Establishing systems of care in Germany: a long and winding road.

Since 1995/1996 a long-term care insurance (LTCI), which promised to develop new support structures, in particular for the group of potentially frail elderly people, has been implemented in Germany. It will be shown that this LTCI has undoubtedly improved the social situation of the persons in need of care, even if its scheme is only providing basic support with a ceiling in cash-benefits and benefits in-kind, and privileging home care by informal caregivers. But certain misdevelopments in the LTCI have shown that the present scheme requires further effort to cope with these negative effects and to elaborate new integrated models of care that bridge the still existent gap between medical and social support. This article points to long traditions of separating the social and medical dimensions in Germany which have also resulted in divided institutional arrangements. The current scheme of the LTCI, its organizational principles and its entitlements and benefits are outlined, which gives the opportunity to point out certain deficiencies, e.g., the still inappropriate provision for dementia care which is due to the dominant IADL-orientation of the medical assessment procedure and its implicit negligence of social care elements. The public debate about necessary improvements in benefits for the demented aged has already led to slight revisions of the LTCI, and will develop into a more comprehensive movement to path-bridging models of social and medical care in which the quality dimension will play a decisive role.