The Korean Long-Term Care System: 2024 Update
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Korea’s older population aged 65 and over is expected to exceed 20% by 2025.1) There are two separately managed National Health Insurance and Long-Term Care Insurance (LTCI) systems supporting for long-term care hospitals (LTCHs) and nursing homes (NHs), respectively, with out-of-pocket payments ranging from 0% to 20%.2) In response to these developments, the Korean Ministry of Health and Welfare (MOHW) has announced a series of policies. The following section will focus on the most significant of these policies, which pertain to LTC for the older adults.
1. Implementing Integrated Care
From 2019 to 2022, the Korean government conducted a pilot project for integrated medical and social care for older adults in 16 local governments across the country.3) The project yielded the development of various integrated care models, which were identified through the identification of services tailored to local conditions. The effects of these models were confirmed to include improvements in the subjective quality of life of care recipients, reductions in the burden on caregivers, and increases in the number of days patients can stay at home after being discharged from the hospital. 4) In July 2023, the new government initiated a new pilot project for integrated medical care support for older individuals, scheduled for implementation in 12 local governments by December 2025. The project has delineated the target population, which includes homebound LTC recipients, and older individuals who are hospitalized or at risk of hospitalization. In particular, the objective is to expand home care services and establish a linkage system between individual systems and services related to health and care.4) Following this pilot project, the Integrated Community Care Assistance Act was promulgated in March 2024 and will be implemented from March 2026.5) Under this new law, central and local governments will provide various services such as healthcare, disease prevention and health management, LTC, care for daily living, and family support to older adults and disabled people who have difficulty maintaining their daily lives due to frailty, disability, illness, or accident and need integrated support. These individuals can receive medical, nursing, and other forms of care support from a range of health care professionals, irrespective of their place of residence (Table 1). This represents an expansion and reorganization of the existing LTCI rating system. It integrates procedures such as application, investigation, target selection, and service provision for LTCHs, LTC facilities, and community care services. These procedures are currently operated according to their respective standards. The goal of this integration is to identify accurate medical and care needs based on common standards. This will enable the determination and connection of necessary services for each target.
Article 15 (Healthcare services) of the Integrated Assistance for Community Care Act
2. Strengthening Community Connections for Discharged Patients
One distinctive feature of LTC in Korea is the high prevalence of older individuals requiring LTC who are hospitalized in LTCHs.2) A number of studies have indicated that hospitals are the most common place of death for Koreans. Of the 2,358,211 older adults who died between 2001 and 2014, 57.82% died in hospitals, 32.12% died at home, and 2.61% died in social welfare facilities.6) Additionally, a study reported that 91.5% of terminally ill cancer patients in Korea died in hospitals in 2013.7) However, the introduction of insurance-covered, home-based hospice care in September 2020 led to an increase in the probability of patients with cancer dying in their own homes, as evidenced by a December 2021 survey.8) This illustrates that changes in the cost of care can result in changes in place of death. In November 2019, the National Health Insurance Service (NHIS) introduced the LTC Hospital Discharge Patient Assistance Program, which provides guidance to LTCHs on the establishment of patient support teams.9) These teams, composed of multidisciplinary staff including doctors, nurses, and social workers, are responsible for guiding patients towards discharge from LTCHs 120 days after admission. In addition to this, the NHIS also provides an assessment fee to these teams for connecting with the community.
3. Enhancing Medical Capabilities Outside of Hospitals
In 2019, the NHIS initiated a pilot program to enhance the provision of skilled nursing care in NHs.10) The standard for nursing staffing in a skilled nursing unit (SNU) is a minimum of one registered nurses (RNs) or licensed practical nurses per six residents, with a minimum of 50% of these being RNs. SNU care by nurses includes enteral feedings, insertion and removal of catheters, bladder irrigation, oxygenation, tracheal tube changes, ventilator care, tracheal suctioning, suture removal, pressure ulcer dressings, cancer pain care, and dialysis care. Additionally, visiting physicians are required to conduct at least one weekly visit.
In 2023, the MOHW announced plans to increase the number of home-based primary care centers to 250 by 2027 through the implementation of the 3rd Basic Plan for LTC.3) The MOHW also provided institutional support through three separate pilot projects for healthcare physicians for the disabled, for the medical fee of primary health care visits, and for LTC home health care centers, respectively. Consequently, the Korean Home Health Care Association (https://www.khhca.org/index) was established in 2023, and the number of local clinics offering home-based healthcare services is gradually increasing.
4. Efforts to Improve the Quality of Care in Hospitals
In contrast to NHs, the cost of care by care assistants in LTCHs is not covered by national insurance, resulting in a notable decline in the quality and quantity of care provided in LTCHs. In 2024, the MOHW initiated the inaugural phase of the pilot project, selecting a total of 20 LTCHs across the country to receive financial assistance for care costs.11) In light of the findings yielded by the pilot project, the MOHW has announced its intention to implement a comprehensive LTCHs care support system in 2027.
5. Conclusion
The enactment of the Integrated Assistance for Community Care Act will represent a significant transformation in the trajectory of the Korean LTC system. Patients will transition from LTCHs and NHs to their homes, which will require clinicians to be removed from the hospital setting. The implementation of multidisciplinary approaches and comprehensive geriatric assessment and care skills will be crucial for this transition.
Notes
CONFLICT OF INTEREST
Hyuk Ga has been working at a long-term care hospital for 18 years and nursing homes as a visiting physician for 10 years. Also, he is currently the role of academic director of the Korean Convalescent Hospital Association. Except for that, no potential conflict of interest relevant to this article was reported.
FUNDING
None.