Formal care in the community analysis of current utilisation

This section reviews in greater detail the evidence on utilisation of formal care in the community from a number of complementary sources: the 2006 National Disability Survey; the HSE database on home help and home care package recipients; and the TILDA study, which conducted interviews spanning 2009 to 2011.

The HSE database was established in 2006, in which year it did not record recipients' ages. Since 2007 the database has separately recorded home help clients aged 65 and over; and since 2008 the database has also distinguished home care package clients by age. A Home Care Package (HCP) is defined by the HSE as consisting of "community services and supports which may be provided to assist an older person, depending on their individual assessed care needs, to return home from hospital or residential care or to remain at home." The HCP may comprise "paramedical, nursing, respite and/or home help and/or other services depending on the assessed care needs of the individual applicant" (Health Service Executive 2011). The HCP data include care packages provided by HSE employed staff or by voluntary or private providers, if assisted by a HSE cash grant.

Similarly, the home help data include home help delivered by HSE staff or funded by the HSE and delivered by voluntary or private providers. The data do not include privately purchased and supplied services and are not therefore comprehensive. In estimating overall numbers of formal home care recipients, home help and home care package recipients should not be aggregated because there is a high degree of overlap between the two categories. Consequently, the number of home help recipients is employed as the baseline estimate for formal home care utilisation. Numbers of home help recipients in total and aged 65 years and over are seen to have increased in the years from 2006 to 2008 and to have peaked in 2008 with reductions subsequently (Table 5.15). Numbers of home care package recipients in total and aged 65 years and over increased over the years 2006 to 2011.

Table 5.15 Home help and home care package recipients and home help hours, 2006- September 2011; Source: HSE database

2006 2007 2008 2009 2010 Sept

2011

Home help recipients 49,578 54,736 55,366 53,791 54,011 51,166

Home help recipients aged 65+ 41,596 44,014 46,536 45,622 45,752 43,672 Home help recipients aged 65+ as %

age cohort 8.9% 9.2% 9.4% 8.9% 8.7% 8.0%

Home care package recipients 5,283 8,035 8,990 8,959 9,941 10,752 Home care package recipients aged 65+ 5,146 7,826 8,386 8,372 9,335 9,929 Home care package recipients aged 65+

as % age cohort 1.1% 1.6% 1.7% 1.6% 1.8% 1.8%

Note: Degree of overlap between home help and HCP package recipients not known. Recipients aged 65+ of home help in 2006 and of Home Care Packages in 2006 and 2007 estimated based on average share of recipients aged 65+ in subsequent years. Data are point in time: month or year end.

There appears to have been an intensification of care within formal home care, while the proportion of the older population in receipt of such care has reduced. The HSE National Service Plan 2012 is explicit about this more targeted approach:

"We will focus on the maintenance of home care packages at 2011 levels and on re-focusing home help services to prioritise personal care. Home care packages which support the most dependent to remain in their own homes will not be reduced in 2012 and the number of people in receipt of them will be the same as in 2011. There will be reductions of 4.5% nationally in the level of home help hours provided but this reduction will be compensated by a more rigorous approach to the allocation of these supports to ensure that the people most in need receive them by deprioritising non-personal care. Service efficiencies will mean that despite this level of reduction, the reduction in the number of people in receipt of home help services will be kept to 1.2%." (Health Service Executive 2012: 7)

The National Disability Survey records the percentage of people of all ages and by older age cohort who receive home help and carer/personal assistant services. The 21,378 recipients of either or both forms of care, who were aged 65 and over and with ADL difficulty in 2006, is much lower than the recipients of home help services of the same age, estimated from the HSE data. If this estimate, which is based on the age breakdown in later years, accurately reflects the age composition of home help recipients in 2006, the disparity with the NDS count of the percentage of older people with ADL difficulty receiving home help, carer or personal assistant services suggests that a substantial proportion of recipients of such services in the HSE count do not fit the NDS ADL definition.

Table 5.16 Recipients of formal home care 2006, HSE and NDS counts compared

2006 HSE home help recipients:

At all ages 49,578

Estimated numbers aged 65 and over 41,596

As % population aged 65 and over 8.9%

NDS home help and carer/personal assistant recipients with ADL difficulty:

Numbers aged 65 and over 21,378

As % population aged 65 and over 4.6%

Population aged 65 and over 467,926

Source: HSE database and 2006 NDS

This finding accords with evidence from the first wave of TILDA, derived from interviews conducted with older people in the community over the years 2009 to 2011. Analysis of the TILDA data has shown that while 8.3% of those surveyed aged 65 and over received care from a home help or personal care attendant, a higher proportion of this grouping reported no

ADL difficulty (62%) than reported an ADL difficulty (38%). This study has found that the grouping without either ADL or IADL difficulty who received formal home care were in general older and living alone; and were more likely to have had health system contact in the previous 12 months than those who did not receive care. Significant numbers experienced loneliness. This has been interpreted as suggesting that factors such as pressure to free up acute care beds may trigger home-based social care (Murphy 2011: and Appendix to this chapter). The utilisation rate of formal home care of 8.3% of the TILDA sample aged 65 and over would convert into approximately 7.9% of the population of that age, when adjusted for the exclusion of older people in residential LTC from TILDA.

The evidence from TILDA and the HSE database suggests that the NDS utilisation data for people with disability or ADL difficulty under-represent the actual utilisation in 2006. While the HSE database does not include people who purchase home care privately, the estimated utilisation rate of home help services at 8.9% of population aged 65 and over in 2006 and in the range of 8.9% to 8.0% in the years 2009-2011 when the TILDA first wave was conducted, exceeds but does not greatly diverge from the adjusted TILDA estimate of the utilisation rate of home helps and personal care attendants at 7.9%. This discrepancy may reflect the exclusion from the TILDA interviews of people with such cognitive disability that they were incapable of providing informed consent to their participation. It emerges then that none of these sources can supply a comprehensive count of utilisation: the HSE database excludes privately purchased care; the NDS excludes persons who do not report disability; and the TILDA dataset excludes persons with significant cognitive impairment. This analysis combines the evidence from two of these sources - the HSE database and the NDS - to estimate utilisation of formal home care in 2006, the base year. The NDS provides data on the proportions of older people in the community who pay and do not pay for the help they receive with everyday activities. People with disability pay for care in greater numbers at older ages and proportionately more women pay than men (Table 5.17).

Table 5.17 Older people who pay for help with everyday activities, 2006

Percentage with disability who pay

for help with everyday activities Numbers with disability Population in Age Cohort Numbers with disability who pay

for help with everyday activities % Population in Age Cohort who pay MALE 65-74 1.5 20,200 127,435 303 0.2% 75+ 8.6 20,500 79,660 1,763 2.2% FEMALE 65-74 5.4 21,500 135,113 1,161 0.9% 75+ 12 36,300 125718 4,356 3.5% TOTAL 65-74 3.5 41,700 262,548 1,460 0.6% 75+ 10.8 56,700 205,378 6,124 3.0% 65+ 7.7 98,400 467,926 7,583 1.6%

Although from the NDS it appears that 7,583 people with disability paid for help with everyday activities in 2006, due to the practice of "voluntary" contribution to home help services provided by public organisations (described in Chapter 3), some proportion of these respondents may not in fact have purchased care from private providers and may be included in the HSE count of recipients of public home help services. For this reason formal home care utilisation is estimated on two bases in this analysis. The first - and lower - basis is the utilisation rate of home help services, derived from the HSE data, of 8.9% of people aged 65 and over in 2006. The second basis adds the NDS numbers paying for care to the numbers estimated from the HSE data as in receipt of publicly funded or delivered care. The second basis brings the total number of people aged 65 and over and in receipt of formal home care to 49,179, representing a 10.5% utilisation rate for the population aged 65 and over (Table 5.18). To enable disaggregated forecasts of home care utilisation based on 2006 utilisation patterns, this analysis assumes that these estimated utilisation rates in the population aged 65 and over can be further disaggregated by two older age cohorts and by gender according to the utilisation proportions for people with ADL difficulty in the NDS (Table 5.18). In forecasting future utilisation of formal home care in Chapter 8, this range of utilisation rates is employed to generate alternative forecasts.

Table 5.18 Estimated utilisation of formal home care (home help, carer, personal assistant) 2006 Pop. in Age Cohort NDS With ADL and formal home care Percentage all aged 65+ with ADL and receiving such help Basis 1 estimated utilisation Basis 2 estimated utilisation Basis 1 utilisation rates as % pop. Basis 2 utilisation rates as % pop. MALE 65-74 127,435 1,330 6.2% 2,588 3,060 2.0% 2.4% 75+ 79,660 4,325 20.2% 8,415 9,949 10.6% 12.5% FEMALE 65-74 135,113 3,306 15.5% 6,433 7,605 4.8% 5.6% 75+ 125,718 12,416 58.1% 24,158 28,562 19.2% 22.7% TOTAL 65-74 262,548 4,636 21.7% 9,020 10,665 3.4% 4.1% 75+ 205,378 16,742 78.3% 32,576 38,514 15.9% 18.8% 65+ 467,926 21,378 100.0% 41,596 49,179 8.9% 10.5%

Sources and method: HSE numbers receiving home help services (Basis 1); NDS numbers paying for care added to HSE numbers (Basis 2) to generate total aged 65 and over in receipt of formal home care. NDS proportions disaggregated by age and gender of recipients of formal home care with ADL difficulty applied to total numbers in receipt of care estimated for the two Bases.

The TILDA first wave results report utilisation rates of formal home care by older age cohort surveyed. The combined utilisation rate of home helps and personal care attendants (assuming no overlaps) by people aged 70-79 is 7.1% and by people aged 80 and over is 22.5%, comparable rates to those generated above for two somewhat younger cohorts (Barrett et al, 2011).