Care for the aged at risk of marginalization (CARMA)

The demographic development of the Austrian society will result in a sharp rise of the percentage of elderly and very old people. This fact is usually connected with the fear about the sustainability of the welfare systems. However, also positive effects of an ageing society can be observed: aged societies are more peaceful because they cannot afford to lose young lives in wars and aged societies also have a markedly lower crime rate, since criminal offences are a domain of young males. Unfortunately most people associate ageing with sickness and decay and the welfare state's response to ageing is dominated by health services, although only a minority of the old and very old people in Austria are actually in need of permanent care. An alternative perspective on ageing will have to consider specific social risks connected to ageing. To react to these social risks may not need to involve expensive health care professionals, but the care of social workers. These risks are e.g. loss of social roles due to retirement and bereavement. The latter is particularly significant if there has been a long care relation between the two partners (which is evidently frequently the case), which consequently leads to the situation that the widow/er not only loses a spouse but also the role of being a care giver with all its obligations attached. Among the social risks dementia is also very likely to affect aged persons and again it could be dealt with in social work, and not just with medication as it is currently the case. The social environment can compensate for a lot of the deficits occurring with dementia. The role of social work is twofold: prevention and coordination: to help to prevent social isolation and social deprivation by encouraging older people to organise themselves in cooperatives and community groups. In addition, social workers are needed to coordinate the fragmented care system in the interest of the care dependent and his/her family. If informal and formal care should work together this needs a lot of coordination work. Also social workers are in charge of the most vulnerable older people like homeless, migrants, alcoholics and people with dementia. The main challenge of social workers for the elderly is the situation that an old person refuses help which s/he objectively needs; patience, empathy and respect for the individual is required in these cases.

The book chapter focuses on the question of whether the social policy of European welfare states is actually converging and if so, how this phenomenon can be explained. A comparison of pension schemes and elderly care systems shows that policy convergence occurs in both areas. Further, it is possible to observe convergence within specific country groups (convergence clubs) and trends towards a comprehensive Europe-wide convergence. The analysis is based on the assumption that convergence can be induced by internal, national factors such as countries exhibiting similar socio-economic development, having similar societal problems, or comparable political-institutional arrangements. Convergence can also be triggered by external factors through the transnationalization of social policy. In the book chapter, first, (bilateral) transfer processes between countries are examined, asking whether individual countries learn not only from their own experiences, but also from the experiences of others. Secondly, it is discussed how the policy of the European Union affects the social policies of the individual member states. In the area of pensions, comprehensive policy convergence was promoted by concepts such as the multi-pillar model. In the area of care for the aged, an intensive Europe-wide exchange of experiences between experts has been limited to the types of care services, while differences in the modes of funding remain. With the application of the Open Method of Coordination in both areas, EU social policy has entered a new phase. International comparative research mostly emphasises on cross-country studies to reveal country differences and similarities. The analysis of exchange processes between countries and the impact of supra-national institutions, e.g. the EU, is only rarely in the focus of comparative research. The three level of analysis situation within the country, exchange processes between countries and the supra-national institutions enable a differentiated discussion on the development. The results give insight into exchange processes between countries and the process of Europeanization of social policy. Pension systems and elderly care approaches differ in some respects e.g. type of policy, time of establishment of the first policy approaches - which offer a platform for a meaningful comparison of different areas within social policy. The book is oriented towards scientists within political science, social policy research and high ranking political experts within national and European administration dealing with issues of European social policy. The new conceptual approach as well as the findings can be used as a starting point for further comparisons, e.g. in other policy areas by social or political scientists. High-ranking experts within national and European administration find scientific knowledge about exchange processes, about changes within countries and indications of a possible impact of the European Union. The chapter is published in a book on The European Social Model, which is often quoted within science and discussed and reviewed within high-quality newspapers. Moreover, an English translation is already under review in a referred journal.

The document begins with information on the Carma Project as part of the 5th Framework Programme of the European Commission, it details the partners involved and describes the project and methodology, which will be used. The context is then described with information provided in general terms on the structure of the United Kingdom, which includes basic demographic details. The context is further developed with information provided on Northern Ireland detailing its Government, demographics and ethnicity. As research shows financial problems are a major contributing factor in the marginalisation of older people a section is devoted to the financial situation of older people in the United Kingdom. This includes a summary of allowances provided by the state, details of allowances available for carers and information on company pensions, which are provided by employers. Ill health and caring for people with ill health are also major causes of marginalisation in older people consequently information is provided on the National Health Service in England, Scotland and Wales, and the Health and Personal Social Services system in Northern Ireland. The structure of health and social service management and delivery is explained including information on the Department of Health, Social Services and Public Safety, the Social Services Inspectorate, Health and Social Services boards, and Health and Social Services Trusts. It is well known and well documented by researchers, including work undertaken within the Carma project that older people prefer to remain living in their own local community. It is therefore appropriate the document moves on to consider community health and social services in Northern Ireland. The elderly programme of care had a total cost of £356 million in 1999/2000 within N. Ireland, and a table is provided breaking down the expenditure by activity. Recognition is given to the care provided in the community by family friends and neighbours and a number of principles are outlined: - Care should be provided to people in a way that supports their independence and respects their dignity, - Services should meet each individual¿s specific needs pulling together social services, health, housing, education or any other service needed, access to services should be fair, open and consistent, - Every person should be protected against abuse, neglect or poor treatment while receiving care, - People receiving care should have an assurance that the staff they deal with are sufficiently trained and skilled, - People should have confidence in their local social services knowing that they work to clear and acceptable standards. A list and description of the principle services used by older people follows. The majority of services are free to the service user. This includes hospital services and all community health and personal social services. Residential and nursing homes are means tested and currently 15% of these service users pay either full costs or an assessed contribution. The services commonly used by older people are: The Doctor (General Practitioner), the Pharmacist, Community Nursing Service, Community Mental Health Services, Allied Health Professionals which includes the Physiotherapy, Occupational Therapy, Podiatry, Speech and Language Therapy and Dietetics. The list also includes Community Care Assessment, Social Work Services, Home Care Services, Residential and Nursing Home Care, Housing Adaptations and Aids, Sheltered Dwellings, Supported Housing, Day Care Services, Meals on Wheels, Sensory Impairment Services, Care and Protection Teams for older people, Hospital Discharge Planning Teams, Transport Services and Intermediate Care Services. The final section of the document is titled ¿Strategy development for the future¿ and highlights a number of new services aimed at reducing marginalisation by providing services responsive to the needs of older people in new ways. These include the Rapid Response Service of South and East Belfast Trust, a One Stop Assessment Centre at the Ulster Community and Hospitals Trust, an A & E Diversion Scheme at Home First Community Trust and a Hospital at Home Scheme with Down Lisburn Trust. In the conclusion of the document one issue raised was the administration of health and social care and the number of public bodies involved. In November 2005 as part of the Review of Public Administration in Northern Ireland The Health Minister has announced the four health & social services boards will become one regional authority and 18 health and social services trusts will become five.

The "CARMA anthem" is a song based on the music of the ode in Beethoven's ninth symphony, which since 1985 is the official anthem of the European Union. The lyrics of this CARMA anthem were created by the consortium in August 2005 as one of the creative measures of dissemination. The lyrics are as follows: Generations are united Europeans young and old we can all be happy persons and lead our active lives. We will live at home forever using tailored services barrier-free environments and really well-trained personnel. World premiere 25 Aug 2005, Bad Aussee/Austria. Estonian premiere 24 Nov 2005, Tartu/Estonia.

The project website has started to be created at the beginning of 2003 and is periodically updated and maintained. It is hosted by COOSS Marche. It contains the description of the project, its activities and partners, all the public deliverables produced and also the links to the contact persons from each country. It is available in English and, for some specific sections, in the national partners' languages.

The document includes an overview of the welfare model and the health care for the elderly in Norway. Part of the content: The Norwegian welfare model History - development of the welfare state in Norway, The classical period of the welfare state 1945-66 / 1966 to present, Home based nursing, Principles of developing open care- the LEON principle, Demographics: Population foundation, Demographic challenges, How about the future?, Immigration, Pension System, National insurance, Retirement pension, Contract pension (CP), Disabled pension, Labour market pensions, DESCRIPTION OF SERVICES: Formal care, Man-labour years executed in the municipal nurse- and care services, Kinds of care services offered, and kinds of occupational involved, Informal care, Informal network, What tasks does the informal network perform?, Living arrangements. OTHER OFFERS FOR SENIOR CITIZENS: Volunteer organizations, Volunteer bureau, Welfare service centres for the elderly. INTERVIEWS WITH 10 PERSONS: Status of Norwegian geriatric care, Challenges and needs in the future, The relationship between public and private care.

The Guidelines on the website are based on the framework and empirical research in the CARMA project. Presented on the web: Framework on Marginalization, Self-care capacity and Coping, Results from a longitudinal study, investigating the need of permanent institutional care. A model for health-promoting care. Framework on: Marginalization, Coping, Self-care , Advice on: Salutogenic thinking, Self-help strategies, Organizing services, Care arrangements, Survey of coping resources, Assessment of care, Health indices, Glossary , On health-promoting theory and practice, Downloadable deliverables, The CARMA documents, User Evaluation. The Guidelines are targeted at health care professionals.

The result contains three reports (Del. 1-3), which summarise the findings of WP 1. WP 1 aimed at giving a summary on the debate on social exclusion in old age and changes in elderly care approaches based on a literature review. The different research strands are combined to provide a new conceptual approach for the analysis. Report 1: Comprehensive description of the social process of marginalization of the aged according to the social scientific literature". Within the report the readers find an overview on the scientific research and debate on social exclusion done within the area of international comparative welfare state research. The report discusses the definition problems of the concept and compares a weak and a strong definition of social exclusion. The transfer to the area of old age distinguishes between variables related to social exclusionary processes on an individual-, family- and societal level. Concepts and findings within the research area of social-gerontology provide a framework for an in depth analysis and insights into the life situation of care-dependent elderly. Finally, with the examples of vulnerable groups the findings are put in more concrete terms. As vulnerable groups are selected men and women living alone, because the living situation is one decisive risk factor for the development of exclusionary processes. Migrant pensioners are at a double disadvantage: firstly as members of an ethnic minority and secondly they are often members of the lower socio-economic classes with low educational level and a low level of pension payment. The analysis of their life situation illuminates processes and risks for certain disadvantaged groups. The analysis of the situation of informal carers reveals that the risk of social exclusion concerns not only the care-dependent elderly themselves but also the informal carers due to the heavy care burden. Report 2: Social exclusion and care for the elderly. Theoretical Concepts and Changing Realities in European Welfare States. The scientific concept of social exclusion, the definition of a multidimensional ageing process, its transfer to the area of elderly care are used as a starting-point for the analysis of the development of elderly care approaches within Western European countries. As key characteristics of high-quality care are defined the availability, accessibility and affordability of care services, integrated and comprehensive care offers, the integration of informal and formal care and support structures for informal carers. The findings reveal that in particular in continental Europe new types of funding of care services on a national level have been introduced, which universally cover at least basic care services. However, the limitations of the funding, the emphasis on additional private means and the focus on basic nursing care only limit the improvement. In all countries efforts have been undertaken to establish a diverse range of care offers and to promote processes of integration. As obstacles can be identified in the availability and accessibility of the offers for vulnerable groups in society and the still fragmented services. Finally, support systems for informal carers have been established, which differ in range and scope between the countries. Despite this, informal care work is often strongly related to a high care burden. Report 3: Social Exclusion and inclusive care. The (short) report summarises and draws conclusions on the reports one and two and describes risks of social exclusion in old age by defining a multidimensional ageing process and cumulative social vulnerabilities during life time related to different types of inequality. Moreover, characteristics of inclusive care such as access to services, the quality of services and supporting system for informal carers are discussed. The strength of the research work lies in its innovative combination of different strands of research within the three reports and the creation of a conceptual framework for a neglected issue. (International comparative welfare state research on social exclusion and elderly care as well as socio-gerontological research). Within the framework of the EU-project the result has been used for further publications and development of an empirical study (WP 5). The reports have already been disseminated to social politicians and practitioners at care provider associations/organisations in different countries. The literature review provides a sound basis for further conceptual and empirical scientific work as well as for the development of new regulations in social or care policy. It also gives practitioners an insight into the development in different European countries.

The Fano proceeding contains an overview of the services provided to elderly people in the different countries involved in the project, together with a presentation of the most relevant economic, social and legislative factors concerning older people. The objectives of the book are the comparison among the different welfare systems in Europe aimed to identify the best practices of service provision, mainly devoted to prevent the marginalization of older people. These findings derive from a wide research activity carried out at national level aiming at investigating, among others, the following indicators: demography, pension systems and national and local welfare. The proceeding, published in English in 1.000 copies, has been distributed to the partners for further dissemination at national level. It will be particularly useful to policy makers, local administrators and managers of social organizations when designing new social plans and/or services, but also to trainers and students involved in social matters and disciplines.

The paper provides a new conceptual framework for the evaluation of elderly care. To do so, it combines lines within different research areas. It transfers the concept social exclusion , which has been developed within international comparative welfare state research, to the areas of social-gerontology, sociology on professions and service work. Based on a literature review it investigates, how exclusionary processes in old age in case of care-dependency can be understood. In addition, it defines criteria with regard to elderly care approaches, which should be fulfilled to encounter processes of social exclusion. The multidimensionality of the concept of social exclusion requires a definition of a multidimensional ageing process, which reveals the different dimensions of ageing and the role of care-dependency. Processes of social exclusion are strongly related to different types of inequality putting women, members of the lower classes and migrants at a disadvantage. The discussion on social exclusion in old age challenges the present approaches of elderly care and makes demands on certain changes. Basically, a comprehensive and integrated care arrangement is necessary including both formal and informal care and universal access to care services on the basis of social rights. In the course of the article the challenges are discussed within different areas of elderly care in a greater detail. In a first part the issue of access to and freedom of choice between care offers are discussed on the basis of present research findings. The findings reveal that the introduction of the freedom of choice between offers related to the concept of consumerism does not secure access and does not offer a real choice. The outcomes of the introduction of cash payments are more contradictory, which depends in particular on the level of the payments. The introduction of social rights and corresponding assessment procedures can give the elderly more often fair access to economic support or care services. However, a wide range of further developments are necessary. In a second part the nexus of formal and informal care are analysed. Since the 1990s the development of care services has inspired scientific research and debate on the combination of formal and informal care. Moreover, the integration of formal and informal care can be viewed as a prerequisite for an integrated and comprehensive care arrangement. Research findings of empirical studies show that an increase of formal care provision does not result in a withdrawal of the informal carers, but may lead to new forms of cooperation and the definition of new caring-tasks. However, in daily care work obstacles are visible, which impede a cooperation; i.e. the low professional status of the activity and the neglect of the competences and experiences of the informal carers by the formal carers. In sum, the literature review reveals the challenges with regard to the development of elderly care, the obstacles but also the chances. The paper is going to be published within a referred English-journal, which is read by sociologists doing research within the area of service work or professions. Moreover, this volume is a special issue, which combines welfare state research and service work. In particular, the broad conceptual framework may inspire researchers within the different areas. The conceptual framework is already used for an empirical study within the EU-Project CARMA (compare Del 17).

The CARMA game was created by the consortium in August 2005 as one of the innovative and creative measures of dissemination. The objective of the game is to raise the awareness of excluding mechanisms, risks, coping resources and to disseminate the CARMA recommendations. The target groups of the game are social work and other students, health and social care professionals and everyone who is interested in the life of care dependent persons. The CARMA game is showing one year of an elderly care dependent person and how the person copes with unexpected events/risks related to the four seasons. The winner of the game is the player who stays in the game while all others drop out. At the start each player gets different identities, which represent unequal starting positions/conditions related to income, health status, housing conditions, family network, ADL-level. Further each player gets three capital cards at the start which are related to supportive factors of a care arrangement as laid out in the CARMA recommendations. Players roll a dice and move over squares on the game board. A stack of capital cards is put in the middle of the game-board and every time a player moves to a positive or negative square he/she has to take or give away a certain number of capital cards. The capital cards help the player to overcome the risk fields or negative events. There are neutral, risk/negative and positive squares. Some positive squares are connected with positive events in the life of elderly (e.g. wedding of grand children, birthday party). If you get to a risk square and you cannot produce the required number of capital cards, you are out of the game. Whenever you pass the start again you get a random sample of 3 capital cards from the stack.

The book contains all presentations of the invited keynote speakers as well as the discussions and comments retrieved at the conference "Strategies against Social Exclusion of Older Persons - Lessons learned from Practice" which took place in Graz April 22 and 23, 2005. All keynote speakers and workshop leaders were asked to comment on a first - unpublished - draft version of the CARMA report on a study about interactions between service providers and service clients. The proceeding is published in German. The aim of the conference was to present first interesting results to an interested audience and discuss the results with them. The conference was attended by some 81 participants, mostly practitioners or students of social work with the elderly and senior care workers. The member of the Provincial Government of Styria (Kurt Flecker in charge of Social Policy) was giving a keynote, as well as Giovanni Lamura from the EUROFAMCARE project and Katie Campbell and Nora Walsh from the Belfast project Sydenham Court. A total of 6 workshops covered the following topics - The Question of Care for Older Persons in European Social Policy (Jörg Leichtfried, Member of European Parliament/ Gertraud Dayé, International Cooperation Officer of EURAG - European Federation of Older Persons) - Service Provision vs. Control? The Tasks of Regional Social Policy (Jakob Kabas - Sozialhilfeverband Liezen and Brigitte Schafarik - Volkshilfe Styria) - Social Exclusion in the Intersection between Family Care and Professional Services: Preliminary Results of a European Research Project on Family Caregivers (EUROFAMCARE) (Giovanni Lamura, Ancona/Italy) - Identifying and Overcoming hidden Entry Barriers of Social Services (Methodological Aspects) (Guido Cuyvers/ Geel, Belgium and Marianne Egger de Campo/Compass, Graz) - State of the Art in Assistive Technologies (Georg Edelmayer and Paul Panek - Research group on Rehab Technologies FORTEC, University of Technology Vienna) - Social Work with Older Persons: the Concept of a Modern Profession (Klaus Posch and Rainer Loidl-Keil/University of Applied Science, Graz). This book will be particularly useful to local policy makers, administrators and managers of social organizations, but also to students of sociology and social work.

Within the book chapter the concept of social exclusion is discussed and transferred to the issue of care-dependency in old age and elderly care approaches. In a next step, on the basis of a literature review on the development of elderly care approaches in Europe and on the basis of an empirical study on the development in Germany, characteristics of elderly care approaches are assessed. In the conceptual part the basic features of the concept of social exclusion, which have been developed within international comparative welfare state research, laid out and combined with findings of the research areas social-gerontology and elderly care. The multidimensionality of the concept of social exclusion requires a definition of a multidimensional ageing process, which reveals the different dimensions of ageing and the role of care-dependency. Processes of social exclusion are strongly related to different types of inequality putting women, members of the lower classes and migrants at a disadvantage. The discussed concepts and findings make demands on the further development of elderly care approaches. Basically, it needs a comprehensive and integrated care arrangement including both formal and informal care oriented towards different social groups in society and universal access to care services on the basis of social rights. In the second part the analysis of the changes of elderly care approaches in Western Europe reveal an expansion and diversification of care facilities. Further, in particular in continental Europe new separate tax- or insurance based schemes have been introduced to cover the costs of elderly care. However, the benefits are often oriented towards basic nursing care and social needs are neglected. In addition, the expansion and diversification of services in accordance with efforts of privatisation enhance the fragmentation of services and thus impede the establishment of a comprehensive care arrangement. The analysis of the German situation showed a specific type of fragmentation in particular between basic nursing care delivered within the framework of the long-term care insurances and the social services at the local level. It is also characterised by a high level of social inequality with regard to the use of home-based care services, residential care and with regard to the situation of informal family carers. Informal family carers of lower socio-economic classes are only rarely supported by formal care services. In addition, women of the lower socio-economic classes are overrepresented in the use of residential care in nursing homes. The chapter is published in a book, which is oriented towards researchers in applied social or health science, practitioners or social policy experts. Books of the series are widely used and discussed. The chapter can open up the debate for the new topic on social exclusionary processes in old age and adequate elderly care approaches. In particular, the emphasis on social care and the interplay of different dimensions contribute new perspectives to the debate.

The report is the final result of a study about interactions between service providers and service clients. It considers the discussions and comments retrieved at the conference "Strategies against Social Exclusion of Older Persons - Lessons learned from Practice" which took place in Graz April 22 and 23, 2005. The conference was attended by some 81 participants, mostly practitioners of social work with the elderly and senior care workers. The member of the Provincial Government of Styria (Kurt Flecker in charge of Social Policy) was giving a keynote, as well as Giovanni Lamura from the EUROFAMCARE project and Katie Campbell and Nora Walsh from the Belfast project Sydenham Court. A total of 6 workshops covered different topics. All keynote speakers and workshop leaders were asked to comment on a first - unpublished - draft version of this report. WP 3 Instructive Deviance - Interaction between Users and Service Providers collected data about so-called deviant clients in 4 countries' service provision systems represented by Compass in Austria, KHK in Belgium, CooSS Marche in Italy and SEBT in UK. The study aims at exploring the social reality beyond the routine client of the service practice. Deviance is operationalized as a behaviour or condition of the client that either prevents her/his admission, leads to discharge or causes friction in the service provision. The report is organised as follows: A first methodological chapter lines out the research design and the research process. Then the findings are summarized (the converged categories of risks of exclusion are described and a logic model analyses these categories). Two alternative interpretations of the findings are presented and a final chapter sums up recommendations which can be concluded from the empirical data and the discussions of the data on the conference. In the appendix the reader will find: - The data collection instruments - The description of the data collected in three different research steps: the data sheets, the participant observation and the feedback loop interviews. Each source of evidence is divided in four subchapters for each participating country. - The presentations and speeches of all invited keynote speakers in English. - The summarised discussions of these contributions in English. The objective of studying 'deviant' cases of users was to reveal the preconditions a client has to meet in order to get proper service and support. We assumed that whenever friction or exclusion of a certain type of client appeared this would enable us to observe the process of marginalization. Consequently, we planned a study about how and why excluding processes may even affect those older persons that were identified by a service system as being vulnerable - i.e. who have bad health and/or lack access to e.g. economic, social, and/or cultural resources. What the present study aims at is building a theory about exclusion processes, developing a logic model and revealing scope for intervention of the responsible agents (be they policy makers or managers in providing organisations).

The result Documentation of services for reintegration of the aged in Belgium has the purpose to provide higher education with a concise overview of the Belgian situation. The report gives a detailed overview of the present services (2003) for older people in Belgium; this includes mobile health and social care services and Day Centres for seniors. In addition, we mention services like meals on wheels or other community based support services for older people, which are designed to enable older people to stay in their communities when they are in need of care and help. First of all we give some context information about the demographic development and the financial situation of the aged in Belgium. We explore how the provision of these services is organised; give quantitative information about the number of persons being served, the number of personnel employed and the costs incurred to the clients. We also document the access to the services from a client's perspective. For nurses, family doctors and occupational therapists such an overview is necessary. The deliverable can be used at university level as well as on the level of higher education. The added value of this result is the synthesis of rather fragmented information about services for the elderly.

The report gives a detailed overview of the present services (2003) for older people in Austria; this includes mobile health and social care services and Day Centres for seniors. In addition, we mention services like meals on wheels or other community based support services for older people, which are designed to enable older people to stay in their communities when they are in need of care and help. Institutionalised long term care that tends to create so called "total institutions" (1961) is explicitly excluded from this overview. First of all we give some context information about the demographic development and the financial situation of the aged in Austria. We explore how the provision of these services is organised; give quantitative information about the number of persons being served, the number of personnel employed and the costs incurred to the clients. We also document the access to the services from a client's perspective. We try to give a picture of the present situation in Austria, which is a rather difficult task, since the nine provinces in charge of the social services for the older people operate on different legal bases and consequently offer different service profiles. Further, the statistical information available is heterogeneous across the provinces and not comparable. In general this report looks at the available offers and their costs from a potential user's view, thus we neglect questions of the provision costs or the providers' or administrations' view of the whole system of care for the aged. The report is concluded with the identification of three main problems of the Austrian health and social care system.

Estonia is one of the fastest ageing nations in Europe. In the beginning of year 2003, 15.6% of the population was 65 years old or older. According to the prognosis the proportion of seniors in the population will be over 19% in 2030. In the context of senior citizen policy, attention is mostly paid at citizens entitled to old-age pension. Reforms in the old-age pension system have been carried out during the last decade and will have much more impact on future pensions of persons being young or middle-aged nowadays than of those who are already retired. The mean old-age pension is less than 40% of the mean salary. Services for the aged that aim at preventing marginalization are provided by two systems health care and social care which are quite seperate systems, causing problems for regional and local management of elderly care. Better cooperation, networks and a common data base for health and social care are needed. Implementation of interdisciplinary geriatric assessment would optimise allocation of resources and reduce unmet needs of seniors. Health care reforms carried out since 1992 concentrated on decentralisation of health care administration, establishment of solidary health insurance, development of family physician care and reforming acute hospital care. Nursing care development started only in 2001. Primary health care by family physicians, specialised medical care and hospital care are available for older persons all over the country. Nursing care, especially home nursing is much less developed and there are big regional differences. Geriatric medicine is not available at all. Financial access to health care services is quite good for Estonian seniors. Long waiting lists for some health care services, limitations in financing of rehabilitative, nursing care and dental care services, but also high costs of drugs are the biggest problems. The development of social care services is characterised by prioritisation of supporting independent coping. Persons with special needs can apply for a small allowance for themselves and for their personal informal carer. Senior centres (day centres) providing social counselling, recreational activities and services like sauna, washing laundry, massage etc at a discount, also home help services are available in all cities and bigger villages. Availability of placement in general care homes varies by regions. In big cities long waiting lists are common. Residents of care homes have quite often serious health problems needing intensive nursing and are placed into care homes only because of time restrictions in nursing hospitals. There are very few intermediate care services (intensive home care, supported living houses, care of older persons in a family, day care centres for people with dementia etc.) in Estonia. Financing of social care services includes almost always the person¿s own contribution which is small for seniors not having children but is rather big and often beyond one s strength for those having children. In conclusion, for preventing marginalisation of older persons a better assessment of needs, more diverse services, a flexible financing system and improved cooperation between health and social care systems are needed in Estonia. Much more attention should also be paid to families caring of their elders.

The report provides an in depth insight into the Italian situation, the pension system, the demographic and economic trends, the migratory flows and their consequences, the supply and management of services at local level. It has been created taking into account some basic indicators agreed with partners to allow a comparative analysis. It has been made available in paper version for consultancy and in PDF format accessible by the project website. It is available in Italian and in English and it can be consulted by whoever might be interested in the matters, as students, teachers, trainers, researchers and managers.

CARMA research has produced 12 clusters of recommendations. There are some natural groups but in some cases there is an arbitrary division between clusters. Essentially, they are closely inter-related with recurring themes across clusters. The clusters are as following: - Enhance the System itself Paradigm Shift in Caring; - Cultural Change; - Assessment Procedures; - Integration of care & case management; - Information and Empowerment; - Financial Aspects of the Care System; - Support of Informal Carers (family, neighbours, friends); - Provider Policy; - Service Diversity and New Services; - Physical Environment: Contribution from Domotics; - Training of Care Personnel; - Working Conditions of Care Workers. The recommendations are based on empirical research and identify common themes which cross national, regional, geographical, political and cultural boundaries. This is because they centre on basic human needs and the need to consider these in a holistic way. The target group of these recommendations are policy makers, service providers, educators and care professionals. The group of policy makers is particularly important as they can help to shape the health and social care systems across Europe for older people for generations to come. These are not simply about economic resources because they are also related to the values and principles that influence political decisions which in turn should shape state organisational arrangements, professionals and providers involved in the care of older people. The implementation of these recommendations would be a positive step and provide a bedrock upon which more integrated and better quality care could be provided. This will influence professionals who have a vital role in the assessment and provision of services. This will be part of a more integrated and holistic model that incorporates the whole community, agencies, families and all older people including those who become care dependent.

In this article our work group gave an explanation to the expression "marginalisation of elderly" and talked about different causes of it. Under the different causes of marginalisation we described the following indicators: economical exclusion under this heading an overview about how the economic situation affects the marginalisation of elderly was given; social exclusion this passage talked about the main cause of social exclusion the lack of social relationships and about the lack of engagement in social life for the elderly; cultural exclusion the form of exclusion that is conditioned from ethnic and racial differences; institutional exclusion what it means; environmental exclusion safety and security of the homestead, how the surrounding environment affects coping with everyday life. In addition to the problem of the marginalisation of elderly we also paid attention to the danger of marginalisation of the carers of the elderly. We summarized the article with the discussion about how it is possible to support the coping with everyday life for the elderly through offering different social services. The article ended with a brief description of the CARMA project.

Capability of coping with everyday life and quality of life of long-term nursing care patients depends on good integration of health and social care competencies and services. As a part of European 5th Framework project CARMA a description of services, access to them and the obstacles in collaboration of different systems was evaluated in seven European countries. In Estonia we used semi-structured interviews (in total 17) of regional health and social care leaders to find out problems in the field of long-term care. Data from the interviews were analysed based on the cross case method. The most important research conclusions are as follows: - All respondents were convinced of the necessity of co-operation between health care and social welfare workers, the respondents would like to see it improved, but they believed that everything important somehow now gets done. - Inter-institution integration is rather poor according to the respondents. They believed that the problem stems from the fact that already at the Ministry level the health care and social welfare systems are separated, which creates a similar pattern in the counties. - The bigger hospitals have social workers, but there are still too few of them. The expectations on social workers are not so much related to professional consultancy but rather their contribution to help senior patients leave hospitals fast. - The interdisciplinary services (making rehabilitation plans, geriatric evaluation) were unanimously regarded as essential. It was pointed out that there was no co-operation network between the specialists, no common databases and that their usage was not regulated. As a conclusion it can be said that the counties social sphere executive officers regard it vital to significantly improve the co-operation between health care and social welfare, to create common databases and evaluation teams and to support the informal carers.

The result (Del 17) discusses the conceptual approach and the findings of the investigation into Care arrangements patterns and negotiation processes (WP 5). The deliverable gives information on care arrangement patterns, their prerequisites and consequences as well as patterns of social integration, support of mobility and the psychological situation of care-dependent elderly in five Western European countries (Austria, Belgium, Germany, Italy, Northern-Ireland). On a theoretical basis it draws on the concept of social exclusion, which has been developed in international comparative welfare state research. The basic characteristics of the concept of social exclusion are laid out and combined with findings of the research areas socio-gerontology and elderly care. Processes of social exclusion are strongly related to different types of inequality putting women, members of the lower classes and migrants at a disadvantage. As preconditions for the establishment of successful action strategies against marginalization the accessibility of adequate care resources, the integration into social- and family networks and on a psychological level, feelings of belonging are defined. Based on this approach the main research questions concern care arrangements and their consequences for the care-dependent elderly and informal carers, patterns of social integration, retention of mobility as a precondition for social integration and the psychological situation of the elderly. An investigation into care arrangement patterns and the social situation of care dependent elderly in five European countries - Austria, Belgium, Germany, Italy, United Kingdom (Northern-Ireland) - forms the basis of the empirical findings. Elderly care approaches of the participating countries differ with regard to the underlying values, the availability, affordability and accessibility of services and the regulations of freedom of choice between cash payments and services. The universal approach of elderly care embedded within the idea of a societal responsibility for care provision in Northern-Ireland shows the most favourable situation for the elderly and their informal carers as a whole and for certain risk groups, e.g. people living alone or with low income. The continental European approach characterized by a responsibility assigned to the family and the society simultaneously in Austria, Belgium and Germany creates country-specific obstacles and risk groups. The family-oriented approach in Italy does not provide an adequate care provision to the elderly without sufficient family support. The elderly living on their own with limited family support complain about unmet needs and report often about feelings of loneliness. The report provides a broad use potential within research and social policy development. In particular, within the research areas international comparative welfare state research on social exclusion or (elderly) social care and within socio-gerontological research the new conceptual approach and the empirical findings offer opportunities for further development in theoretical and empirical work. The empirical findings and their relation to the concept of social exclusion can be used as a knowledge base for the development of care- and social policies as well as an adaptation of regulations and professional care services to the needs of different user groups (at risk of marginalization). Up to now the deliverable has already been used as a basis for publications (two book chapters forthcoming, and a planned journal article) and as basis for a planned seminar with social politicians at the ministry of the Federal State of Berlin. In October 2005 the empirical findings have been presented and discussed at the international conference Care for the elderly and social integration: A European comparison at the Social Science Research Center (WZB) in Berlin.

Estonia is one of the fastest ageing nations in Europe. In the beginning of year 2003, 15.6% of the population was 65 years old or older. According to the prognosis the proportion of seniors in the population will be over 19% in 2030. In the context of senior citizen policy, attention is mostly paid at citizens entitled to old-age pension. Reforms in the old-age pension system have been carried out during the last decade and will have much more impact on future pensions of persons being young or middle-aged nowadays than of those who are already retired. The mean old-age pension is less than 40% of the mean salary. Services for the aged that aim at preventing marginalization are provided by two systems - health care and social care - which are quite separate systems, causing problems for regional and local management of elderly care. Better cooperation, networks and a common data base for health and social care are needed. Implementation of interdisciplinary geriatric assessment would optimise allocation of resources and reduce unmet needs of seniors. Health care reforms carried out since 1992 concentrated on decentralisation of health care administration, establishment of solidary health insurance, development of family physician care and reforming acute hospital care. Nursing care development started only in 2001. Primary health care by family physicians, specialised medical care and hospital care are available for older persons all over the country. Nursing care, especially home nursing is much less developed and there are big regional differences. Geriatric medicine is not available at all. Financial access to health care services is quite good for Estonian seniors. Long waiting lists for some health care services, limitations in financing of rehabilitative, nursing care and dental care services, but also high costs of drugs are the biggest problems. The development of social care services is characterised by prioritisation of supporting independent coping. Persons with special needs can apply for a small allowance for themselves and for their personal informal carer. Senior centres (day centres) providing social counselling, recreational activities and services like sauna, washing laundry, massage etc at a discount, also home help services are available in all cities and bigger villages. Availability of placement in general care homes varies by regions. In big cities long waiting lists are common. Residents of care homes have quite often serious health problems needing intensive nursing and are placed into care homes only because of time restrictions in nursing hospitals. There are very few intermediate care services (intensive home care, supported living houses, care of older persons in a family, day care centres for people with dementia etc.) in Estonia. Financing of social care services includes almost always the persons own contribution which is small for seniors not having children but is rather big and often beyond ones strength for those having children. In conclusion, for preventing marginalisation of older persons a better assessment of needs, more diverse services, a flexible financing system and improved cooperation between health and social care systems are needed in Estonia. Much more attention should also be paid to families caring of their elders.

Estonia is participating in the European FP5 project CARMA (Care for the Aged at the Risk of Marginalization) project with two partners - Estonian Association of Gerontology and Geriatrics and the Tartu University Hospital for Internal Diseases. The project lasts from 2003-2005 and its main aim is to develop directions for avoiding marginalization of the aged. In the year of 2003 a research was carried out within the project of CARMA. The aim of the research was to describe the social- and health care services provided to the elderly and their caretakers, the conditions for accessing the services, the biggest problems in connection with this and the possibilities to improve the situation here in Estonia. In the research following social services, the availability and propable problems were dealt with: counselling service, day centres, care home service, welfare services for the demented respite care, social housing service, sauna and shower service, laundry service, meals on wheels service, the possibility for subsidised meals, discounts for technical aids, customised accommodation services, asylum service, transport service. To prevent the marginalization of the aged their needs have to be addressed more specifically, more and different services are needed. The funding of the services needs to be more flexible and the cooperation between healthcare and the social welfare needs improvement. In addition to this the families who take care of the aged, need more sufficient support.

The result (Del 10) provides on overview on the development of home-based, semi-residential and residential care facilities in Germany since the introduction of the long-term care insurance in 1995/96. Moreover it gives information on the social care and counselling offers established by the municipalities. As context information figures on demographic change in Germany, the pension system and the economic situation of the pensioners as well as the regulations of the long-term care insurance defined by law are discussed. The evaluation is based on a wide range of statistics and interviews with high-ranking experts. In the course of the evaluation statistics on the availability and use of service offers, user structures and costs for the users, situation of the staff, strengths, obstacles and future developments are considered. The findings reveal an expansion, modernisation and diversification of all types of care facilities. Despite this, a range of difficulties were found. One difficulty concerns the issue of access to different types of formal care offers. The orientation of the long-term care insurance towards basic funding of care services only, limits the use of services. This applies in particular to the members of the lower socio-economic classes and results in lower take-up rates. In addition, regional inequality can be found with regard to the social services provided by the municipalities. The service offer is voluntary for the municipalities and thus in economically poor regions and in the country side the service offers are less developed. Quality problems apply to the fragmentation between home-based care and the local offers, hospital and ambulant care and different counselling offers. The semi-residential care offers, e.g. short-term care facilities, are not sufficiently oriented towards rehabilitation of the care-dependent elderly and counselling of the relatives. There are no adequate service offers for elderly with dementia illness or further psychological difficulties respectively for unburdening of their relatives. Due to the lack of an adequate home-based care an increasing nursing home admission can be stated. A final problem applies to the financial basis of the long-term care insurance. The introduction of two separate branches, i.e. a social long-term care insurance which covers 90% of the population and a private long-term care insurance which covers the 10% more wealthy inhabitants results in a difficult financial situation. For the social long-term care insurance the expenditure exceeds the income (insurance contributions), while the private insurances use their surplus to build up big financial reserves. The report provides a lot of information on the quantitative and qualitative development of different types of care services or care facilities in Germany. It can be used by national and international researchers within the area of elderly care, but also by social politicians and experts within service provider associations. It is already used by social politicians, or high-ranking experts within the care insurance or associations in Germany and other European countries, e.g. Italy, Spain. Further it is already read and discussed by researchers in Germany and other European countries.

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