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Social and Health-Care Policy for the Elderly in
Denmark
By: Mary E. Jarden and Jens Ole Jarden
Clinical Geriatrics
Ms. Jarden is a nurse development consultant, and
Dr. Jarden is Chief Neurology Attending and Chairman, Stroke Department,
Amager Hospital, Copenhagen, Denmark.
Trends in Denmark's aging population warrant a
discussion of its mainly government-organized and -financed social service
and health-care system, which is so closely associated with the well-being
of its citizens. Over the last decade a more intensive and active
engagement with this rapidly growing older age group has led to
government-sponsored research and new standards in health law. In
addition, new clinical and social service approaches, as well as the
efforts of senior citizen special interest groups, have gained a strong
influence on government decision making.
This article introduces the Nordic and, more
specifically, Denmark's social service and health-care system and policy
regarding the care of its elderly.
The Nordic Countries
It is typical of Nordic tradition that the federal government assumes
responsibility for the welfare of the elderly. This means that the state,
regional council districts, and the municipalities are responsible for
organizing efforts that cover the elderly's needs. The federal government
establishes a budgetary limit for each district and municipality, while
local leaders formulate policies and services within those constraints
according to the special needs of the community. Generally this effort is
organized through an "institutionalized" setting, whereby care
is offered and given in either special institutions or at home. Current
policy is aimed at providing conditions that allow elderly to stay in
their homes for as long as possible. The trend is bringing the care to the
patient instead of expecting the patient to seek out care. When assistance
or specialized care is needed, a network of nurses and physicians employed
by the municipality visits the elderly in their homes or senior living
units. If an elderly person reaches a point at which they cannot remain at
home, they are offered one of several residential options in senior care.
The Nordic countries have successfully introduced a
growing number of senior day care centers, at which a range of activities
are available for all senior citizens. In addition, Sweden and Denmark
have introduced social volunteer efforts whereby the elderly can help each
other in a variety of ways.
Geriatrics hospitals and departments specializing in
dementia, orthopedics, general internal medicine, and terminal care have
also evolved. The Nordic approach represents a system of care that focuses
on the individual needs of the patient.
Taking care of senior citizens is part of a greater
Scandinavian tradition covering societal groups not active in the labor
market, including children, the handicapped, etc. This tradition is based
on equal rights legislation, which secures the aging population an
overall, consistent access to health care and other needed services. At
the same time, health-care providers are guaranteed equal employment
conditions.
The traditional Nordic social service and health-care
model is now considering a more privately organized home-care approach. A
few of Sweden's municipalities have allowed private businesses to take
over the responsibility of home care, but in Denmark, privatization has
been attempted in only a few selected areas such as meal and cleaning
services. This trend is still the exception in the Nordic countries,
however, and it seems that although many municipalities are interested in
finding new ways to cut budgets through private means, others still cling
to the more traditional public management of their elderly.1
Geriatrics in Scandinavia
A shared Nordic approach to comprehensive geriatric assessment has been
established through the research efforts of academic geriatricians in
Scandinavia. The Nordic version of a geriatric work-up is based on
Scandinavia's common attitudes and comparable organization of the
health-care system as well as the tradition for shared collaboration
within geriatrics.2 The concept of Nordic geriatric assessment
is based on a model, defining health and disease in old age in terms of
functional limitations, pathology, impairments, and disability, modified
by extra- and intraindividual factors. The model is founded on the
American "Disablement Process" developed in 1994,3
and it is used as the common Nordic framework for evaluation and
rehabilitation efforts.
Geriatrics in Denmark
The present trend is that of establishing specialty units within county
hospitals for the elderly, that is, geriatrics units with special
departments for dementia, orthopedics, stroke, general internal medicine,
and terminal care.
Of the total population over 65 years of age, 4 to 6%
suffer from a socially isolating dementia.4 Dementia patients
are no longer diagnosed and treated solely by psychiatrists, but are often
also in the care of geriatric specialists or neurologists. Special
hospital departments and nursing homes provide services for senile
persons. This recent interest in patients with senile dementia has brought
about multidisciplinary team approaches, using new strategies and
treatment methods. Preventive and supportive measures are initiated in
dementia cases to avoid, for example, the social collapse of a demented
person's family. Other geriatric preventive strategies include programs to
prevent cardiac disease, illness related to physical inactivity, spinal
degeneration, and reduction of learning ability. Initiation of this
preventive approach is developed to improve quality of life in the aging
population, whether an older individual is defined as a healthy
well-functioning senior citizen or a person suffering from dementia.4
Denmark's Senior Citizens
The average life expectancy in Denmark today is 76 years. Of Denmark's
total population of 5.2 million persons, approximately 790,000 (16%) are
65 years or older. Those 80 years or older account for 189,000 persons
(3.6%). It is estimated that over the next 19 years, the number of those
over 80 years of age will rise by at least 20%, whereas the number of
those 65 to 79 years of age will remain stable.5
Denmark has for practical reasons adapted a
classification system for individuals over 60 years of age, with those
over 60 referred to as the third age group and those over 80 as the fourth
age group. This age grouping is sustained by the fact that nearly all of
the employed have retired by the age of 70 years; 50% retire by the age of
60,6 and the average retirement age is only 61.7 Of those older than 65
years of age, 20% require home health visits/care, whereas 50% of those
older than 80 years require this support.8 Approximately 80% of
the elderly live independently in the community, and 40% receive
state-subsidized social and health services. However, the population over
65 years is responsible for one-third of all hospital admissions, which
translates into over 50% of the total number of hospital days in Denmark.9
Because one-fifth of the population is over 60 years of age, one-third of
all hospital admissions are persons over 60 years of age; in other words,
every other hospital bed in Denmark is occupied by an elderly patient. It
is believed that as much as 10 to 20% of all hospital admissions of those
over 65 years are due to the side effects of medications, an example of
which is the tendency to over treat with antihypertensive drugs, resulting
in falls that causes fractures and other complications.10
Denmark's Social Service and Health-Care System
The Danish social service and health-care system is based on free
comprehensive medical and social care benefits financed by the government
through a relatively high personal tax of 50 to 70% and a tax on goods and
services of 25%. Approximately 5.6% of Denmark's gross national product is
spent on health-care costs as compared with 10.7% in the United States.
This figure even includes expenses for day care, sick leave,
hospitalization, and general health care.
Caring for the Elderly
It was earlier believed that most social and health-care problems of the
elderly should be solved through institutional care. Currently, however,
the idea is to provide conditions allowing the older person to remain at
home for as long as possible. This policy is reflected by the large shift
in expenses from the secondary to the primary sector. For example, the
number of patients that a public health nurse visited increased 52%
between 1981 and 1993; the frequency of visits increased by 132%. These
substantial increases in number of home health care patients and frequency
of visits are explained by the increased number of citizens over 67 years
in the same period.11 From 1981 to 1993, there was a concerted
effort toward building communication and cooperation between the hospital,
family practitioner, and the public health-care system. The Health Care
Committee introduced a model that integrated nursing homes and public
health nursing in 1989. In 1983, only 39 local communities offered 24-hour
services, a number increasing to 269 in 1995. Over a 12-year period, a
total of 230 communities completely revised their policy of care for the
elderly.11
Helping Elderly to Help Themselves
To accommodate the preference of senior citizens to remain in their own
homes, the municipality has developed a wide range of services aimed at
helping these elderly to help themselves. These includes assistance with
cleaning, shopping, washing, preparation of meals, and personal hygiene
and care. Home care can be used to assist or relieve family members caring
for a sick or handicapped person. Two forms of home care are available,
long term and temporary help. Long-term care is provided free of charge,
whereas temporary home care visits may warrant individual payment
depending on the income of the recipient.
The public health nurse offers free around-the-clock
services including patient education, care, and treatments, and help in
filling out applications for various needs, change of residence, aid, and
emergency help, as well as applications for senior centers and senior
day-care facilities.
All handicapped, sick, or infirm individuals can have
an emergency or safety phone-calling system installed, with direct 24-hour
contact to the public health nurse.
Living Situation
When elderly persons are in need of another living situation due to health
reasons, a more suitable residence is offered. An array of
possibilities are available based on each individual's needs and desires.
Senior citizen residences, gated communities, assisted living units, and
nursing homes are designed especially for the elderly and handicapped when
they no longer can take care of themselves, offering a one- or two-room
apartment, elevator, and emergency/contact system as well as social
activities. They often differ in their management and administration, and
some residences are associated with nursing homes supplying health aides.
Resident councils provide representation of the needs of the residents in
these senior citizen units.
A day-care center is offered as an option for those
who do not wish to move permanently, but for a shorter or longer period
require extra care. Transportation to and from the day-care center is
arranged. There is also the option of using a nursing home for a shorter
period, to provide a respite for the family.
Senior citizens receive a full pension while being monetarily responsible
for individual services received, such as meals, cleaning, care, and rent.
However, no more than 15% of the pension is expected to go toward the
rent.7
Pension and Aid
At 67 years of age, all individuals automatically receive a state pension.
In addition, another extension of the social safety net is a supplemental
labor market pension, paid for by the employers and designed to supplement
the state senior citizen pension.12
A retiree is entitled to a tax-free monetary supplement to their pension
fund based on the person's or couple's total income. Therefore expenses
such as heating bills and expenses related to illness, medications, dental
procedures, and eyeglasses are often financed publicly.
All retirees can apply for monetary supplements or
loans for their housing rent whether they rent or own their residence.
Seniors living in a collective housing community can also apply as long as
five of the residents are at least 55 years of age.7
Supplements for foot care and treatment for persons with diabetes, scar
tissue, and ingrown toenails are provided. The general
practitioner's referral to training centers for rehabilitation purposes is
free of cost, and physical therapy sessions are given at a 40% subsidized
rate. Special dental home care visits can be arranged in many districts.
A food service is available, with meals being
delivered to the home at a subsidized rate. Additional home and yard
services are available to senior citizens through their municipality at a
low rate.7
"Seniors Help Seniors" Program
Volunteer work is a new phenomena in Denmark. The Social Service Law of
July 1998 administered 700,000 dollars yearly for developing and expanding
social volunteer efforts in Denmark. In 1999, regional and municipal
districts used as much as 46% of the funding. This project has reached 120
of 275 municipals. The intention is to fight loneliness by creating a
network for senior citizens. The goal is to establish volunteer help in
the remaining 155 municipalities over the next three years. The
perspective is to broaden the volunteer profile by integrating volunteer
work into the senior citizen's daily life regardless of the volunteer's
age, profession, or ethnic background, thus developing a "shared
social understanding" that hopefully will strengthen Denmark's social
welfare profile.12
Home Support of the Elderly
In the last decade, societal developments have made it difficult for
families to care for elderly family members. As a consequence, care taking
of the aging population has become a societal responsibility. At least 80%
of the women in Denmark are employed, and over 95% of children are
enrolled in some form of day care. It is no longer typical for the younger
family members to take care of the older family members, with only 5% of
senior citizens living together with their families and 6 to 7% of those
70 years of age and 25% of those 80 years of age living in a senior home
facility.6 However, 80% of the elderly see their families once
a week, as 60% live within a half-hour drive from family members. Most
families use resources available within the family structure, for example,
two-thirds of all families help each other by caring for grandchildren,
doing yard work or repairs, washing clothes, cleaning, and preparing
meals.1
Most of the elderly living in their own residence are
self sufficient, albeit they have some degree of chronic illness and take
multiple medications daily. Of those individuals 75 years of age, less
than 5% have problems with making their own food and with personal
hygiene, 15% have impaired vision, and 10% have impaired hearing.
Aging Minority Groups
Aging immigrants in Denmark have traditionally been cared for by their
children and family members. This tradition is expected to shift, however,
and follow the Danish societal pattern. It is believed that younger
immigrants, due to employment and educational responsibilities, will
entrust the care of their elderly relatives to the municipality. The
number of immigrants over 60 years of age will almost triple in the years
to come. In 1997, there were 34,000 immigrants over 60 years of age in
Denmark; the projection for the year 2020 is 86,000.13
The language and cultural barriers that the immigrant senior citizen will
potentially meet could cause great isolation, because this immigrant
elderly population will probably not take advantage of the wide spectrum
of opportunities available to them. As a result, immigrants are strongly
encouraged to learn Danish and health-care workers are educated in the
special aspects of immigrant elderly care.
Political Goals and Trends in Policy
Political interest in the aging population has intensified, and great
initiatives have been undertaken to improve quality and efficiency while
controlling costs in the social service and health-care systems.
Highlights of political goals and trends are as follows:9
In 1977 the Priority Committee suggested shifting the main responsibility
of caring for the elderly from the hospital to the public health-care
sector with special emphasis on health promotion and preventive efforts.
This suggestion led in 1985 to improvements of conditions for elderly in
their own homes, during hospital admission, discharge, and during
follow-up care.
In 1984 Denmark adopted the World Health
Organization's goals for health in "Health for all in the year
2000," prioritizing prevention and supportive care. Goal 6 is about
healthful aging adding years to life as well as life to years. Adequate
care within an acceptable economical framework is enforced, and new
programs and facilities for long-term care are introduced. The basic
philosophy is to maintain the elderly's mental and physical capacities for
as long as possible by offering the appropriate care and support.
The Health Ministry's report in 1993 stated that a
general demand for better planning and coordination of offered social and
health-care system services would be prioritized. The elderly individual
is guaranteed optimal treatment, care, and rehabilitation, with the goal
of regaining their functional level prior to their illness and with the
intention of helping that older person reach the highest level of
independence possible.
The "Roedovre project" from 1984 created
the basis for the new law on Preventive Home Visits to the Aging (July
1996), documenting the effect of prevention on illness, weakness, and
psychological and social problems. All persons over 75 years of age are
entitled to receive at least two home visits annually. The goal of these
visits is to secure safety and well-being by recognizing their own as well
as the municipality's resources.14
Another change in social service and health-care
practice in the 1990s at the national level was that all persons, 70 years
or older, can receive a public health nurse visit no later than three days
following discharge from a hospital. This nurse is responsible for
follow-up and ensures that adequate help is available in the home.
Conclusion
As a result of an active interest in the aging population at the
governmental, health professional, and societal level, social service and
health-care practices have evolved to directly protect and enhance the
quality of life of the senior citizen. Whereas Denmark places a great
emphasis on state provisions, a care system that allows for more
flexibility in the living conditions and the social environment of older
persons has developed. However, it is not without its share of challenges,
facing a rise in health-care expenses while confronted by the question of
how to provide universal service while containing costs.
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© 2002 Global Action on Aging
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