Israel was the first country in the world to legislate the right to nursing care (Long Term Care National Health Insurance Law) over thirty years ago. However, only a small percentage of the older adults living in the community who need rehabilitation – for instance, after an acute event or following a decline in their condition – actually receive it.
It is estimated that by 2035 there will be more than half a million older adults living in Israel with limited ability to carry out household-related activities – more than double the figure today. The World Health Organization recently determined that the most important consideration for older adults is functional ability, not necessarily illness. For this reason it set 2 maximizing functional skills as the primary goal for the individual and the state, and recommends policies promoting the rehabilitation and preservation of functional ability.
In Israel, the right to rehabilitation falls under the auspices of the health funds. Public rehabilitation frameworks include only a handful of centers for multi-disciplinary day rehabilitation, mainly in the center of the country; home treatment units that do not provide a multi-disciplinary rehabilitation approach; and physiotherapy and occupational therapy centers for mobile patients.
However, all these are overburdened and usually unsuited to the older population. Consequently, only a fifth of the 100,000 older adults in Israel who require rehabilitation each year actually receive it.
As a result, these people may suffer a decline in functional ability, increased dependence on others, and may require repeated hospitalizations, even culminating in institutionalization. All this contributes to a significant rise in health costs.
Why is geriatric rehabilitation in Israel in such a dismal state? First of all, because of misplaced budgets. The State of Israel annually invests some ten billion NIS ($2.77 billion) in nursing, mainly to fund care for those eligible under the Nursing Law and to maintain geriatric institutions. However less than one billion NIS ($277 million) is spent on rehabilitation. The 120 nursing companies that provide publicly funded home nursing services to some 170 thousand older adults in Israel actually increase their income the more a person’s condition declines.
The second reason is the separation between the State, that funds the nursing services and most of the cost of hospitalization in geriatric institutions through the Ministry of Health, and the health funds (HMOs), which fund the rehabilitation services. It is in the health funds’ interest to reduce the number of repeat hospitalizations. However, if the un-rehabilitated older adults experience a decline in functional ability and are subsequently institutionalized, then in most cases the expensive health costs of their final years will be transferred to the State.
Bottom line: The State must change the ratio between nursing and rehabilitation budgets by encouraging nursing companies and health funds to promote a rehabilitative approach, as it began to do in the Nursing Reform (2018). In addition, the State must increase public geriatric rehabilitation services within the community by developing a financially feasible professional model. We are currently developing such a model in JDC-Eshel in collaboration with the Ministry of Health, in eight centers that were established in the social-geographic periphery. They combine multi-disciplinary rehabilitation (physiotherapy, occupational therapy, speech therapy, nutrition, social work, psychology, nursing and medicine) with a healthy lifestyle. Once the construction of this model is complete it will be possible to establish similar centers throughout the country.
Finally, the State should increase the demand for rehabilitation by raising awareness of its importance, improving access to information, improving the care continuum between hospitalization and the community, and incorporating an integrated care approach within the health and welfare entities that require it.