This account of nursing home care in Australia begins with a brief history of four phases of policy development from 1963 to the early 1990s. The structure of the nursing home system is then outlined; particular attention is given to data sets generated from administrative systems that are used for monitoring nursing home care. Arrangements for pre-admission assessment and assessment of resident dependency and care needs, to which reimbursement levels are related, are described next. A profile of resident characteristics and their patterns of utilization of nursing home care is presented, drawing on these assessment data. Policy issues arising in the 1990s are addressed in the conclusion; these concern the place of nursing home care in the overall balance of aged care services and the enhancement of outcomes of nursing home care in regard to quality of care and workforce training. Finally, the contribution of the continuing development of data sets for monitoring trends and outcomes to policy and program development is noted.

Long-term care in Canada is situated within a universally accessible publicly insured program. The Government of Canada establishes certain minimum standards for health care as the basis for the federal share in funding health programs, although the programs themselves are administered provincially. Examples are drawn from the Province of Manitoba. While the dependency ratio has been decreasing due to a slower increase in the number of persons under 17 years of age, the percent of the population over 65 years continues to increase. Population projections forecast that by the year 2031, one-quarter of the population of Canada will be over 65 years of age. Expenditures on health care doubled from 1981 to 1990 for both Manitoba and Canada. The policy response to ever-increasing costs of delivering health care to an aging population has been to seek alternative methods of delivery. Specifically, the long-term care bed-to-population ratio has been reduced and the authors anticipate continued modest increases in the use of community care.

During the 1960s and 1970s, The Netherlands had one of the youngest populations in Western Europe. In fact, a significant increase in the proportion of elderly in the population will not begin until after the year 2010. Despite this relatively late aging of the population, the Dutch government developed a policy on aging at an early stage, with particular attention to institutional care for the elderly. This move resulted in a high proportion of elderly living in institutions. In 1982, 3 per cent of the 65 + population lived in nursing homes and 9 per cent in homes for the elderly. These care institutions are organized on a non-profit basis and financed through direct or indirect taxation. Their population can be characterized as “frail elderly”. However, homes for the elderly were originally considered to be housing facilities for the elderly. The costs related to institutional care increased considerably in the 1960s and 1970s, but through procedures like specific planning criteria and assessing the need for admission into a home for the elderly, the government has attempted to contain the costs. Until the end of the 1980s, these attempts had not been very successful. One of the more successful means of containing costs seems to be the stipulation of community long-term care.

Using routine data, surveys, and data from a local area study, this article describes the long-term care sector in Norway. Some comparisons with Denmark and Sweden are also presented. Typical for the Scandinavian solution is tax-financed formal care, provided as a highly decentralized public service. In Norway, three stages of development have been identified since 1955: establishing a basic structure of long-term care (LTC) (1955–70), expansion (1970–80), and reorganization (1980–90). The current Norwegian system is characterized by well-staffed, small institutional units integrated with home care. The turn-over rate in nursing homes is high. Most admissions and live discharges constitute an interchange with the home-care system. Although Norway occupies an intermediate position between Denmark and Sweden, there is now a strong tendency of convergence among these three LTC systems.

Major milestones in the evolution of nursing home care in the United States between 1960 and 1985 were the introduction of Medicaid and Medicare (resulting in a rapid growth in beds), national health planning (slowing the growth of beds), and prospective payment system for hospitals (shifting the case mix to a more disabled population). Critical policy concerns for nursing home care in the mid-1980s were the appropriate mix of public and private expenditures, impoverishment of some elderly persons as a result of long stays, improvement of the quality of care, and the funding bias toward institutional longterm care. Policy changes in the past few years have addressed quality by requiring a standard assessment linked to a care plan, although quality remains a major issue. Recent policies creating home care and community-based care programs may signal a shift away from institutional care. The issues of impoverishment and of the appropriate mix of expenditures are unresolved. Nursing homes certified by Medicaid and Medicare differed from those not certified in providing more services, having more nursing staff, and having more residents with disability and behaviour problems. Between 1985 and 1994, there were some significant changes in sources of funding for national nursing home expenditures. Out-of-pocket expenditures dropped, while government expenditures rose, with the increase occurring in the federal-government share.

In 1985 there were about 5.5 million functionally disabled elderly persons (65 +) in the United States (U.S.) living in the community and an additional 1.3 million in nursing homes. By 2020, these figures are expected to almost double to 10.1 million and 2.5 million respectively. The long-term care system (LTC) in the U.S. is large and complex. Fundamentally, it consists of: (a) informal care, provided voluntarily by one's family, friends, neighbours, and community organizations; (b) home and community based care, covering formal (paid) services provided in one's own home or other community based settings; and (c) nursing homes, which provide specialized medical, nursing, and social services in an institutional setting. Home and community based care includes a variety of services and financing streams, including (a) Medicare home health care, (b) Medicaid home health services, (c) Medicaid home- and community-based services, (d) programs and services under the Older Americans Act, (e) state sponsored social services funded by the Social Services Block Grant, (f) Supplemental Security Income payments, and (g) a range of supportive housing arrangements. Data on the LTC system are available from several key sources: national surveys, administrative records, inventories, state and local data systems, and demonstration programs. The LTC system remains decentralized. The frail elderly want dignity and independence in the latter years, plus access to needed services and an acceptable quality of life. In policy terms, their caregivers and the taxpaying public continue to struggle to find the appropriate mix of public and private support to meet the needs of the LTC population.