LONG-TERM STAY INSTITUTIONS IN LEBANON

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1 GERIATRICS / GÉRIATRIE LONG-TERM STAY INSTITUTIONS Nabil NAJA* Naja N. Long-term stay in Lebanon. J Med Liban 2012 ; 60 (4) : DEMOGRAPHIC TRANSITIONS Countries worldwide, whether industrial or developing, rich or poor, are currently experiencing a demographic transition of profound importance due to the rapid growth of the proportion of the population aged 65 years and above. This growth can be linked to several demographic factors and transitions, most notably the rise in life expectancy at birth (attributed to the decline in mortality rates of infants and older people) and the decline in fertility and birth rates. With respect to Lebanon, the demographic situation is very similar to other Arab countries. The decline in fertility rates (from 4.6 in 1970 to 1.9 in 2004) has led to a decline in the proportion of the population under the age of two, thus causing the base of the population pyramid to become narrower [1]. In addition, the decline in mortality rates (from 9.1 per thousand in 1970 to 7.1 per thousand in 2004) and the rise in life expectancy at birth (from 66 years in 1970 to 74 years in 2004) has resulted in an increase in the proportion of the population over the age of 65 years from 4.6% in 1970 to 7.4% in 2004, thus expanding the top of the population pyramid [2]. TRANSITIONS IN THE LEBANESE FAMILY *President, Lebanese Society for Geriatric Medicine; Geriatric Department, Dar Al Ajaza Al Islamia Hospital, Beirut, Lebanon. nabilbnaja@gmail.com A g i n g S u c c e s sf u l l y The Lebanese family has changed from an extended family to a nuclear family, and the number of family members decreased from 5.4 members in 1970 to 4.8 members in 1997 to 4.3 in 2004 [1]. This transition resulted in a decrease in the rate of caregivers available for older people at home. Aside from demographic transitions, social and economic trends also play an important role in the provision of care for the elderly. The traditional role of the family in providing care for senior members has declined due to employment conditions and the transformation in women s role from traditional caregiver to an effective member in the workforce, thus making caring for older family members at home a tedious and difficult task. In addition, the diminished economic capacity of the family in Lebanon has made it very difficult for families with limited income to provide appropriate care. The observed increase in the burden of care of the elderly can also be attributed to the rising cost of health care in Lebanon and the absence of health insurance coverage for 53.3% of the population. This is a systemic problem most evident in the elderly, a segment of the population who can least afford to be without insurance. Persons older than 65 years represent only 8.2% of the total number of beneficiaries of health insurance available [1]. Furthermore, long-term care benefits are often separate and costly insurance plans, not purchased by most elderly. INSTITUTIONS FOR SENIORS : ORIGIN AND SERVICES The existence of that provide care for the elderly in Lebanon dates back to the beginning of the twentieth century. These early facilities had the specific role of acting as a shelter for homeless seniors and providing them with hotel services such as food, drink, and sleeping accommodations, accompanied with limited medical supervision. In the mid-twentieth century, increased interest by Lebanese religious organizations resulted in the establishment of a succession of religious and charitable that provided care for seniors. The idea of institutional-based services for the elderly evolved and became characterized not only by hospitality services but also by healthcare services manifested in medical and nursing care. By the end of the twentieth century, Lebanon had multiple specialized that care for the frail elderly. During this time, the social scope of caring for older people developed into an important component of the continuum of healthcare services. Institutions for seniors are no longer limited to residence-care service (i.e. long-term care facilities). Institutions providing daycare services for the elderly have been established such as clubs for seniors and home-care programs for the frail, mitigating the health, social, and psychological problems associated with aging in Lebanon. TYPES OF INSTITUTIONS FOR SENIOR CARE Institutions for seniors in Lebanon vary widely but are interrelated and overlap in the types of services offered as demonstrated below: 252 Lebanese Medical Journal 2012 Volume 60 (4)

2 Residence-care service 1. Nursing facilities for seniors: care for older people who are functionally independent and provide basic supportive care, social services, and recreational amenities. 2. Rehabilitation centers: specialize specifically in treating debilitated elderly and the disabled of all ages, usually on a short-term (sub-acute) basis. These centers provide therapeutic, rehabilitative, and mental services and support through physical therapy, occupational therapy, psychosocial therapy, as well as other treatment modalities. 3. Nursing homes for the elderly including the infirm: care for frail older people who are functionally dependent in their activities of daily living and require medical, physical, and custodial support for safety. 4. Nursing homes not specifically for the older people: care for the functionally dependent and disabled persons of all ages (including children and young adults) such as spinal cord injury patients and those with developmental disorders. Day-care 1. Clubs for seniors: provide day services through social and recreational programs. 2. Adult day-care centers: provide daytime (non-residential) mental, social, and physical activities for seniors in a safe and supervised setting. These centers may also assist with medications and provide nutrition support. Home/domestic-care service provide professional health care for seniors in their homes, including medical, nursing, and rehabilitative services. In addition, meals and medication delivery, assistive devices, custodial support, and much more may be covered. Outsourcing lease medical equipment and assistive devices for use by senior in their homes. These are mostly for-profit private, but can be outreach programs provided by hospitals, pharmaceutical companies, or by the manufacturers. Clinics for seniors provide social and medical health services specifically for seniors. Restaurants for seniors prepare meals for seniors and deliver them to the where they reside, or to their homes. Residence-care service for seniors are generally based in the civil service sector, while their number is constantly declining in the private sector and becoming increasingly limited in the public sector. It is important to note, however, that the relationship between public and civil sector is governed by the contracts signed by the two parties and which mandate the provision of a predetermined daily monetary allowance to civil. However, this allowance often tends to be low, insufficient, and not monitored or controlled by the concerned parties [1]. According to the Ministry of Public Health (MOH) Decree No pertaining to the rules of treatment adopted by hospitals as well as public and private contracted with the Ministry, facilities which provide shortstay treatment and medical services (internal medicine, surgery, obstetrics, pediatrics, etc.) are considered First Category Institutions. Second Category Institutions are facilities specialized in providing healthcare services for conditions encountered in long-term care settings including mental hospitals, nursing homes, orphanages, and rehabilitation centers. Accordingly, monetary contribution by MOH is allocated to various facilities. The Ministry of Social Affairs also funds residence-care service as described later. However, no governmental exist for managing the payment allocation between various long-term care funding sources, in contrast to the existence of such for facilities belonging to the First Category. In 2010, a study titled The National Report on the Services Available for Older People in Lebanon was published in collaboration with the Ministry of Social Affairs in Lebanon, the United Nations Population Fund (UNFPA), the Permanent National Commission for the Care of Elderly Affairs in Lebanon, and the Program of Population and Development [3]. The main aims of the study were to: 1. Describe the current reality of the that provide services for older people in terms of specialized human resources, equipment, buildings, etc. 2. Define the characteristics of the services available in these and how to access them. 3. Identify the trends in the gaps, constraints, and needs among the different types of involved in the study. The following facility description is mostly derived from this study. CHARACTERISTICS AND SPECIFICATIONS OF RESIDENCE-CARE SERVICE INSTITUTIONS Residence-care service in Lebanon provide care and health services to residents for periods ranging from long-term to medium-term periods of stay. They host a population of which 93.9% are seniors of indefinite stay. These vary in terms of their number of beds, geographical distribution, and variety of services offered. Until this day, residence-care have not been categorized in a national classification system. Number and geographic distribution of residence-care service The total number of residence-care service in Lebanon was determined to be 49 with a total of 4,000 residents. These institutionalized residents constitute less than 1.4% of the total number of seniors in N. NAJA Long-term stay in Lebanon Lebanese Medical Journal 2012 Volume 60 (4) 253

3 TABLE I DISTRIBUTION OF RESIDENCE-CARE SERVICE INSTITUTIONS ACROSS LEBANON ACCORDING TO PROVINCE Province Mount Lebanon 57 % North 20 % Beirut 14 % Bekaa 6 % South Lebanon and Nabatieh 2 % Lebanon. We therefore conclude that the remaining 98.6% of seniors live in their homes. These are distributed across the provinces according to table I. Nature of residence-care service Approximately 44.9% of these belong to the civil service sector while 53.1% belong to the private sector; the latter are predominantly not-for-profit charities. 57.1% of these are custodial-care, 40.8% are healthcare, and only one institution provides health services exclusively. TABLE II DISTRIBUTION OF RESIDENTS HEALTH CONDITIONS UPON ADMISSION ACROSS 49 INSTITUTIONS Special Health Cases ELDERLY Not infirm/incapacitated 91.8 % Infirm with physical handicap 79.6 % With chronic disease 75.5 % Requiring specialized health care 69.4 % (pressure ulcers, catheter, malnutrition) Requiring palliative care 15.3 % Requiring rehabilitation 59.2 % Infirm with mental handicap 55.1 % In a coma 22.4 % Using artificial respiration device 14.3 % With infectious disease 8.2 % Sources of funding for residence-care service Most common sources of funding for long-term care include: 1. Contracting with the MOH: 38.8% of the. 2. Contracting with the Ministry of Social Affairs (MSA): 40.8% of the. 3. Contracting with municipalities: 6.1% of the. It should be noted that the level of monetary contribution of the public/formal sector to residence-care service is not related to the level or type of service offered. For example, the monetary contribution made by the MSA is 4,300 L.L. per senior per day, while the MOH pays an amount of 15,600 L.L. per senior per day. Residents can only benefit from one guarantor institution, regardless of their general health condition, and, as previously mentioned, the absence of government that address this purpose is in contrast to that govern First Category payment. Daily cost for a senior resident in residence-care service The average daily cost for seniors in residence-care service varies according to the service provided. The ceiling cost specified reaches 60,000 L.L. (sixty thousand Lebanese pounds) for 71.4% of the. This figure exceeds the maximum official tariffs by four times. Specific health cases admitted by residence-care service Residence-care service vary widely in the nature and acuity of care provided, and hence the type of patients admitted. The cumulative prevalence of health conditions across the 49 upon admission is outlined in table II. Human resources in residence-care service The National Report on the Services Available for Older People in Lebanon indicates that residence-care service use a multidisciplinary task force distributed according to table III. The ratios in the table signify the scarcity of contracting or consulting with specialists in geriatric medicine as well as geriatric nurses specialists. TABLE III DISTRIBUTION OF AVAILABLE HUMAN TASK FORCE ACROSS 49 INSTITUTIONS Available Human Task Force Ratio of elderly to specialists* Practical Nurse 75.5 % 11 Registered Nurse 69.4 % 30 General Practitioner (Physician) 51.0 % 42 Physiotherapist 51.0 % 113 Health and Social Supervisor 40.8 % 167 Dietician 24.5 % 322 Psychiatrist 24.5 % 299 Geriatric Physician 18.4 % 465 Geriatric Nurse 14.3 % 523 Psychologist/Psychotherapist 14.3 % 597 Organizer of Social Activities 12.2 % 279 Occupational Therapist 10.2 % 697 Speech Therapist 10.2 % 836 Technical Supervisor and Social Worker 6.1 % 697 Psychomotor Therapist 2.0 % 4181 *The ratio of elderly to specialists is applicable in almost all residence-care service (ratio is applicable at the national level: The total number of seniors benefiting from the services at the level of the total number of residence-care service ). 254 Lebanese Medical Journal 2012 Volume 60 (4) N. NAJA Long-term stay in Lebanon

4 TABLE IV DIAGNOSTIC MODALITIES ADOPTED ACROSS 49 INSTITUTIONS Method of Diagnosis Dental examination 98.0 % Electrocardiography 46.9 % Laboratory and X-Ray 20.4 % Psychological testing 18.4 % Ultrasound 16.3 % Electroencephalography 12.2 % Audiography 4.1 % Diagnosis of ophthalmological diseases 2.0 % This is because geriatric specialties are either unavailable or unknown to these, or due to the lack of financial capacity of these to employ specialists. These are therefore obliged to rely on general practitioners and non-specialized nurses. The report also indicates that 30.6% of the are operating without licensed (registered) nurses. Health services offered in residence-care service Long-term care facilities provide various types of health and diagnostic services for their residents such as hematologic tests, radiologic imaging, medications, and other treatments. Health services provided are categorized as follows: 1. Hematologic tests: Approximately 73.5% of residence-care service conduct periodic hematological tests for their residents, and 44.9% of these tests are done within the. 2. Diagnostic services and tests: Several of the 49 residence-care service utilize a variety of diagnostic methods, either within the facility or by contracting locally (Table IV). Availability of services varies according to cost, reliance on specialized equipment or personnel, and logistics. 3. Medications and treatments: The resident and his/her family members bear the full responsibility of securing medications in 20.4% of the residence-care service, with only 18.4% of the facilities providing medications for their patients. In the remaining 59.2%, the facility shares the responsibility of securing medications and treatments with the resident and his/her family. Characteristics of the building facilities and environment in residence-care service The National Report on the Services Available for Older People in Lebanon shows that 25.5% of the are not equipped with nursing stations, which may compromise care of the residents. It is considered the standard of care to have a nursing station on each floor of long-term care. In addition, only 18.4% of residence-care service have an Alzheimer s unit, suggesting that the majority of house patients with mental disability along with those who are cognitively intact, often in the same room. Such an arrangement can be disruptive to both parties, and neither will receive optimal care in a therapeutic environment. Regarding room occupancy, 49.2% of the have rooms with a single bed and a bathroom. The remaining rooms are double occupancy or more, and 44.9% of the have electrically powered beds. Finally, it is worth noting that 75.5% of these have garden space. OBSTACLES TO BETTER CARE Many obstacles remain. In order to provide competent and comprehensive long-term care to older adults in Lebanon, three deficiencies must be addressed: adequate funding and availability of facilities, qualified personnel, and social acceptance. The National Report on the Services Available for Older People in Lebanon indicates that 91.8% of residence-care service experience financial difficulties, 32.7% suffer from social and family difficulties, and 8.2% of human resource difficulties. The taboo of placing a parent in a chronic-care facility is a cultural obstacle that can only be overcome when centers of excellence meet or exceed social, lodging, and nurturing expectations. Such centers must be staffed by trained personnel devoted to improving the quality-of-life of the elderly, because they choose to not because they have to. CONCLUSION Comprehensive scientific studies on long-term care in Lebanon are relatively few. Perhaps the most comprehensive study is The National Report on the Services Available for Older People in Lebanon issued in 2010 by the Ministry of Social Affairs and UNFPA [3]. What is most notable is that institutional care for the elderly in Lebanon is mainly dependent on the civil and private sector for funding, and on charities. The formal government sector takes minimal responsibility for this age group, as its largest financial contribution does not exceed 25% of the actual cost of providing adequate care for the elderly. In addition, Lebanon is lacking laws that decree the provision of health, social, and economic protection for seniors. While waiting for the completion of legislation that benefit the elderly, the family continues to perform its caregiver role towards senior members and 98.6% of them continue to live at home. REFERENCES 1. Ministry of Social Affairs; Central Administration of Statistics. Lebanon Family Health Survey, [In Arabic] 2. Ministry of Social Affairs; Central Administration of Statistics; United Nations Development Program (UNDP). N. NAJA Long-term stay in Lebanon Lebanese Medical Journal 2012 Volume 60 (4) 255

5 Living Conditions of the Households in Lebanon, [In Arabic] 3. Ministry of Social Affairs; United Nations Population Fund (UNFPA). The National Report on the Services Available for Older People in Lebanon, [In Arabic] Additional reading: Ammar W, Mechbal A, Nandakumar AK: National Household Expenditures and Utilization Survey, 1999, Vol 3, Beirut: Ministry of Public Health in collaboration with Central Administration of Statistics, World Health Organization and World Bank, ESA. Population Division of the Department of Economic and Social Affairs (ESA) of the United Nations Secretariat. World Population Prospects: The 2008 Revision. (Accessed March 2010). Chahine LM, Bijlsma A, Hospers AP, Chemali Z. Dementia and depression among nursing home residents in Lebanon: a pilot study. International Journal of Geriatric Psychiatry 2007; 22 (4): Chemali Z, Chahine LM. Prospects of older adult care in Lebanon: Towards stronger and sustainable reforms. EMHJ-WHO Regional Office for the Eastern Mediterranean, 2008; 14: Kronfol N. Rebuilding of the Lebanese health care system: health sector reforms. Eastern Mediterranean Health Journal 2006; 12: Lebanese Medical Journal 2012 Volume 60 (4) N. NAJA Long-term stay in Lebanon