare consumption. This information could be used to learn about and reduce such
overconsumption, but it is not sufficiently widely disseminated.
The involvement of public agencies in facilitation activities, which help to fight against
reduced autonomy, is patchy and generally insufficient, although some Ehpads have
introduced a number of noteworthy policies in this area.
Lastly, the tools introduced by the law of January 2, 2002, such as facilities projects and
assessments, are still too infrequently used in structured initiatives to improve quality.
Insufficient efforts have been made to encourage the participation of residents and their
families in CVS (social life advice) schemes. Although personalised support projects
which
are major determinants in quality of care
have been set up in most establishments, they are
rarely updated during the year, and do not benefit all residents.
Pricing and contracting methods that are now reaching their limits
The financing of Ehpads is complex. It is based on three sections (care, dependency,
housing) and on the almost automatic calculation of allocations based on pricing equations,
aimed at making them more objective.
There seems to be a need for simplification and territorial harmonisation of this funding.
Firstly, the distinction between expenditure linked to care and expenditure linked to
dependency is less and less justified, and it seems appropriate to group these two sections
together, under the aegis of a single managing body, which could be the regional health agency
(RHA). Secondly, the criteria for evaluating the degree of dependence of residents, or iso-
resource group points (GIRs), which determine the funding allocation and differ from one
department to another, need to converge, thus putting an end to territorial disparities. Such a
measure would represent an additional financial envelop
e of an estimated €0.3 billion for
alignment with the 9th decile of departmental GIR points.
Moreover, it is important that the pricing equations take greater account of the specific
needs related to the care of residents' cognitive disorders, and that they make certain
allocations conditional upon indicators relating to the quality of prevention.
At the same time, it is necessary to improve the regional and quality-based aspect of
CPOMs (multiyear objectives and resources contracts) agreed between each manager, the
RHA and the department, and to coordinate them better with the home help services, thus
guaranteeing the role of the departments.
Finally, the authorisation regimes need to be reviewed, in order to allow greater flexibility
and promote the development of home services by Ehpads.
The CPOMs, which could have been a tool for improving local networks, have had very
limited effects: firstly, only a minority of Ehapds are equipped with it to date; secondly, their
4
content lacks scope. In particular, the financial and qualitative component of the CPOMs must
be strengthened, with a view to developing a public health policy, particularly in terms of
prevention.
More generally, a reform of the CPOM model is worth considering, in order to reduce the
barriers between home and establishment and to make Ehpad
s play the role of a “resource
centre” in gerontology.
Regional care in need of restructuring, structures still too isolated
The structuring of geriatric care at local level has been disparate and remained focused
on the health sector for too long, without sufficiently integrating Ehpads or home help services,
despite the fact that progress has been made since the health crisis.
There is a need to systematically integrate Ehpads and other services intended for
elderly persons of reduced autonomy into a regional structure that offers tailored pathways for
the elderly according to the evolution of their needs. In particular, the contribution of hospitals
to this regional structure should be better integrated into the medical plans of regional hospital
groups (GHTs).
This redesigned structure must be accompanied by strengthened controls and greater
transparency
as is already the case in several foreign countries, which publish the results of
quality indicators in Ehpads, enabling the general public to have access to this information.
In private-sector associations or commercial organisations, the trend towards
consolidation among management bodies continues, although it remains incomplete. On the
other hand, autonomous public Ehpads are very widely dispersed. However, an Ehpad
’s
membership of a group or affiliation with a health establishment provides it with access to
better expertise in terms of organisation and the ability to benefit from shared resources in
support of its work. It is therefore necessary to encourage mergers between establishments,
as well as the pooling of their resources into social and medico-social cooperation groups
(GCSMS).
Possible avenues for a new model of Ehpad
Avenues for future change in the Ehpad model should be identified via four drivers:
greater transparency in the measurement of quality, improved control over care management,
more consideration of the diversity of the populations received, and more dynamic integration
at local level.
The first driver consists of the publication of indicators measuring how well each
establishment complies with the applicable standards. The powers of inspection and control of
the RHAs and the departments must also be exercised effectively, to assess the
establishments’ compliance with the quality and health prevention objectives defined in the
CPOMs.
It is also vitally important that families have simple, transparent access to information
concerning elderly people in care homes with nursing. This transparency is a valuable resource
for improving quality. The many digital systems implemented during the pandemic and the
digital investments planned as part of the “Ségur de la santé” consultation process can act as
a useful complement to older resources such as patient support bodies or complaints registers.
The second driver involves arranging for residents’ access to a general practitioner
if
necessary salaried in cases where self-employed doctors are in short supply
and doing more
to support preventive measures in Ehpads. This would require opening the universal pricing
system up to more establishments. This option makes it possible to finance all medical activity
in the form of a lump sum for the establishment and facilitates the use of salaried doctors,
5
which
for the establishments which benefit from it
translates into less reliance on hospital
admissions and lower consumption of drugs. However, to identify the net cost, it would be
necessary to be able to assess the savings induced by this system. The data available to the
Cnam
would allow this to be done. At this stage, the Court has estimated the figure at €0.4
billion.
Taken together, the measures concerning the financing of Ehpads recommended by the
Court could, depending on the options adopted for the reform of the Pathos grid and on the
basis of the assessments to be carried out on the impact of the extension of the universal
pricing system, represent expenditure of between €1.30 billion and €1.90 billion, i.e. an
increase of 12-17% in the overall amount of allocations. Moreover, the experiments in progress
on the recruitment of prescribing physicians and the establishment of on-call night nurses are
already starting to demonstrate their worth.
The third driver consists of making better allowance for the prevalence of
neurodegenerative diseases among Ehpad residents, and ensuring that the appropriate care
units and systems in the establishments are consistently available. However, Ehpads must
continue to provide care for residents with reduced autonomy who are not affected by
neurocognitive disorders, using care methods that are more conducive to home and
community life. To manage the diversity of its target market, the sectorisation and modularity
of Ehpads must be increased, which implies access to suitable buildings and premises. The
Court invites all funders to identify establishments that are still unsuited to hosting certain
patient types, and to anticipate changes in the target market and the care provided.
Lastly, the fourth driver concerns changes over time in the role of the Ehpad within its
geographical area of operation. There is universal recognition of the need to diversify methods
of support for the elderly and to overcome the dichotomy between institutions and home
services. Ehpads that
had been designed to act as “resource centres” would be places for
structuring, coordinating and optimising the resources of a local region in line with a philosophy
of providing services for elderly people with reduced autonomy. This would leverage the skills
of the technical platform represented by the establishment and deploy them externally, thus
positioning it as a platform providing resources for the home.
6
Audit recommendations
Integrate Ehpads better at local level, review the role of the supervisory authorities
and reduce administrative burdens
2
.
Merge the care and dependency sections under the aegis of the regional health authorities
(RHAs) in order to simplify Ehpad pricing and reduce departmental disparities (
DGCS,
CNSA
).
7.
Transform multiyear objectives and resources contracts into strategic and financial
management tools and provide them with:
-
a plan for integrating the Ehpad system into its health and social environment (care
component under the aegis of the RHAs and services and prevention component
handled autonomously with the departments);
-
multiyear financial resources, a portion of which is conditional on public health and
quality objectives;
-
a specification of the terms for tailoring a residential services offering to the target
audience. (
DGCS, CNSA, SGMAS
).
8.
Increase the use of pooled resources and initiate mergers between single-establishment
management entities (
RHAs, departments, Ehpad managers
).
11.
Promote the development of Ehpad
s as “resource centres” (
DGCS, DGOS, CNSA
).
Improve medical care in Ehpads.
1.
Provide better support for people with cognitive disorders, by:
- providing additional and more reliable data on the prevalence of neurodegenerative
diseases, ensuring more tailored care for sufferers (
DGOS, DGCS, CNSA, SPF
);
- including specific needs related to cognitive disorders in indicators of dependency
(average weighted GIR) or level of care required (average weighted “Pathos” profile)
thus enabling the funding of care for the persons concerned without loss of resources for
Ehpads. (
DGCS, CNSA
).
3.
Make the assessment of GMPs and PMPs by declaration an annual occurrence, and help
the establishments to develop the necessary IT tools (
DGCS, CNSA
).
10.
Encourage and finance the wider use of Ehpads at the universal rate (
DGCS, DSS, CNSA,
Cnam
).
4.
Ensure wider dissemination of aggregated resident health data per Ehpad, obtained from
health insurance data (Resid-ESMS application), as a tool to combat drug overuse.
(
Cnam
).
7
A greater emphasis on quality
5.
Systematically implement a quality improvement process, using resources such as
regularly updated individual living plans, and organise support while fitting in with existing
living patterns (
RHAs, departments managing Ehpads
).
6.
Introduce regulations formally defining the functions of nurse coordinator (
DGCS)
.
9.
Having developed indicators for quality (consumption of psychotropic drugs, etc.) and
required resources (including ratios of medical and nursing staff, presence of prescribing
doctors), make their publication compulsory for each Ehpad (
DGCS, HAS, CNSA
).
8
Annexe n° 7 :
international comparisons of healthcare services in care
homes with nursing
1
Germany, Belgium, Canada (Ontario), Denmark,
Japan, Sweden
The investigations conducted for this executive summary benefited from input from
foreign financial jurisdictions, and from social advisers at French embassies. They were also
supported by international contacts of university hospital doctors specialising in the key issues
of prevention and care for the elderly residing in EHPADs, i.e. areas in which high levels of
scientific consensus (deprescribing, nutrition, etc) are observed. This work also benefited from
the significant international experience of several private groups with commercial status who
manage EHPADs.
With such countries that have structur
ed social protection systems similar to France’s,
two series of comparative data can be identified:
- those that illustrate fundamental convergences, sometimes over and above the
institutional differences that are apparent at first sight;
- those that indicate strong differences on various specific aspects and may provide
fruitful grounds for study into future changes in public policies for the elderly in France.
Fundamental convergences, over and above institutional differences
International comparisons come with their share of concerns and difficulties in
accessing relevant and sufficiently comparable information. Among these, and regarding the
medico-social sector of establishments for the elderly, one of the first obstacles usually referred
to is the highly decentralised nature of policies regarding the elderly in the countries studied,
sometimes with a federal structure. However, it is striking to note that, for many of them, there
is a hybrid structure to both regulation and funding, as seen in France with the RHAs and the
departments. The growing social and political impact of ageing, accentuated by the Covid-19
crisis, has shown a tendency to nationalise or federalise policies for the elderly, either with
earmarked national or federal credits to supplement decentralised funding, or with federal or
national processes for monitoring good professional practices in EHPADs and mass
publication of their results (see below). This hybrid nature, which can take the form of a wide
range of different mixes and processes, is structurally part of the need for economic parity
between geographical regions which, within the same country, are subject to widely differing
demographic trends and resources. This is particularly true between the eastern and western
parts of Germany, and between the French-speaking and Flemish-speaking areas of Belgium.
In addition to that
and as documented in numerous European Union and OECD
publications
all these countries face common challenges:
- a demographic shift that is already very pronounced in Japan and strong in Germany,
Spain and Italy;
- the high prevalence of cognitive impairment observed during institutional admissions;
- severe recruitment difficulties in EHPADs or equivalent institutions, with significant
use of employees of foreign origin;
- such structural tensions have been seriously aggravated by the covid-19 crisis.
Faced with this situation, countries everywhere have initiated strong policies in favour
of home support for the elderly, and the data show strong convergence in the percentages of
1
The equivalent nomenclatures in other countries cover a multiplicity of different acronyms and expressions: long-
term care homes (Canada, Japan), “stationary” establishments (Germany), retirement and care homes (Belgium),
etc.
9
elderly people admitted to nursing homes facilities. Some countries have experienced a rapid
decrease in this proportion, such as Sweden, but they started from a higher initial level.
However, it should be noted that several countries are faced with waiting lists, and are currently
asking themselves how to supplement their existing resources (Germany, Belgium, Canada,
Japan).
Among the other convergent options, several common trends should also be noted:
- establishment sizes mainly between 60 and 80 beds, with a recent trend towards an
increase towards 100-120 beds, accompanied by the creation of internal 15-20-bed
entities or “households” in an attempt to combine agility and close personal service with
efficiency and shared fixed costs;
- the
parallel development of “special project” establishments, mirroring social
expectations of more individualised and personalised support. These establishments,
which tend to be smaller in size, are often more costly for users and for public authorities;
- the success of institutional projects that place an emphasis on the socio-emotional
aspects of staff relations with the elderly (Tubbe, Montessori, Humanitude, Abbeyfield,
RAI, “zero restraint” methods, non
-drug approaches, etc.) to avoid confining said relations
solely to the technical mastery of nursing care activities;
- a strong diversification in the portfolio of solutions for the elderly, with (a) the creation
of platforms that combine several complementary approaches (home services, day care,
temporary accommodation, sheltered housing) on the one hand, and also (b) an
encouragement of other uses and access to premises by other age groups (medical or
paramedical or dental surgeries, restaurants, shops, crèches, cultural third places, etc.).
In terms of this overall discussion, the extensive use of day care in Japan is a stimulatingly
original concept. It should also be noted that in Belgium, as in France, the unsuitable
regulatory framework for temporary accommodation requiring dedicated rooms prevents
operators from engaging in this highly useful practice, due to excessive economic
constraints, unless within the context of being required to informally (and logically) operate
in holiday situations for permanent accommodation (Belgium recently waived the
requirement for dedicated rooms).
- increasing openness to private management companies with commercial status,
either directly or under a management, concession or leasing mandate. Belgium, for its
part, has established a cap of 50% of available residential facilities for this component
a
percentage already reached in its Wallonia region.
Finally, similar difficulties experienced by a number of countries include the following:
- considerable difficulties in the fight against polypharmacy among elderly residents of
EHPADs, and in the drive towards deprescribing, despite the very high level of
international medical/scientific consensus on this subject;
- difficulties in terms of oral care, preventive and compensatory measures for (visual or
auditory) sensory disorders in Ehpads, with the exception of a few successful but isolated
initiatives. With regard to hearing disorders, it should be emphasised that deafness is the
main preventable factor in severe cognitive disorders, and that preventive, rehabilitative
and compensatory measures are not limited to hearing aids;
- gaps in oral care, which should form a coherent whole with nutrition and adapted
physical education to combat sarcopenia and falls (negative impact of polypharmacy).
10
However, many countries have taken a strong stance on the issues of nutrition and
adapted physical education (Germany, Canada, Denmark, Sweden), and this is also an area
of strong investment in France, both at national level and in many Ehpads, thanks in particular
to the programmes developed by organisations such as Maison Gourmande, Silver Fourchette
and Siel Bleu. These programmes involve a large number of professionals and deserve to be
more widely deployed among a large number of Ehpad residents, given that nutritional
depletion is one of the marked effects of the Covid-19 crisis.
Differences regarding policies for the elderly and changes in residential
establishments over time
The main inspiring difference worthy of mention is the adherence to national methods
of external control of good professional care practices in Ehpads, with data accessible to the
general public. Results of quality indicators for each establishment are published on the Web
in Germany, Canada (Ontario), Denmark and Sweden
2
. The proportion of psychotropic drugs,
the number of falls and the level of satisfaction experienced in relations with staff and with
meals are included as part of an approach that includes both in situ inspection and public
transparency. As noted by the Auditor General of Ontario
3
, the main benefit of an indicator is
to clearly designate what is important, beyond its numerical value alone: measuring residents’
satisfaction is a questionable approach given the potential subjectivity of the method, but the
alternative of not measuring is probably much more open to criticism, given the resulting
negative picture this paints for residents. The same is also true of staff satisfaction. The key
priority is the repetition of measurements and analysis of changes in them, rather than any
isolated finding on a given date.
Clear differences can be observed with regard to the levels of oversight observed in
thirteen countries by the same care homes manager. Although in some countries this rate is
higher (Ireland) or very slightly lower (Netherlands) than one staff member per resident, it is
less than half of this in others (Belgium, Czech Republic). France, for its part, has a figure of
0.66 staff members per resident. Taking legal working time into account, and comparing across
all countries on a common basis of 40 hours per week (the weekly time is 48 hours in Ireland),
the supervision ratio in Ireland then works out at 1.38 FTE for a resident, while the French ratio
drops to 0.57 (for 35 hours). This consideration enables comparisons between supervision
rates
4
.
In this global context, the ways in which doctors are involved in Ehpads vary
significantly:
- some countries have systems offering free medical care and salaried collaborative
practice (Denmark, Sweden), with residents registered on a list of practitioners with shared
responsibilities towards the country’s population;
- others have a social protection system geared towards private practitioners in care
homes (Germany, Belgium, France), with a coordinating doctor within the establishments
(Belgium and France) where applicable;
- finally, some countries have nursing homes facility structures that include their own
salaried medical teams: Spain and Italy, and also in France in cases where the
establishment has been eligible for universal care pricing.
2
For detailed information and sources, see report R-2021-0912-2 on international comparisons dated 2 August
2021, produced for the sixth chamber of the Court of Accounts, and the country-specific notes annexed to it.
3
President of the Ontario Financial Authority.
4
In the same spirit, comparisons of remuneration from one country to another need to factor in the duration of
activity required for full-rate retirement pensions, as well as the income replacement rate.
11
With regard to the diversification and flexibility of solutions for the elderly, it is worth
pointing out that the legal and financial regulation of establishments and services in Belgium
and Japan includes the possibility of decompartmentalising the entities, with operating
methods and obligations that can be mixed and pooled:
- between care homes with nursing and independent living homes operating on the
same site (Belgium, between MRS and MRPA
5
, and even with sheltered housing);
- or a combination of residential establishments and home care services, forming
establishments that can be “medicalised on a place
-by-
place basis”, as is the case in
Japan. In the related disability sector, France has long practised the budgetary
“medicalisation” of some of the places in existing
nursing homes, gradually moving them
towards medical nursing
homes, as and when dictated by residents’ care needs.
With regard to differences in perceptions of health needs from one country to another,
it is worth pointing out the Danish health authority’s strong scientific and educational
involvement on Lewy body disease, a relatively little-known pathology within the so-called
“related diseases” of Alzheimer's disease, constituting a major missed opportunity for
residents, in France and elsewhere.
In other countries with a federal or highly decentralized structure, the uncoupling of the
federal or regional hospital care system from federated or municipal care homes with nursing
creates the type of difficulties that were well known in France before the move towards
rapprochement which saw the establishment of the RHAs. This is an aspect that has become
all the more important given that t
oday’s focus on home care, in the interests of avoiding or
delaying admission to nursing homes wherever possible, correlatively requires increased
resourcing in the supply of geriatric care, including outpatient and day hospital care for
medicine and geriatric follow-up and rehabilitation care.
Another French particularity is the existence of private groups with commercial status,
which have enjoyed a strong international presence for 20 years; these have no equivalent in
the other countries studied.
5
MRPA (retirement home for the elderly)