Summary table
Reference Vignette(s)
Country
Region
C - Long-term care for the elderly
All C vignettes Municipality of Zofingen (Canton of Aargau) and Lausanne (Canton of Vaud)
Switzerland
Canton of Aargau (Zofingen) and Canton of Vaud (Lausanne)
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Name of the measure(s)
Elderly Care
Definition “Elderly care”:
“Elderly care” In Switzerland means assistance designed long-term which promotes and
supports the independence of persons over the age of 65 especially regarding health and
social matters. This includes various measures such as medical care and domestic support.
Financial support is generally treated separately and is mostly not part of elderly care
(occasionally also called long-term care in Switzerland). Informal care (by family, friends,
neighbours, etc.) and formal care (professional outpatient and inpatient care) are distinguished.
A) Medical care
According to the Provision on Sickness Insurance (KLV) (1996, article 7) (national legislation)
the service catalogue of the mandatory basic insurance includes the following services:
- Clarification and counselling measures
- Examination and treatment measures
- Basic care measures
Medical care can either be outpatient (e.g. by home care organisations) or inpatient (e.g. by old
person’s or care homes) services. The share of outpatient and inpatient care varies from
Canton to Canton. The scope of transitional care and rehabilitation have been expanded.
B) Domestic support
Domestic support includes cleaning, meals, transport, accompanying and relatives services
which are generally provided at home by private, charitable organisations such as Home Care
(“Spitex Zofingen”), Pro Senectute Zofingen, the Red Cross, etc. The costs are not covered by
the mandatory basic insurance of the Sickness Insurance. They are possibly covered by an
optional Additional Sickness Insurance if a medical certificate is presented.
C) Financial support
See Financing
2
Legal basis
Federal Administration:
According to the federal constitution every citizen who is faced with an emergency situation
and is not capable of sufficiently providing for himself is entitled to assistance, care and support
which is necessary for a humane existence. This includes care and assistance at home.
Elderly care is nationally regulated by federal law as part of the Sickness Insurance Act (KGV
1996). Elderly care organisations are accredited by and the scope of services is set out in the
corresponding Provision on Sickness Insurance (1996, article 7).
Financial support is set out in the Sickness Insurance (1996) (“Prämienverbilligung”), Insurance
of the Elderly and Surviving Dependents (AHV) (1948) -> Attendance Allowance
(“Hilfslosenentschädigung”) and Supplementary Benefits (“Ergänzungsleistungen (EL) zur
AHV) (1966).
Canton:
The actual design of elderly care is defined at cantonal level and mostly in several acts: A
general health act sets out the design of the health system of a Canton and specifies tasks of
the Canton and the Municipalities.
(Canton of Aargau: Health Act (1988); Canton of Vaud: Loi sur la santé publique (LSP) (1986).
Care centres providing inpatient care are generally subject to the Hospitals Act, Old People’s
Homes are subject to the Old People’s Home Act (Canton of Aargau: Hospitals Act (2001); Old
People’s Home Act of 1974; Canton of Vaud: Loi cantonale sur la planification et le
financement des établissements sanitaires (LPFES) (1979)).
In the Canton of Aargau a care act is currently in consultation which shall regulate inpatient
and outpatient care from the perspective of persons receiving benefits.
In the Canton of Vaud outpatient care is regulated at cantonal level Loi créant un Organisme
médico social vaudois (LOMSV) (1967), Loi d’aide aux personnes recourant à l’action médicosociale (LAPRAMS) (2006)). OMSV provides services on behalf of the Canton. In addition,
there is an act for financial support in the form of individual assistance in inpatient institutions
as well as subsidies in the area of outpatient care (Loi d’aide aux personnes recourant à
l’action médico-sociale (LAPRAMS) (2006)).
Agencies which are
responsible for
administering the
measure(s)
Municipalities:
The role of the Municipalities is set out in the respective laws at cantonal level (see Cantonal
Health Laws). They can conclude individual service agreements to provide the service with
private, non-profit organisation in particular for outpatient services (e.g in Zofingen service
agreement between the municipalitly and Home Care organisation; e.g. the City of Lausanne:
Convention de Subvention with the Association Pro Senectute Vaud).
Case management is organised differently in the individual Cantons. In the larger cities there is
generally a central contact or information centres, at least for inpatient care. In smaller cities
the persons affected have to contact the respective institutions. There is no integrated case
management. Case management is provided in the institutions providing the service: In the
care homes (“Krankenheime”, “Alters- und Pflegeheime”) and NPOs for medical care and
home assistance. In the Cantonal Compensation Fund regarding financial support. The local
Pro Senectute offices play an important role as contact centres of low level of inhibition.
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Financing
In principle the costs for medical care should be covered via the mandatory basic insurance of
the Sickness Insurance regardless of location (hospital, care centre, Old People’s Home,
outpatient care at home). However, the Sickness Insurance only covers part of the care costs
less excess (= fixed annual amount) and participation on all services of 10%. Depending on
the location of care the amounts are calculated according to a different assessment system.
The remaining sum is covered by the person receiving the services. Some institutions,
especially in the area of inpatient care, may also charge costs of stay based on income; this,
however, does not have a very big impact on the overall costs of stay.
In 2005 the average premium for an adult in the Canton of Aargau is Eur 158.8 (CHF 254) and
in the Canton of Vaud Eur 220.6 (CHF 353) per month.
There are various possibilities as to how an elderly person can be financially supported. These
are services depending on need which can only be claimed in certain health or financial
situations:
Attendance Allowance according to the Old Age Insurance Act 1948, article 43
(”Hilfslosenentschädigung”): The Old Age Insurancegrants Attendance Allowance if in at
least four of the six central activities (dressing, standing up / sitting down / lying down, eating,
body hygiene, going to the toilet, walking and establishing contact) can only be performed with
the help of third parties, if a person needs non-stop care or personal surveillance and
helplessness has persisted for at least one year. Attendance Allowance is independent of
income and savings. A slight degree Attendance Allowance is granted for people staying in
homes. People staying in homes, however, usually have a medium to severe degree of
helplessness. For a medium degree of helplessness Eur 339.75 (CHF 543) and for a severe
degree of helplessness Eur 537.5 (CHF 860) are paid per month. In 2005 2,436 people in the
Canton of Aargau and 3,816 people in the Canton of Vaud received Attendance Allowance for
a medium or severe degree of helplessness.
Premium Reductions according to the Sickness Insurance Act 1996, article 65
(“Prämienverbilligung”): The personal and family conditions are decisive for Premium
Reduction. If the guideline premiums for mandatory healthcare insurance exceed 11% of
decisive income, she is entitled to a maximum of Eur 772.5 (CHF 1,236) per year as an adult.
People drawing Supplementary Benefits or social assistance are entitled to full Premium
Reduction. In 2004 160,4151 people in the Canton of Aargau and 155,278 people in the
Canton of Vaud are entitled to Premium Reduction (this data includes all persons of all age
groups).
Supplementary Benefits the Old Age Insurance Act 1966 (“Ergänzungsleistungen (EL)
zur AHV”): Supplementary Benefits consist of the annual Supplementary Benefits which are
paid on a monthly basis and the medical costs. It is a service oriented towards the needs: The
amount of supplementary service corresponds to the difference between the expensed
acknowledged by law and allowable income. Certain medical costs incurred in Switzerland and
which result in expenses exceeding income can be refunded on provision of a medical
certificate within 15 months from the date of billing. Furhtermore, a person must be an Old Age
Pensioner and be living in Switzerland for 10 years to be able to receive the Supplementary
Benefits.
Per person a maximum annual amount of Eur 21,330 (CHF 34,128) in Supplementary Benefits
can be claimed in the Canton of Aargau and Eur 19,312.5 (CHF 30,900) in the Canton of Vaud.
In addition, both Cantons grant an annual maximum of Eur 15,625 (CHF 25,000) in medical
costs per person. At the end of 2005 6,290 persons are receiving Supplementary Benefits in
addition to Old Age Insurance (7.3% of pensioners) in the Canton of Aargau and 17,000
(16.4% of pensioners) in the Canton of Vaud. Eur 6.2m (CHF 9.9m) were paid annually in the
Canton of Aargau: 53.9% to cover participation of the Sickness Insurance, 26.4% for dental
bills, 12.2% for domestics support, 3.3% for transport and 4.1% for other expenses.
Canton of Aargau:
In the Canton of Aargau there are no further cantonal benefits. If the stated financial support is
not sufficient to cover the cost of living the persons affected must apply for social assistance. In
2004 0.3% of 65 to 79 year-olds and approx. 0.8% of over 80 year-olds depend upon social
assistance in the Canton of Aargau.
Canton of Vaud:
In the Canton of Vaud there are additional forms of individual support depending on needs:
LAPRAM (2006): For people living in homes who cannot cover the cost of living in the home
despite the financial support stated. The support consists of maximally Eur 15,625 (CHF
25,000 per person and year. 75% are currently benefiting from this support (295,176 Person in
2005).
Tarif dégressif : These are price reductions for people require domestic support from the
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charitable Home Care organisation (“Spitex Zofingen”). Domestic support CHF 4 to CHF 22
price reduction. Meals CHF 3 to CHF 6 price reduction. Cases of social assistance 65+?
Agencies which are
responsible for
implementing the
measure(s)
Target population and
coverage rate
- Care centre (”Krankenheim”): inpatient care, transitional care
- Old People’s Home (”Alters- und Pflegeheim”): inpatient and temporary stays
-Home Care (“Spitex Zofingen”): outpatient care and domestic support
- Pro Senectute Zofingen, Red Cross, etc.: domestic care (cleaning, meals, transport,
accompanying and relatives services)
- Private organisations with specific services
- Self-employed carers (rare)
- Self-help organisations (e.g. Alzheimer’s disease groups)
Elderly care is not limited by a certain group of people by law. People with simple care needs
used to be looked after in Old People’s Homes. Nowadays outpatient care is more prominent.
People staying in homes (2005):
Switzerland: 2,566 people
Canton of Aargau: 391 people (0.7 of 1000 citizens)
Canton of Vaud: 41 people (0.1 of 1000 citizens) -> these numbers have to be verified!
Home Care clients (2004):
Switzerland: 147,238 people, 6,647,723 hours
Canton of Aargau: 8,554 people, 337,300 hours
Canton of Vaud: 18,600 people, 1,017,546 hours
53% of home care clients are older than 80 in Switzerland. In the Canton of Aargau it is 46.8%
and in the Canton of Vaud 55.7% of the people older than 80. Women present 70% of the
persons receiving services and men 30% throughout Switzerland.
Domestic support:
A) Home Care (“Spitex”) (2004)
Switzerland: 113,366 people, 4,812,943 hours.
Canton of Aargau: 6,493 people, 268,184 hours.
Canton of Vaud: 15,324 people, 339,506 hours.
B) Pro Senectute (2005):
Switzerland: 53,254 social counselling sessions for 30,000 people (increasing). More than
71,000 people use the range of domestic support (increasing): cleaning service 79,000 hours,
55,000 visiting service, 20,400 feet care service, 19,000 transport service, 1,500 administrative
support. 557,000 cold meals, 622,000 warm meals (decreasing).
Social counselling Pro Senectute: Of the 30,000 people who consulted social counselling in
2005: 2/3 were women, 70% were between the age of 70 and 89, 55% were living alone.
Access criteria
Assessment and case
management
Financial support: see Financing
“The social Sickness Insurance grants services in case of illness, accident and maternity.”
(Art. 1 Sickness Insurance Act 1996). There is no legally anchored “right for care”. Anybody
living in Switzerland is obliged to take out a Sickness Insurance after at least three months. So
everybody with mandatory insurance can claim treatment and care as required by a medical
certificate. A needs assessment is legally required in the medical area (KVL, article 8). There is
no legally anchored entitlement to clarification and respective care for domestic support.
There is a legally anchored entitlement to financial support. In detail: see Financing.
The need assessment can be performed by various people: By the physician, a home care
specialist or old person’s specialist, by a physician of the care centre. In order to settle the care
costs by the mandatory basic insurance of the Sickness Insurance or the domestic support
costs by the optional Additional Sickness Insurance, the care services must be prescribed by a
physician. A prescription by a physician is, however, not always precondition to be admitted to
an Old People’s Home. There are varies of handling this depending on Canton: In Zofingen
(Canton of Aargau) a person does not necessarily need a certain need for care in order to be
given a place in a home. In Lausanne (Canton of Vaud), however, a home care carer
establishes whether need for inpatient care is given (triage?). There is no integrated case
management. Case management is performed by the organisation providing the service.
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Type of entitlement
Type of services and in-kind
supports foreseen
- Medical care: legal entitlement (Sickness Insurance Act 1996)
- Health and social counselling: legal entitlement (Sickness Insurance (1996) and cantonal
Social Assistance laws)
- Domestic support: no legal entitlement
- Additional services (visiting and accompanying services, transport service, etc.): no legal
entitlement.
A) Medical care according to Provision on Sickness Insurance (1996) (national legislation):
- Clarification and counselling measures
- Examination and treatment measures: Measurement of vital signs such as pulse, blood
pressure, temperature, breathing, simple assessment of sugar in the blood and urine,
extraction of examination material for laboratory purposes, measures on breathing therapy
such s O2 administration, inhalation, simple breathing exercises, siphoning, applying probes or
catheters and the thus involved carte measures, measures for haemolysis and peritoneal
dialysis, administration of medication especially by injection or infusion, aeteral or parental
administration of nourishing solutions, measures to monitor infusions, transfusions and devices
which serve to treat or control and maintain vital functions, rinse, clean and attend to wounds
incl. stomaostomy and tracheostomy therapy as well feet care for diabetics, care measures for
micturition and defaecation difficulties, incl. rehabilitation exercises for incontinence, help for
medical, partial or full baths; application of packings, packages and FaNPO packings.
- Basic care measures: For patients who cannot perform the activities themselvels: Wrapping
up legs, putting on compression tights, bedding, seating, exercises, mobilising, decubitus
prophylaxis, measures to prevent or remove skin damage resulting from treatment, support for
oral and bodily hygiene, dressing, eating and drinking; psychiatric or psychogeriatric basic
care.
B) Domestic support:
- Cleaning service
- Preparing meals
- Transport service
- Accompanying and visiting services
- Relative services
Criteria for keeping
entitlement?
Control mechanisms
Waiting time between
request and service delivery
C) Counselling
- Health counselling (Home Care (“Spitex”), partly Pro Senectute)
- Social counselling (Pro Senectute, partly Home Care (“Spitex”))
The need for medical, domestic and financial support must be regularly proved.
- Medical care: The measures for long-term care are prescribed every 6 months and must be
verified after this term. From a helplessness of medium degree the measures must be
prescribed without limit.
- Domestic support: varies from organisation to organisation
- Financial support: annual verification of entitlement to Attendance Allowance, Premium
Reduction and Supplementary Benefits.
The Cantons are generally responsible for the quality assurance. They keep care home lists for
inpatient services. The homes must meet certain quality requirements so the can be listed and
so the costs for medical services may be settled via the mandatory basic insurance of the
Sickness Insurance.
It is attempted to improve the inpatient services by introducing certain conditions in service
agreements. These service agreements are located depending on Canton and institution at a
different state level (e.g. Canton of Aargau: Home care -> Municipality; Pro Senectute ->
federal administration. Canton of Vaud: Home care -> Canton, Pro Senectute -> “convention”
with the Municipality).
With regard to the service providers the Sickness Fund (regarding medical care), the Cantonal
Compensation Funds (regarding Attendance Allowance, Supplementary Benefits and cantonal
additional services) as well as the municipal social authority have certain access records rights
and controlling authorisations.
The waiting time is – if at all – a problem in inpatient care. But overall the waiting time has been
significantly reduced over the past years. This has been achieved due to the expansion of
temporary solutions and partly due to a change of the application procedure (no provisional
application for a place in a home, more careful assessment of needs, stronger prioritisation of
home admission based on care). There is no specific stated waiting time for home care. But it
will probably be compensated by the arrangement of the initial meeting.
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Policy debate
Facing the tight financial situation of the federal government, there is a discussion regarding
proposed new regulations for the care of the elderly and the financing of such care. This
discussion takes place within the context of the “new design regarding the balance of
1
payments between the federal and Cantonal governments” (NFA ) and the revised regulations
2
concerning financing of care, as a partial review of the Sickness Insurance legislation. In the
context of NFA, the care of the elderly should remain shared between the federal government
and the Cantons. The Swiss Federal Council (Bundesrat) intends to retreat further from
financing ambulant care and Supplementary Benefits for residents of long-term facilities (Old
People’s Home). In the context of the new regulations on care financing, the application of the
lowest level of Attendance Allowance eligibility to Old Age Pensioners living at home, along
with the concurrent removal of upper limits on Supplementary Benefits, the burden currently
borne by health insurers should be reduced considerably. At the same time, in the coming
years, Cantons and Municipalities, as well as private households, will see a corresponding
increase in their share of overall expenditures for care of the elderly.
1
The Neugestaltung des Finanzausgleichs und der Aufgabenteilung zwischen Bund und Kantonen (NFA) will be implemented as of
1 January 2008.
2
The new regulations for financing of care are currently undergoing consultation processes (during the Spring 2006 session).
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