Evaluation of access to long-term care services for old people ageing in place in Slovenia

The purpose of this paper is to examine how informal carers of old people, ageing in place, and using an array of formal long-term services (LTC) in community in Slovenia, evaluate access to formal LTC, used by older people. To this purpose, we explore and operationalise the theoretical five-dimensional (availability, accessibility, accommodation, affordability, acceptability) model of access by Penchansky and Thomas (1, 2). Specifically, we observe perceptions of informal carers of older people, as most often they are the ones who organise and assist access to formal LTC services and are well aware of their characteristics. Their views are especially important regarding the absence of one entry point to LTC services and longstanding division of health and social protection systems in Slovenia, which is pertinent in LTC (3,4,5,6). Access to LTC is an important issue in Eastern and Central European countries (3,4,5), so this study will contribute to understanding the user experience in a broader geographical area. The paper is structured as follows. First, we present major characteristics of Slovenian LTC delivery; this is then followed by a description of the five-dimensional model of access and an outline of hypotheses on the basis of literature review.

The percentage of private, out-of-pocket expenditure for formal LTC services in Slovenia is ranking the fourth in Europe, as 24% of all costs for the services consists of private out-of-pocket contribution (3). LTC expenditure represents 1% of GDP and 70% of the budget is allocated to health care (7). Altogether, 6.7% of population aged 65+ receives LTC, and among them, the majority (75%) receives institutional care (3). Compared to other European countries, this is a unique situation, as in all countries for which data is available, the majority of users receive LTC at home (3). This specific composition of Slovenian LTC may be partially explained by historical reasons, as institutional care has a long tradition in Slovenia (4), and formal services for old people aging in place became available more recently (3,4,5,6). How users of Slovenian LTC services and their informal carers perceive its quality is so far known only from descriptive comparative research (3). European Quality of Life Survey (EQLS) shows that Slovenia is the third country in Europe, ranking in difficulties to the access to long-term care (3). Nearly all users of LTC services state that they encounter difficulties with access (89% - report affordability as an issue, 84% availability (waiting lists, lack of services) and 60% accessibility – distance or opening hours as a source of barriers to access). Quality of care is rated more favourable, as only 46% report quality as difficulty related to LTC services, which is about EU average. It is therefore important to explore in detail how users of formal LTC services and their informal carers perceive their quality.

The theoretical model of five dimensions of access has been proposed already in 1980s (1, 2), and often utilised in research on the quality of LTC or individual services (13,14,15,16,17,18,19,20,21,22,23,24,25,26). Access is broadly defined as fit between peoples’ (users or patients) needs and expectations, and services (e.g. health or LTC) that are offered to them in their community or region (1, 2). Availability refers to the relationship between volume and types of services and resources that are offered by the system and users’ needs (1,2). We refer to formal LTC services as the system in this study. Accessibility is fit or distance between location of service and location of users (1,2). It includes geographical distance between service provider and users’ homes, and includes all resources that are needed for users to reach the facilities, such as transfer costs and time spent on the voyage (1, 2). Waiting time between the initial contact between service provider and user and the date of actual service is also included in accessibility (1, 2). Accommodation refers to the quality of the organisation of the services, such as parking spaces, appointment system (phone, in person, the Internet), opening hours, time spent in the waiting room. Satisfaction of users with accommodation shows how suitable these characteristics of service provision are and how much they are a match to expectations of users (1, 2). Affordability refers to fit between total costs of the system and users’ ability to contribute to the costs either via insurances, taxes, or with direct out-of-pocket private co-payment (1, 2). Acceptability measures the fit between characteristics of service providers, such as their race, ethnicity, gender, attitude, professionalism, language, etc. (1, 2). Problems with access will influence users as well as the services in three ways, namely: the usage of the services will be lower, users will be less satisfied with services and provider practice patterns may be inadequate or less than optimal (1, 2).

Very often, the usage of services of LTC, access and barriers to access are evaluated from the point of view of users and their informal carers at the same time (13, 14, 18, 22, 23). Quite often, access is evaluated from the perspective of users of services of LTC (16, 18, 21) or informal carers (24,25,26) or even from the perspective of professional carers (19). Both qualitative (18,19,20, 22, 25, 27,28,29,30) and quantitative (15, 17, 21, 31) approaches were found in the literature, and we tried to take into account evidence from both types of studies to postulate our hypotheses about access to long-term care services for older people, ageing in place in Slovenia.

At the end of each following paragraph we outline a hypothesis, based on literature review of articles presented in this paragraph. Rural areas are characterised by lower availability and accessibility of services (15, 29, 31,32,33). Low awareness and lack of information about services among potential users and their informal carers, and reluctance to use formal services were also identified among barriers (16, 29). Insufficient public transport in rural areas was found to be a significant barrier to access to health services, which is important for older people aging in place and their informal carers (32). Gaps in services provision were related to timing of the service or to the ways service was organised around an individual user (16, 29, 33). This accumulation of barriers to access to LTC in rural areas would result in systematic perception of lower access to services across all five dimensions of access also in the Slovenian context.

Inadequate attitude by formal carer or physician, her/ his lack of communication skills or failure to provide information was also identified as a factor that has a negative effect on the perception of access for all dimensions of access (15, 33). Considering that the quality of LTC was rated as relatively good by EQLS, we expect favourable evaluations of quality of service provision in Slovenia, measured as acceptability and accommodation, as opposed to other dimensions.

Need of care recipient and informal carer, taking into account both illnesses and disabilities as well as psychological impairment, such as problems with memory, would increase the usage of formal services (15, 21, 31, 33). We hypothesise that informal carers with higher amount of illnesses and disabilities rate access to LTC services across all dimension of access lower than respondents with lower amount of illnesses and disabilities.

Financial constraints are an obvious barrier to the access to any kind of service that requires out-of-pocket private contribution, both in rural and urban areas, as well as taking individual or household income into account (15, 26, 29, 31,32,33). The type of relationship between informal carer and care recipient(s) is also important, as children are more often found to facilitate the usage of formal services than spouses (16, 26, 31, 33), and male carers more often than female carers (16, 26, 33). Education also fosters the usage of formal services (21, 31), and more educated carers may have higher expectations about service provision and service quality, and thus rate access less favourably than informal carers with lower education. We hypothesise that affordability of the LTC services rates the least favourable among all components of access, and that the evaluations will be negatively associated with higher care needs of care recipients and caregivers with lower income and higher education.

Table 1

Descriptive statistics.

Table 2

Descriptive statistics II.

Evaluations of five dimensions of access considerably vary on average since the mean acceptability is very high (4.02) and affordability quite low (2.90). Informal carers of users of social home care are, on average, 60 years old, in majority they are women (62.6%), in majority they can manage with family income, in majority they have completed high school (69.3%), and they report a lower level of scope and intensity of their own health issues on average (2.17). They provide a substantial amount of informal care to care recipients who mostly reside in their own households (61.1%). The majority of care recipients have two or more long-term physical or psychological impairments, illnesses or disabilities that limit them in daily life activities, and about 30% have severe memory problems.

Table 3

Results of multiple linear regression analysis.

Models for five dimensions of access perform differently, as the proportion of explained variance in access varies between 2 and 15 percent. The smallest amount of explained variance was found for accessibility and acceptability, whereas the biggest amount of explained variance was found for affordability.

Perception of availability of LTC services is significantly influenced by evaluation of family income, informal caregivers’ health and type of settlement. Informal carers, reporting difficulties with family income, would rate LTC services as less available (unstandardised regression coefficient b=-.201). Similarly, if they reported a higher degree of their own health problems (b=-.127) and if they are living in a rural area (b=-.102), they rate the availability less favourably. Perception of accessibility is only affected by evaluation of family income. Informal carers reporting difficulties with family income would rate LTC services as less accessible (unstandardised regression coefficient b=-.127). Perception of accommodation is only affected by informal carers’ health problems (b=-.082), similarly as acceptability (b=-.129). Perception of affordability is affected by a number of variables, including care recipient’s health (b=-.226). Perception of affordability increases with informal caregivers’ age (b=.004) and the number of care recipients (b=.085). Perception of affordability decreases with informal carers’ difficulties with family income (b=-.538), informal carers’ own health problems (b=-.137) and living in a rural area (b=-.111). Among predictors, needs of care recipient and informal caregiver and evaluation of family income are among the strongest predictors of access (as suggested by standardised regression coefficients - B), followed by type of settlement, care recipients’ age and number of care recipients.

The purpose of this study was to evaluate access to Slovenian LTC services for old people residing in community. As predicted, financial access or affordability was rated the lowest. Similarly as in other countries, affordability of the LTC services is an important issue to its users and their informal carers (15, 26, 29, 31,32,33). Financial resources obviously represent a persistent and universal barrier to the usage of formal LTC.

Disparities which were observed between rural and urban settlements are not surprising, as they are observed in other countries as well (15, 26, 29, 31,32,33, 35). Financial constraints most likely enhance lower availability of services in rural areas and higher probability of having unmet needs (35). Informal care is related to the lack of financial resources, while the usage of formal services is often related to the financial status of care recipients and their families (34).

Even though financial coverage by insurance reduces financial barriers to LTC services, organisational and geographic barriers will probably persist, similarly as suggested by previous research (15), unless they are specifically addressed by policy makers.

We are less than satisfied with the performance of our appraisal questionnaire, even though all five dimensions of access were addressed explicitly. We acknowledge the lower percentage of explained variability. Quite likely, affordability is an issue that is more important for social care, whereas availability and accessibility are issues that are more important for health segment of the LTC services in Slovenia. This assumption is based on the fact that heath care part of long-term care is financed with insurance mechanism, while the social services part of the long-term care requires high out-of-pocket private contributions from users and their families.

As our findings show affordability as the least favourable aspect of access, we advocate for reconsidering the copayment policy for social home care in such a way that would consider financial situation of users and their families.

Apart from general evaluations of long-term services, there is need for additional exploration of this field in Slovenia. Little is known about respite care or other services designed for informal carers in Slovenia, regardless of their beneficial effects on informal carers of LTC recipients (14, 17), and we encourage in-depth evaluations of services that are available in Slovenia. There is very little known about different experiences in accessing services of male and female family carers (27) and more research is needed to better understand their caring experiences. There is persistent encouragement for co-ordination and integration of LTC services (20, 22), as integrated services guarantee better care to end users and their informal carers.