Dependency refers to a condition in which a person with illness or disability, often due to age , can no longer cope with everyday life independently and is therefore dependent on care or help from others.
Legal situation from January 1, 2017 (care levels)
With the Care Support Act 2 on January 1, 2017, the conversion of levels of care to the nursing degree . People with purely physical limitations were each transferred to the next higher level of care [ie level = level plus 1]. People with recognized significantly reduced everyday skills (PEA) were each given the next but one level of care [ie level = level plus 2].
The aim of changing from care levels to care levels is to take greater account of the needs of people with dementia; in addition, higher benefits are provided for those in need of care. For the care levels, the classification was based essentially on the time spent by the carers. With the new definition of the need for care , the degree of independence of those in need of care is assessed in six areas, which allows a more holistic form of assessment:
- Help with everyday activities
- Psychosocial support
- Need for help at night
- Help needed during the day
- Support with illness-related activities (taking medication, etc.)
- Aid management (organization of aid)
|Care level 1||Care level 2||Care level 3||Care level 4||Care level 5|
|Outpatient cash benefit||€ 125||316 €||€ 545||728 €||€ 901|
|Outpatient benefits in kind||€ 689||1298 €||1612 €||1995 €|
|Inpatient benefit amount||€ 125||770 €||1262 €||1775 €||2005 €|
Legal definition according to the old legal situation until December 31, 2016 (care levels)
According to Section 14 (1) SGB XI a. F. or § 61 SGB XII a. F. Persons who, due to a physical, mental or emotional illness or disability, required considerable or greater help for the usual and regularly recurring tasks in the course of daily life, probably for at least six months.
Illness or disability
The need for help had to be caused by an illness or disability . These are irregularities (damage) to the musculoskeletal system, internal organs or the central nervous system.
The need for help had to relate to the usual and regular tasks in the course of daily life. The activities were finally listed in Section 14 (4) SGB XI and Section 61 (5) SGB XII and subdivided into the four areas of personal hygiene, nutrition, mobility and domestic care.
|personal hygiene||nutrition||mobility||Domestic supply|
|Washing, showering, bathing,
dental care, combing, shaving,
emptying the bowel or bladder
or consumption of food
|Independent getting up and going to bed,
dressing and undressing, walking, standing,
climbing stairs or leaving and going back to
|Shopping, cooking, cleaning the apartment,
doing the dishes, changing and washing
laundry and clothing or heating.
Although not expressly mentioned in the above list, the case law also recognized lying (e.g. repositioning a bedridden patient) and sitting (e.g. transferring a patient in a wheelchair or restraint with a belt) as basic care tasks that can be considered .
The activities listed above have largely been specified in the case law:
- The need for help with nutrition did not require that the person in need of care was still able to supply food through their mouth. If the person in need of care had to be fed artificially via a gastric tube or parenterally , this also fell under the section on nutrition and was insofar considered as a performance.
- Likewise, the need for help with bowel and bladder emptying did not require that the person in need of care was able to empty his bowel or bladder naturally, so that the drainage of urinary fluid by means of a urinary catheter and an artificial urinary bladder could also be taken into account. On the other hand, peritoneal dialysis no longer falls under the concept of bladder emptying; it was therefore not a consideration that could be taken into account.
- The need for assistance for mobility was only to be taken into account if it occurred in connection with one of the other activities specified in the law; Specifically, these were going to the toilet, meals and going to bed.
- There was only a need for help when leaving and returning to the apartment if it was absolutely necessary for the person in need of care to leave the apartment in person, for example to see a doctor. This need for help could not be taken into account if the person in need of care had to leave the apartment for other purposes, for example to attend school, to work or to visit a workshop for disabled people , or for social participation such as attending church services .
The need for assistance for other tasks was not considered in the context of the need for care. Under certain circumstances, if it results in a considerable need for general supervision and care ( limited everyday skills ), it could lead to a special claim to benefits.
Performances within the meaning of the law could only be taken into account if they were absolutely necessary for the existence of the person in need of care. Accordingly, activities could not be taken into account if they only served to secure gainful employment for the person in need of care.
The consideration of treatment care as a performance was highly controversial. The case law decided that treatment care as such does not constitute a performance, but that it can be taken into account if it is either part of a performance specified in the law or if it is necessary for medical reasons in direct connection with a performance specified in the law. On this basis, the Federal Social Court ruled in 2001 that home nursing for the donning of compression stockings of class II and III cannot be provided because this involves help with dressing and undressing, which is already a basic care provision during the investigation the need for care is taken into account and for which the person in need of care has already received care insurance benefits in the form of care allowance. This case law met with such a great lack of understanding that the legislature took this case as an opportunity to change the legal regulations on home nursing so that benefits for putting on compression stockings can no longer be refused with reference to the care allowance as a priority benefit. The Federal Social Court then changed its case law and decided that the person in need of care had the right to choose whether he had the treatment care carried out by voluntary caregivers or by a professional nursing service within the scope of home nursing, which then had the consequence that these services were no more than Need for help could be taken into account. Again, the legislator reacted and changed the legal regulations so that treatment care at the same time justifies a right to home nursing and is to be taken into account in the need for care if it falls under one of the legally regulated activities.
In order to be able to substantiate the need for care, there had to be a need for help with at least two basic care activities and there had to be a need for domestic care several times a week. (Section 15 (1) SGB IX old version)
Permanent need for help
Only those who were in permanent need of help were considered to be in need of care. That was the case if the need for help was likely to last longer than six months. The point in time at which the forecast was prepared (“ ex ante ”) was decisive for the forecast .
Significance of the need for care
The need for care also had to be considerable. The relevance of the need for care was determined by measuring the time required by an average, non-professionally trained caregiver to support the person in need of care in performing the necessary tasks, to guide and supervise him or to carry out the tasks himself. On the other hand, the time required for general monitoring of the person in need of care or constant readiness for action could not be taken into account.
Time was expended when the carer was unable to carry out any other tasks, in particular general housekeeping, during this time. Thus, for example, a doctor's visit by the person in need of care, which is necessary at regular intervals, could also be considered time expenditure if the person in need of care cannot cope with the journey to the doctor on his own, not only within the framework of the pure travel time, but also the time in which the person in need of care is examined by the doctor and is treated.
The time required was based on the individual needs of the person in need of care, insofar as these were objectively justified. If, for example, a person in need of care had to be bathed particularly frequently and at great expense due to a skin disease, these activities could be fully taken into account, even if they only occur due to the illness.
In the case of children, the additional need for help compared to a healthy child of the same age was decisive. They had to meet the same relevance requirements as adults.
The extent of the need for care was described using so-called care levels. Those whose need for care is significant was classified in care level I, care level II was given for severe care needs and care level III for the most severe need of care. The medical service of the health insurance (MDK) or other independent experts carried out the examination of whether the prerequisites for the need for care have been met and which level of the need for care is present.
A “care level 0” was used when there is a need for help with basic care and domestic care, but not to an extent that is considered significant according to the definition criteria, or when there is a need for care that does not relate to the defined everyday activities - a need for care that does not lead to a division into one of the three other care levels. This is often the case with people with dementia.
Both a minimum requirement for basic care (help with tasks in the areas of personal hygiene, nutrition, mobility) and overall was defined.
|Care level I
(considerable need for care)
|Care level II
(severe need for care)
|Care level III
(most severe need of care)
|Need for help with personal hygiene, nutrition, mobility (basic care)||for at least two tasks at least at one time of the day||at least three times a day||around the clock, even at night|
|average daily effort for basic care||more than 45 minutes||at least 120 minutes||at least 240 minutes|
|Need for help with housekeeping||several times a week||several times a week||several times a week|
|Average daily effort for the total help||at least 90 minutes||at least 180 minutes||at least 300 minutes|
According to the law, help was required at night if the help had to be carried out between 10 p.m. and 6 a.m. and could not be postponed to a time before 10 p.m. or after 6 a.m. It was not sufficient if the person in need of care went to bed or woke up during this time, even if there was a need for help for these activities; however, it was not necessary for the caregiver to wake up from their nightly sleep in order to perform the tasks.
The monies that are paid monthly by the long-term care insurance to people who are certified to be in need of care are increased by the 2nd Long-Term Care Act. Benefits that result for the individual care levels, see above.
Comparative consideration of care levels and degrees of care
Care levels and degrees of care consider the concept of need for care from completely different perspectives, which ultimately produces different results.
The exclusive consideration of basic care activities in the system of care levels with the sole consideration of the time required was almost exclusively designed for physical disabilities; mental and psychological impairments were not taken into account. As more and more elderly people suffered from dementia due to demographic change , the relatives often found that they had to pay almost all of the care at their own expense, because according to the system of care levels, dementia sufferers did not need care, although they undoubtedly could not be left unattended . The introduction of limited everyday skills as an additional criterion that could justify a need for care alleviated this problem to a certain extent, but did not completely solve it.
In contrast, the new system of care levels considers the self-help ability of the person from several perspectives, including psychological and cognitive impairments. The mere expenditure of time plays less of a role than the ability of the person in need of care to lead an independent life at all. As a result, for example, a wheelchair user who, apart from his physical disability, leads a completely independent life, according to the system of care levels, simply because he is sitting in a wheelchair, could receive care level I or II (which is then classified as care level 2 or 2). 3), but in the new system there is a risk of receiving care level 1 at best.
In this respect, it was in most cases much cheaper for physically disabled people to submit an application for the determination of the need for care before December 31, 2016 so that they could continue to be assessed according to the old care levels and then enjoy grandfathering, while many people with dementia and Mentally ill people only receive access to long-term care insurance benefits through the care level.
In the case of fully inpatient care services, at the same time as the introduction of the care levels, the home resident's own share was standardized across all care levels, whereas with the old care levels the own share depended on the own care level. The old legal situation meant that it was usually financially disadvantageous for the person in need of care if they were given a higher level of care, as this also led to an increase in the co-payment and this usually rose far more than the flat-rate for long-term care insurance. Although there was an improvement in this regard as a result of the new legal situation, this increased the personal contribution for those in need of care of the previous care level I compared to the old legal situation. In addition, the flat-rate long-term care insurance for lower care levels has been reduced compared to the care level, so that it could also be advantageous to move into a nursing home in 2016 because of the amount of the flat-rate as well as the co-payment to be made grandfathering applies.
Current relevance of the need for care
The need for long-term care often sets in, but not only, in old age. In addition to the elderly, children or adults can also be chronically ill or experience severe restrictions in their self-determination over a long period of time due to sudden accidents. Disabled people or people with multiple illnesses can also be affected by the need for care. Due to the more frequent need for care in old age, demographic change also plays a role in the percentage increase in people in need of care in the population. In Germany, the current demographic change manifests itself in the increase in people of senior age and the decrease in young, employed people. According to the statistical offices of the federal and state governments, the number of people in need of care is estimated at around 2.72 million people in 2020, 3 million in 2030 and 3.76 million in 2050. There are therefore increasing problems for society, such as B. the financing and provision of care, its extent and qualitative changes (e.g. due to diabetes, dementia). Social and health policy, preventive medicine and nursing science try to find answers to this.
Legal framework of long-term care
The introduction of long-term care insurance into the German social security system in 1995 was of greatest socio-political importance. Statutory long-term care insurance (GPV) is compulsory insurance for the entire population. With the help of this insurance, people who have paid contributions to health and pension insurance throughout their working life should not be dependent on social assistance when they need care. In 2010 there were over 21 billion euros in long-term care insurance expenditures, of which over 20 billion were benefit expenditures.
Benefits in the event of need for care are regulated in the following laws: Help for care of social assistance according to §§ 61 ff. SGB XII, help for care according to § 26c of the Federal Pension Act, compensation payments (“care allowance”) according to Section 35 of the Federal Pension Act or the laws that provide a corresponding Provide for the application of the Federal Pension Act, statutory accident insurance benefits in the event of need for care in Section 44 (in the fifth section of SGB VII).
New legal regulations of the Care Strengthening Act 3
So far, there has been no legal relationship between care allowances and other social benefits related to care. This fact is to be changed with the third Act to Strengthen Long-Term Care , passed on June 28, 2016, so that long-term care insurance and the other social benefit systems of SGB XII , which concern long-term care, are given priority. In the home environment, care services are therefore considered to have priority over integration assistance services , while the opposite is the case in the inpatient environment.
Nursing scientific understanding of the need for care
The need for long-term care can be caused by many factors, whereby the causes can hardly be influenced by the individual person. The need for care has different dimensions:
Social dimension: the need for care can lead to isolation not only for the affected persons: the care of persons in need of care is usually provided by relatives, especially women (daughters, wives, etc.).
Economic dimension: the need for long-term care is expensive. Own funds often have to be used in considerable amounts. Since the risk of being in need of care increases steadily from retirement age and there is usually insufficient income, the need for care can lead to impoverishment. Even in Germany, the costs for care services are not fully covered by long-term care insurance.
Psychological dimension: The experience of being in need of care is a stressful experience for people, as the severe, long-term restrictions associated with the need for care reduce the quality of life.
Social dimension: Every person is at risk of being in need of care. Developments in recent years have made it clear that supportive and compensatory care costs money, regardless of whether it is provided in one's own home or in a care institution (nursing home). Corresponding cash reserves must be created for this (insurance). Scientific studies lead to insights into what each individual can contribute to reducing the risk of long-term care. The active health care which u. a. to protect against diseases such as dementia, which often leads to the need for care, not only affects the elderly, but every person. It is clear that an active and healthy lifestyle can reduce the risk of being in need of care. It is assumed that in addition to state funding programs, initiatives in cities and municipalities are necessary to create awareness of the problem. Various nursing science projects try to find ways to minimize the risk of being in need of care and how to delay the need for care. It is examined how the services of the care can be compensated to a realistic extent, since the services of the German long-term care insurance do not yet reflect the real necessities.
According to the care statistics of the Federal Statistical Office , there were a total of 2.5 million people in need of care at the end of 2011, 65.5% of them women. 17% of those in need of care were under 65 years of age, 47% between 65 and 84 years and 36% were 85 years or older. 29.7% of those in need of care were cared for as inpatients in homes. Around 2/3 of those cared for at home were cared for by relatives, 1/3 by outpatient care services alone or together with relatives.
Number of people in need of care in Germany by care level (as of 2011):
|Type of supply||Care level I||Care level II||Care level III|
|at home together with / by the nursing staff||324,385||188,874||63.005|
|Full inpatient in homes||283.266||299,404||151,952|
2.9 million people in need of care are forecast by 2020.
- German Institute for Applied Nursing Research , Study on Nursing Prevention ("Projects" section)
- U. Ziegler, G. Doblhammer: Increasing life expectancy goes hand in hand with better health . DFAEH 1/2005.
- Report of the expert advisory board on the definition of the need for long-term care (PDF file, from patientenbeauftragte.de; 1.73 MB)
- Federal Ministry of Health (Ed.): "Report of the Advisory Board on the Review of the Concept of Long-Term Care", 157 pages, as of January 2009 (PDF; 1.8 MB)
- Federal Ministry of Health (Ed.): "Implementation report of the advisory board to review the concept of long-term care", 61 pages, status: May 2009 ( Memento from August 20, 2012 in the Internet Archive )
- ↑ Further explanations on PEA (link checked on October 11, 2016).
- ↑ Explanations on the transition from care levels to care levels (link checked on October 11, 2016).
- ↑ Everyone group: care levels 1, 2, 3, 4 & 5 - the new care levels 2017 (July 19, 2016)
- ↑ BSG, May 17, 2000, AZ B 3 P 20/99 R
- ↑ BSG, October 8, 2014, AZ B 3 P 4/13 R
- ↑ BSG, August 22, 2001, AZ B 3 P 23/00 R
- ↑ BSG, November 12, 2003, AZ B 3 P 5/02 R
- ↑ BSG, March 10, 2010, AZ B 3 P 10/08 R
- ↑ BSG, August 5, 1999, AZ B 3 P 1/99 R
- ↑ BSG, June 24, 1998, AZ B 3 P 4/97 R
- ↑ BSG, October 10, 2000, AZ B 3 P 15/99 R
- ↑ BSG, February 19, 1997, AZ B 3 P 3/97 R
- ↑ BSG, August 27, 1998, AZ B 10 KR 4/97 R
- ↑ BSG, October 30, 2001, AZ B 3 KR 2/01 R
- ^ BSG, March 17, 2005, AZ B 3 KR 8/04 R
- ↑ BSG, November 10, 2005, AZ B 3 KR 42/04 R
- ↑ BSG, June 17, 2010, AZ B 3 KR 7/09 R
- ↑ BSG, June 24, 1998, AZ B 3 P 1/97 R
- ^ BSG, March 17, 2005, AZ B 3 P 2/04 R
- ↑ BSG, February 19, 1998, AZ B 3 P 6/97 R
- ↑ BSG, August 6, 1998, AZ B 3 P 17/97 R
- ^ BSG, November 26, 1998, AZ B 3 P 20/97 R
- ↑ BSG, November 26, 1998, AZ B 3 P 13/97 R
- ↑ Everyone group: Everything about care levels 0, 1, 2 & 3 (July 19, 2016)
- ↑ BSG, March 18, 1999, AZ B 3 P 3/98 R
- ^ A b Medical Service of the Central Association of Health Insurance Funds : Questions and answers on the new definition of the need for long-term care
- ↑ a b Nico Rau: Quickly apply for a care level . ( Memento from October 14, 2017 in the Internet Archive ) In: WDR Servicezeit, October 5, 2016
- ↑ Changes in home costs due to the Care Strengthening Act II In: BIVA , November 9, 2015
- ↑ Johannes Schleicher: PSG III at a glance. Nursing Strengthening Act 3 (PSG III) at a glance. In: jedermann-gruppe.de. July 4, 2016. Retrieved November 27, 2017 .
- ↑ Federal Statistical Office, care statistics 2011, Germany results, p. 7ff
- ↑ Federal Statistical Office, Care Statistics 2011, Germany Results, Table 1 p. 9 Accessed on May 26, 2013.
- ↑ Federal and State Statistical Offices, Demographic Change in Germany, Issue 2, 2008, Federal Statistical Office, Wiesbaden 2008