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Experience Counts: Chapter 2 - Long-Term Care


Objective: to improve the quality of care in nursing homes and old age homes


Studies conducted in Israel in the late 1970's indicated many shortcomings in assessing the quality of care in long-term care institutions, including lack of a reliable, and comprehensive regulatory instrument to ensure uniform standards, over-emphasis on the structural indicators of care, and failure to take into account the opinion of residents.

In response to the need for improved care, the JDC-Brookdale Institute developed methods and instruments to identify shortcomings in the provision of care. A method for Regulation, Assessment, Follow-up and Continuous Improvement of Quality of Care (RAF) was developed, in which a set of well-defined and frequently occurring problems serve as "tracers" for the evaluation of care. A tracer is a well-defined problem or condition, such as hypertension, incontinence, or impaired mobility, which has a significant effect on an individual's wellbeing. Care for the tracer includes well-defined procedures for at least one of the following: prevention, diagnosis, treatment or rehabilitation. The approach assumes that the manner in which care is provided for specific problems is an indicator of the quality of care of the entire care delivery system; therefore, a limited number of tracer conditions, examined in-depth, can serve as a basis for assessing the overall quality of care provided by a specific service.

Another basic feature of the system is the utilization of residents as a source of information; a sample from each institution is included as a part of the regulatory process.

The evaluation of quality of care is based on the integration of three approaches to measuring care: structural indicators (such as staffing ratios and physical conditions); process indicators (such as staff awareness of problems and the adequacy of treatment practices); and outcome indicators (such as controlling problems including hypertension, cleanliness of residents and resident satisfaction).

Another feature of the system is computerization at all phases of the regulatory process. The basic reports on each individual institution are computer-generated. In addition, the findings from the annual surveillance cycle are integrated into a nationwide databank on quality of care by institution, as a basis for aggregate monitoring of changes and identifying weak areas of care or sectors of the institutional network that require specific intervention, as well as directing the attention of the surveillance process to more problematic areas. An additional by-product of the regulatory process is a supplemental databank which includes data on all the residents of the institution and the prevalence of key conditions which can be used to monitor changes in the institutional population over time.

A preliminary study using this method provided an in-depth view of the quality of care in long-term care facilities, identifying not only deficiencies in care but the causes of those deficiencies, such as unreliable records, manpower shortages or insufficient consultation with medical specialists.

Based on the findings from the preliminary study and employing the RAF method, in 1985 the Brookdale Institute began to develop an experimental program to improve regulation. The program was developed in consultation with the Ministry of Labor and Social Affairs, which is responsible for the regulation of public and private old age homes, and the Ministry of Health, responsible for the regulation of public and private nursing homes and nursing units in general hospitals. The system was first introduced in a sample of homes for the elderly. Representatives of the ministries helped to focus the program on the needs of their agencies, assured the cooperation of field units, and provided feedback. The close cooperation between researchers, policymakers and service-providers ensured that the results would be accepted in the field. The experimental program included workshops and supplementary training for the surveyors, and the surveyors collaborated with the researchers to solve problems which arose throughout the developmental phase of the program.

The system has now been implemented nationwide in old-age homes for the elderly operated by the Ministry of Labor and Social Affairs and in all private nursing homes supervised by the Ministry of Health. The basic approach is now being adapted to other populations, including the physically and mentally handicapped, children at risk, and juvenile offenders.

A comparison of the first and second surveillance cycles conducted under the program (1988-89 and 1990-92) revealed a sharp improvement in the general comprehensive quality index and in most of the specific quality indices. The attitudes of the directors of the institutions toward the adequacy and fairness of the regulatory process also improved dramatically.

Special Features of the Program:

— The use of structured instruments and a standardized method: surveyors now use standardized questionnaires with clear criteria for identifying deficiencies in the provision of care and their causes.

— The approach uses multiple sources of information with special emphasis on input from residents.

— Inspections are now conducted in cycles, which begin when an institution requests renewal of its license. Renewal is granted only upon correction of any deficiencies identified following an annual inspection.

Sponsors: Ministry of Health

Ministry of Labor and Social Affairs


Experimental Phase: Ministry of Health; Ministry of Labor and Social Affairs; JDC-Brookdale Institute; JDC-Israel; National Insurance Institute; The Pinhas Sapir Fund; Mifal HaPayes (Israel's National Lottery)

Ongoing Regulation: Ministry of Health

Ministry of Labor and Social Affairs


The use of the method to evaluate quality of care has been replicated in the State of Florida, under a grant from the Administration on Aging of the Department of Health and Human Services, and in Cape Town, South Africa, under the sponsorship of the Ministry of Welfare and Health. Despite differences among the countries in cultural norms and service systems, the methodology successfully revealed deficient areas of care in residential homes.


Fleishman, R.; Bar-Giora, M.; Ronen, R.; Mendelson, J. and Bentley, L. 1988. "Improving the Quality of Care in Israel's Long-term Care Institutions." World Health Forum. 9:327-335. (English)

Fleishman, R.; Mizrachi, G.; Dynia, A.; Walk, D.; Shirazi, V. and Shapira, A. 1994. "Improving Regulation of Care." International Journal for Quality in Health Care. 6(1):61-71. (English)

Fleishman, R.; Ross, N. and Feierstein, A. 1992. "Quality of Care in Residential Homes: A Comparison between Israel and Florida." Quality Assurance in Health Care 4(3):225-244. (English)

For Further Information:

JDC-Brookdale Institute
POB 13087
Tel. 972-2-66557400; Fax 972-2-5635851.


Objective: to enable the severely disabled elderly to remain in the community by providing entitlements to personal care and home help


In 1986, the Israeli Parliament passed a law which created a community long-term care insurance program administered by Israel's social security system (the National Insurance Institute). The law was enacted against the background of the dramatic growth in the elderly population (particularly the "old-old" and disabled), the growing burden of care on the elderly and their families, and the need to provide supportive services.

The services provided under the law include personal care in the home, homemaking, day care, and the supply of absorbent undergarments for the incontinent. Medical, paramedical and social support services are not provided. In addition to services, the law allocates funds for the development of community and institutional services.

The role of these benefits is not to replace but to supplement family care and responsibilities, as the benefits cover only a part of total needs. Eligibility is determined by the level of functional disability, as assessed in the home by a public health nurse. The less functionally disabled are eligible for 10-12 hours per week of care while the more severely disabled are eligible for 16-18 hours per week.

Although the entitlement to home care services provided under the law is income-tested, it is practically universal as the ceiling is so high that very few are excluded. Only disabled elderly living in the community are eligible for benefits, with the emphasis on in-kind services rather than cash benefits.

The system has led to a rapid expansion in the overall level of home-care services, with 80% of the disabled population now receiving some level of care under the law.

Special Features of the program:

— Inclusion of an entitlement to a service benefit within the social security system, financed by contributions from the working population

— The administering agency, the NII, retains central functions for determining eligibility, reporting and monitoring based on uniform guidelines and instruments, to assure maximum equity under law. However, care planning and service provision are decentralized to assure flexibility in formulating individual care plans.

— High level of interorganizational cooperation: individual care plans are formulated by nurse-social worker teams having direct field contact with eligible persons in their local communities.

— Ongoing research and evaluation during the development of the legislation and the implementation of the law

Research and Evaluation:

The results of ongoing monitoring of the process of implementation of the law, conducted by the JDC-Brookdale Institute, show that after four years, the demand for institutional services has decreased, indicating that enhanced community care is effective in delaying or preventing institutionalization, mainly among the less severely disabled. A longitudinal study revealed that the law has had a positive effect on the wellbeing of the elderly. In addition, family caregivers reported a reduction in the burden of care, even though the increase in formal services has not replaced informal care, which continues to be provided at a high level.

Sponsor: National Insurance Institute (Israel's Social Security Administration)

Financing: National legislation under social security


Brodsky, J. and Naon, D. 1993. "Home Care Services in Israel — Implications of the Expansion of Home Care Following Implementation of the Community Long-term Care Insurance Law." Journal of Cross-Cultural Gerontology 8:375-390. (English)

Factor, H.; Morginstin,B.; and Naon, D. 1991. "Home Care Services in Israel" In Home Care for Older Persons. Jamieson, A. (ed.), Oxford University Press, pp. 157-187. (English)

Julius, R. (ed.) 1988. "Towards the Implementation of the Long-term Care Insurance Law in Israel" Social Security. Special English Edition.

Morginstin, B. 1990. The Impact of Demographic and Socio-Economic Factors on the Changing Needs of the Very Old. International Social Security Association. Studies and Research No. 28, pp. 1-45. (English)

For Further Information:

The National Insurance Institute
13 Weizmann Blvd.
Jerusalem 91999
Tel. 972-2-6709587; FAX 972-2-6528508


Objective: to ensure continuity of care to elderly patients by linking in-patient and community services


Shmuel HaRofe is a government-operated geriatric medical center established in 1980 to provide continuous, comprehensive, and extensive medical care for elderly patients, and to ensure continuity of care in the transfer from hospital to community. The medical center's main functions are to provide inpatient care, out-patient care, and day care in the community; serve as a teaching hospital in the field of geriatric medicine; and conduct research.

The inpatient units provide subacute care, short-term and long-term rehabilitation, psychogeriatric care and skilled nursing. Upon discharge, the center provides patients with ambulatory care in the day hospital or out-patient clinics, if required. There are a number of clinics, including an assessment and rehabilitation clinic as well as clinics for endocrinology, neurogeriatrics, high blood pressure, orthopedics, ophthalmology, dermatology and cardiology. The principal treatment goals of the unit are assessment of functional impairment, cognitive assessment, rehabilitation and medical supervision.

Patients are referred from the emergency room of a nearby hospital, other general hospitals and institutions in the region, and community services.

Procedures in the Geriatric Medical Center are based upon a number of principles:

— the preparation of a comprehensive program: in the 24 hours following admission, each patient is assessed by medical, nursing and rehabilitation staff to determine a program suited to his/her condition.

— the maximum realization of rehabilitation potential

— an emphasis on the provision of strong backing and support to the community service network

Special Features of the Program:

—In-patient and out-patient care are provided in the same facility.

—Geriatric departments with different functions are located in the same facility to enable quick transfer from one department to another.

—The cost per patient day is much lower than that in general hospitals.

—High-level expertise is mobilized.

Sponsor: Shmuel HaRofe Geriatric Medical Center

Shmuel HaRofe, Israel

Financing: Government of Israel

Research and Evaluation

In a study conducted in the short-term rehabilitation department, outcome of care was measured by comparing the patients' functional status on discharge with that on admission. The study found a significant improvement in functional status; more than 80% of patients were discharged into the community following rehabilitation.


Habot, B.; Bentur, N. and Habib, J. "Shmuel HaRofe Geriatric Medical Center: Continuity of Comprehensive Care in a Geriatric Teaching Hospital", Forthcoming. (English)

For More Information Contact:

Shmuel HaRofe Hospital Geriatric Medical Center
Shmuel HaRofe Hospital
Be'er Yaakov 70300
Tel. 972-8-258111; FAX 972-8-237156.


Objective: to improve the quality of care of disabled elderly in the community and help preserve their physical and mental functioning while providing respite to their families, so as to enable the elderly to remain in the community


Day Care Centers:

A network of approximately 120 day care centers serving over 8,000 disabled elderly has been established in Israel since the early 1980's. The day care center movement began as an initiative of JDC-ESHEL (The Association for the Planning and Development of Services for the Elderly in Israel). The number of centers has expanded since the enactment of the Community Long-term Care Insurance Law in 1988, which provides increased entitlements to home care and day care services for almost the entire population of disabled elderly. It is estimated that some 50% of those currently attending day care centers are doing so under the provisions of the law.

Most of the centers have been built as free-standing entities in the community, with enough space to accommodate the range of services provided. The daily attendance averages 50-100 per day. The staff of the centers includes a director with a professional background, activity leaders, and social work and nursing personnel. The centers are certified by the Ministry of Labor and Social Affairs and usually operate 5-6 days a week from 8:00 a.m. to 2:00 p.m., although at some centers the programming has been extended to 5:00. The social model thus reduces the burden on the family caregivers.

Services offered by the centers include social and recreational activities (handicrafts, physical activity, music), personal care (such as bathing), provision of hot meals, transportation, counseling, health promotion and screening and linkage and follow-up to other agencies. In addition, many of the centers have also assumed responsibility for providing services to the elderly who do not attend the center on a regular basis, such as meals-on-wheels and dental clinics. The premises are often used for the well elderly when the space is not being utilized by the disabled. Both these elements contribute to the cost-effectiveness of the centers. For elderly who require rehabilitative services following a medical incident such as a stroke or fall, there is also a network of day hospitals.

Special Features:

—The centers differ from those in many other countries in that they are based on a social rather than a medical model, and thus they represent a lower cost option. In contrast to the U.S., the cost/day is much lower than institutional care.

—The centers are reimbursed under the Community Long-term Care Insurance Law in a manner similar to the medical model of day care in the U.S. The reimbursed social model has become an integral part of the Israeli system and is especially relevant to the health care reform taking place in the United States and Israel.

—This network is considered to be one of the major reasons for Israel's low rate of institutionalization.

Special Day Care Programs for the Cognitively Impaired:

Another significant development within the day care network has been the establishment of special programs for the cognitively impaired, including Alzheimer's and other dementias. The expected increase in the number of cognitively impaired in the next decade, and the need to provide a community-based service for them and respite for their families, has led to a growing number of specific programs for this group —some in community centers and other community facilities, but many set aside within the day care center, with specially trained staff. Participants are usually limited to 10-15 persons, in order to provide individual services and care. Recently adopted standards for adult day-care centers mandate that all new facilities set aside two rooms and separate bathrooms for Alzheimer's and dementia patients.

Special Features:

— The cognitively impaired are cared for within the community, rather than in an institution.

— The cognitively impaired are provided with the special attention they need, but in the context of a larger day care center which offers opportunities for contact with the broader elderly population.

— Reimbursement is not limited to those cognitively impaired who meet the traditional ADL requirements for functional impairment.

Sponsors: JDC-ESHEL (Local Associations for the Elderly)

Other private and non-profit organizations

Financing: Reimbursement from National Insurance Institute under the Community Long-term Care Insurance Law

Social welfare budgets

The elderly and their families


Korazim, M. 1994. An Evaluation Study of Day Care Centers in Israel. Monograph, JDC-Brookdale Institute, Jerusalem. (Hebrew)

For More Information Contact:

JDC-ESHEL (The Association for the Planning and Development of Services for the Aged in Israel)
POB 3489
Jerusalem 91034
Tel. 972-2-6557128; FAX 972-2-5662716.