Changes to Dutch policy on care homes and the impact to older adults

Author: Marianne van Brussel, mySupport study Strategic Guiding Council member, the Netherlands
Date of publication: November 2021
Keywords: healthcare policy changes, economy measures, wishes of older people, loneliness

Changes to the Dutch healthcare system
The Dutch long-term care system had to change drastically to improve the quality of care, to promote integration and to keep the care accessible and affordable in times of increasing chronic conditions and an aging population. In 2015, the Exceptional Medical Expenses Act was replaced by a system of three healthcare laws:

The Zvw (2006), the Care Insurance Act. This system is based on the principle of solidarity: all Dutch citizens pay the same basic premium to cover for basic healthcare, regardless of income and care needs. Since 2015, this basic healthcare also includes care and nursing by a district nurse for people living in the community. As a result, care by a district nurse is covered by law and no longer required a personal financial contribution (2).
The Wmo (2015), Social Support Act, intended for people with disabilities living in the community. It includes domestic support, homecare, day activities, personal assistance, adjustments at home such as a lift, and so on (3).
The Wlz (2015), The Long-term Care Act. It provides access to nursing homes and is exclusively intended for the most vulnerable people (4).

The impact of change on care
In anticipation of these new laws, in early 2013 the Netherlands government recorded the decision to reduce the care for older people in a coalition agreement. As a consequence of this policy, all government–subsidized care homes that provided basic care and supported living, approximately 800, were forced to close their doors in the period 2013-2020 (5). Only the nursing homes remained, that provided more intensive care.

This decision was based on two important developments:

Economy measures due to demographic developments: In the next coming years, the number of 65-79 year olds in the total population in the Netherlands will rise. From 2025, the group of people aged 80+ will increase sharply. Increasing ageing of the population means that there are fewer employed citizens who can pay the costs of the health care (6).
Surveys showed that older people wanted to live independently in their familiar environment for as long as possible (7).

From that moment on, government policy was aimed at having older people living independently at home for longer and the Care Needs Assessment Centre, following this government decision, no longer granted access to care homes. No new residents were placed in the rooms that became available after the death of residents and when it was no longer financially responsible to keep a care home open, the rest of the residents moved to another facility of the multi-chain organization.
The government therefore met the desire of older people to live in a familiar environment for as long as possible with the supporting Healthcare legislation of the new law the Wmo, Social Support Act and the supplementation to the Zvw, Care Insurance Act. In addition to the closure of the care homes, the threshold was also raised to gain access to nursing home care. Stricter criteria for nursing home admission applied under the law Wlz, the Long-term Care Act (8).

The closure of the care homes also meant the end of many social activities for the older residents of the neighbourhood: day-care, barber, pedicure, library, meal service, follow-up personal alarm, outings.

Professional and personal experience

Professional experience
“People want to live independently as long as possible.“ became a slogan of the government. In the years that I worked as an assessment advisor at the Care Needs Assessment Centre, handling many applications for care home admissions, I regularly saw the opposite confirmed; many people needed the safety of a care home. Although the criteria for admission to a care home had become increasingly stricter over those years, the waiting lists for admission remained long. The applicants often had an accumulation of syndromes and associated disorders and limitations that had a major impact on their self-reliance and mobility, which also significantly reduced their participation in society. The care homes provided for the needs of many older people for a safe living environment with 24-hour care in the vicinity, support in the daily activities they were no longer able to do and an inviting environment for social interaction such as shared meals and day activities.

Sometimes, an emergency admission took place out of necessity because of unexpected rapid changes in health status.

Personal experience: My father’s resilience
This was also the case with my father. After my mother passed away, he continued to live at home with domestic help, catering, and visiting schedule so that he had visits from his children and grandchildren several times a week. He was going in the right direction again, enjoying his garden and his pigeons again. My father was a social man with a strong interest in his environment, so he also had many nice contacts in the neighbourhood.

After a fall, he ended up in hospital where a small brain haemorrhage was diagnosed. After a week he went home with home care, but sometime later he started to have increased loss of function and was admitted to hospital for surgery. I then arranged a temporary admission to the care home in his neighbourhood, which was converted into a permanent residence over time. In a short time, he had deteriorated greatly. That was a difficult and sad period for him and for us too.

Within the care home he succeeded in establishing nice contacts with his fellow residents and the care staff. Every morning he had coffee with residents on the same corridor; they read newspapers and discussed the state of the world. And he also recovered physically. We, his children, also knew his gloomy side and often talked to him about it, he had lost so much in a short time. And it did not stop there.

Impact of care home policy changes
Because government policy was aimed at closing care homes, the umbrella organization decided to evacuate the care home where my father had been living satisfactorily for 18 months. It was converted into a nursing home, a small-scale residency for people with dementia. Despite the pressure we exerted, we could not prevent my father from being forced to move to a village 15 km away. His entire circle of friends was spread out over different locations.

The care home he was placed in had a different function, namely separating living and care, and was beautifully converted into modern apartments. Instead of having a small living room that also housed his bed, my father now got a beautiful spacious apartment, spacious living room, bedroom and bathroom. Everything there was beautiful and well organized, but it did not make my father happy. He felt lonely. He stated this for the first time, then 95 years old. Without exaggeration I found that heart-breaking. The main reason for his loneliness was that he no longer met like-minded people there with whom he could meaningfully connect.

In the end
Two years later, my father was diagnosed with vascular dementia and the care home staff could not facilitate his needs. We felt that a resident who had been forced to leave the care home and his village to make room for people with dementia should be the first to return if he himself had dementia. That was not self-evident, but we eventually succeeded after some struggle. He moved back to his village to the small scale residency for people with dementia. This was his third move, at the age of 97.

Conclusion
Many vulnerable older people and their families experience a gap between living at home or in a nursing home, now that the care homes have disappeared from the care chain. The need for collective housing for older people has increased sharply since the closure of care homes which is further exacerbated by the serious shortage of suitable housing for older people. As for my father, the organisation did not put his interests first, the organizational interests prevailed.

So, in conclusion, both the economic reasons and facilitating the desire of many older people to continue living at home as long as possible are legitimate. However, the policy of living at home for longer has a downside, especially in combination with the increased threshold of nursing home admission.

Note from author: This blog is based on my personal and professional experience and my interest in current developments concerning dementia in The Netherlands.

References:

Ginneken, E. and Kroneman, M. Long-term care reform in the Netherlands: too large to handle. Eurohealth, 21 (3) (2015), pp. 47-50 (Accessed 20 September 2021).
Advies – Bekostiging verpleging en verzorging in de Zorgverzekeringswet. Op weg naar integrale zorgbekostiging met resultaatbeloning. [Advice – Financing medical and nursing care under the Care Insurance Act. On the way to integral care funding with result reward.] Nederlandse Zorgautoriteit. 2015. https://puc.overheid.nl/nza/doc/PUC_3252_22/1/ (Accessed 20 September 2021).
Ministry of Health, Welfare and Sport. Wet maatschappelijke ondersteuning (Wmo). [Social Support Act]. Government of the Netherlands. 2015. https://www.rijksoverheid.nl/onderwerpen/zorg-en-ondersteuning-thuis/wmo-2015 (Accessed 20 September 2021).
Wlz-algemeen: Hoe werkt de Wet langdurige zorg? [Wlz-general: How does the Long-term Care Act operate?]. Zorginstituut Nederland. 2015. https://www.zorginstituutnederland.nl/Verzekerde+zorg/wlz-algemeen-hoe-werkt-de-wet-langdurige-zorg (Accessed 20 September 2021).
Kiers B. Sluiting dreigt voor ruim 800 ouderenzorglocaties. [Closure is looming for over 800 care locations for older people]. 2013. https://www.zorgvisie.nl/sluiting-dreigt-voor-ruim-800-ouderenzorglocaties-1178771w/ (Accessed 20 September 2021).
Prognose: Bevolking blijft komende 50 jaar groeien. [Prognosis: Population will keep growing in the next 50 years]. Centraal Bureau voor de Statistiek. 2020. https://www.cbs.nl/nl-nl/nieuws/2020/51/prognose-bevolking-blijft-komende-50-jaar-groeien (Accessed 20 September 2021).
Woonplezier-onderzoek: Ouderen geven hun woning een 8,3. [Residency enjoyment research: Older people rate their homes with an 8.3]. ANBO. 2019. https://www.anbo.nl/nieuws/woonplezier-onderzoek-ouderen-geven-hun-woning-een-83 (Accessed 20 September 2021).
Van Dijk C, van den Burg M, Dik J-W, Heim N. ZorgCijfers Monitor: Op de drempel van het verpleeghuis. [Care Statistics Monitor: At the threshold of the nursing home]. Zorginstituut Nederland. 2019. file:///C:/Users/LBavelaar/Downloads/Zorgcijfers+Monitor+Op+de+drempel+van+het+verpleeghuis.pdf (Accessed 20 September 2021).

Meet the author: Marianne van Brussel, mySupport study Strategic Guiding Council member

Marianne studied at the Social Academy to become a medical social worker, and after graduating started her career at a university hospital. Marianne then worked at a home care organization. During this time Marianne made home visits where she developed a care plan and directed care teams of domestic support workers, caregivers and nurses. Marianne returned to school to become an Indication Consultant and worked at the Central Care Center where she conducted home visits and handled applications for home care, daytime activities, admission to care homes and nursing homes.

Marianne also has personal experience caring for an individual living with dementia, as both her mother and father had been diagnosed with vascular dementia. Marianne’s motivation for participating in dementia research is based on both her professional and personal experience caring for individuals living with dementia