Introduction

Long-term care has not been defined internationally in terms of the scope of services, availability, sources of financing, coordination, and approach to patients.

The World Health Organization (WHO) defines long-term care as a comprehensive health and social support system aimed at helping dependent people in various aspects of their lives. It includes medical services and assistance with basic activities such as hygiene, nutrition, and mobility. The WHO stresses that this care should be easily accessible, well coordinated, and tailored to the specific needs of each patient [1].

In Poland, long-term care (LTC) is regulated by several national laws. It includes nursing and care services in the health care system and care services provided within the social welfare system, which are formally referred to as care services.

In the health care system, LTC includes activities related to the implementation of indefinite, continuous, and professional nursing care, therapeutic services, continuation of pharmacological and dietary treatment, nursing and care services to dependent, chronically ill people who do not require hospitalization in a hospital ward, and have difficulty performing daily activities. This care can be provided in an inpatient setting (in nursing facilities divided into treatment care facilities -TCFs and nursing care facilities - NFCs), or at home, as nursing home long-term care and in long-term home care teams for mechanically ventilated adults, children, and adolescents. This care can be provided by formal caregivers (medical personnel) and/or informal caregivers (family, relatives, volunteers).

Long-term care aims to cover the needs of people who have become dependent due to illness, injury, or age [1,2].

The demand for long-term care in the health care system depends on several factors that affect the number of people requiring long-term medical and care support. Determinants of the demand for care include an aging population, a continued increase in the number of people with chronic diseases such as diabetes, heart disease or dementia and those disabled by injuries or illnesses such as neurological diseases, changes in the family model and social changes (globalization, labor mobility, etc.), the availability and financing of care, state health policies and regulations, the development of medical technologies and their contribution to patient care - telemedicine, intelligent monitoring systems reducing the need for traditional inpatient care.

Long-term care is closely intertwined with other health and social services, creating by design a comprehensive support system for dependents.

In reality, in Poland, we observe that the availability of such services is limited by the legislator (rigid eligibility criteria for patients contained in legal acts, based mainly on medical aspects of dependency) and faces several constraints related to the organization and financing of the health care system as a whole.

Difficulties in accessing long-term care in Poland are mainly due to a shortage of places in facilities, limited funding, a shortage of medical staff, and a lack of effective coordination between different forms of care in the health care system [1,3].

This organization of long-term care services contrasts with WHO recommendations, which are based on integrating health and medical services and an individualized, holistic approach to the patient, which contributes to reducing institutionalization [1].

Currently, more than 20,000 people in Poland are waiting for placement in treatment care facilities (TCF), nursing care facilities (NCF), and long-term home nursing care (LHNC), with waiting times as long as 6 months [4].

Accessibility to long-term care refers to the ability of dependents to receive nursing, rehabilitation, and care services due to chronic diseases, disabilities, or old age. Determinants of accessibility to long-term care are influenced by eligibility criteria (health status and level of independence), material situation (income criterion important in the area of social assistance), care capacity of the family, social support system, infrastructure, quality of care, and patient care model [5].

The availability of long-term care is assessed based on the number of facilities, waiting times for services, and patient eligibility criteria [1].

The legislature has made it mandatory to maintain “waiting lists” for various health care services, including in treatment care facilities (TCF), nursing care facilities (NCF), and home care, to monitor their availability.

Providers place patients on a “waiting queue” based on medical criteria, based on current medical knowledge, i.e., the health of the recipient; prognosis for the further progression of the disease; comorbidities affecting the disease for which the benefit is to be provided; risk of onset, perpetuation, or worsening of the disability.

Patients are categorized as:

The health care system also distinguishes groups of patients eligible for out-of-order services, such as people in emergencies, war invalids, veterans, and honorary blood donors [6,7].

In 2019, 42.6 thousand patients received inpatient long-term care (111 people/100 thousand residents), while 68.5 thousand patients received home care (178.60/100 thousand). In addition, there were 31,149 inpatient care beds available in 2019. In 2019, the largest number of home long-term care centers resided in the Masovia and Silesia provinces, and the smallest in the Pomerania and Podlaskie provinces [8,9]. The number of patients waiting for a placement was, and still is, significant, indicating shortages in the availability of long-term care for Polish residents [9].

A key aspect of caring for bedridden, dependent patients is providing adequate accessibility and quality of care so that the patients, despite their limited independence, can function in a way conducive to sustaining and strengthening their current state of health. Adding new long-term care beds, developing home care, educating medical staff, and supporting informal caregivers contribute to citizens’ health security [10,11].

The study aimed to analyze the availability of long-term care for patients in Poland based on the number of people waiting in line for a place in long-term residential care, using data from the first half of 2023 as an example.

Material and methods

The principles defining the manner of reporting waiting times to care facilities are regulated by such legislation, in particular: the Regulation of the Minister of Health of June 26, 2019 on the scope of necessary information processed by health care providers, the detailed manner of recording this information and its transfer to entities obliged to finance services from public funds [12], the Regulation of the Minister of Health of September 26, 2005, on the medical criteria to be followed by health care providers when placing recipients on waiting lists for health care services [7], and the provisions of the Act of August 27, 2004 on health care services financed from public funds [6].

The research material consisted of data from the Department of Health Care Services of the Ministry of Health, showing the number of waiting patients for admission to inpatient long-term care facilities during the first half of 2023. Population data for each province was obtained from the publicly available report “Area and Population by Territory in 2022” from the website of the Central Statistical Office [13]. The research material was statistically processed. The number of waiting cases per 100,000 population of each province was calculated to standardize the results presented and to be able to compare them across different regions of the country. The analysis did not include places in the queue at TCF and NCF for children (the number of children in the queue in each province was zero or a maximum of 1-2 children).

Results

The waiting queue length for a place in long-term care facilities - Nursing Care Facilities or Units (NCFs) and Nursing and Treatment Care Facilities or Units (TCFs) - was analyzed. As of the date the report was received/generated (07.07.2023), the total number of patients waiting for admission to long-term care in Poland (a country with a population of 37,907,704 in 2022) was 14,514, of which 3,322 people were waiting for a placement in NCF and 11,192 in TCF. Among the analyzed cases of patients waiting in the queue, the majority were stable cases (12,505, of which 2,725 were waiting for NCF and 9,780 for TCF), while urgent cases were 2,009 (of which 597 were waiting for NCF and 1,412 for TCF). After counting, the queue for a place in NCF and TCF (summed up) nationwide averaged 5.30 people per 100,000 residents in urgent cases, and 32.99 people per 100,000 residents among stable cases [Table 1].

The results presented were based mainly on standardized indicators per 100,000 inhabitants, as the individual provinces vary considerably in population (from 985,487 - Lubusz to 5,512,794 - Masovia), making a transparent comparison much more difficult.

Discussion

Long-term care includes personalized medical and non-medical services for people who cannot cope with everyday life independently, regardless of age [14,15,16]. Due to demographic changes in the world and in Poland, the country’s population has been declining recently, but its age structure is changing. The proportion of the elderly population, the main but not the only recipient of long-term care, is increasing. This trend will continue in the coming decades and affect the demand for long-term care. It is estimated that by 2050, the number of people in the population aged 80 and older will increase from 1.7 to 3.5 million, and 65-79-year-olds from 5.5 to 7.6 million, with a reduction in the number of people of working age [17,18]. This creates a problem where, without effective action, long-term care will become less and less efficient, and waiting times will get longer. The number of TCFs and general-purpose NCFs providing long-term care increased from 2012 to 2017 (the number of TCFs from 311 to 359, the number of NCFs from 153 to 155 nationwide), which went hand in hand with a higher number of available beds and provided services.

The President of the National Health Service in the pre-pandemic period indicated the need to develop nursing and care services in long-term home care, with inpatient long-term care also being prioritized from 2020. This was intended to influence the development of this form of care. However, it has been observed that increased expenditures have not significantly increased the number of services [17].

Waiting time for a stay in a PAC or TCF does not directly translate into waiting time for a place in these facilities (when considering inpatient care). This is influenced by several factors, including the procedures for admitting residents to the Facility / Unit, patients already in these facilities - their health status, the different number of deaths at various times, and the organization of care. Once the documents have been submitted and the patient has been qualified for admission to NCF/TCF (the time for decisions is 14 days), they are placed in the waiting queue for a place. In addition to the waiting list for inpatient long-term care facilities, patients who are entitled to services out of order, such as veterans or war invalids, are admitted [6,7]. It is not uncommon for the waiting time for a place in the facilities to be many months.

The data obtained for analysis shows that the number of people waiting for a place in stationary long-term care is at its least favorable in the provinces of Lesser Poland, Opole, and Lower Silesia. Among patients urgently waiting for a placement in the NCF /TCF, the longest waiting queue was in the Opole province and the Subcarpathia and Silesia provinces. Among patients in stable conditions waiting for a placement in NCF /TCF, the highest number of those waiting was in Lesser Poland, Lower Silesia, Opole, and Silesia. The smallest waiting numbers, which probably resulted in shorter waiting times, were observed in the Greater Poland, Podlaskie, and Warmia-Masuria provinces. The smallest number of patients urgently waiting for a placement in NCF/TCF was observed in the Greater Poland and Warmia-Masuria provinces, while the smallest number of patients waiting in stable condition for a place in NCF/TCF occurred in the Greater Poland and Podlaskie provinces. Shorter queues in access to long-term care in less urbanized provinces with an agricultural profile, including Podlaskie and Warm-ia-Masuria provinces, may be due, among other things, to cultural norms and the structure of families living there, multigenerational families who have greater care capacity, and are thus more likely to be able to care for a disabled person.

Long-term care is an integral part of the health care system to provide continuity of treatment, nursing, care, rehabilitation, and support for the chronically ill, dependent, and disabled. It is not only a medical benefit, but also a reflection of the organizational and financial efficiency of the entire health system. The state of long-term care can be considered as an indicator of the functionality of the health care system, illustrating the level of health security and the adequacy of interventions at various stages of treatment and rehabilitation.

The development of long-term care depends on several factors, including the availability of professional staff, the organization of services, funding models, and cross-sector coordination. Deficiencies in these areas burden the health care system, resulting in longer waiting queues for services and increased indirect costs associated with hospitalized patients requiring long-term support. Therefore, optimizing this sector not only improves the quality of life for patients but also reduces the burden on the health system through efficient resource allocation.

Ongoing studies on the quality of long-term care indicate that patients positively evaluate the long-term care services offered and their impact on their quality of life, even with the necessary institutionalization [10,20,21].

The demand for long-term care was and is still high, particularly in rural areas and smaller towns, where the population is aging more rapidly.

In their study, Dziechciaż M. and co-workers observed that the majority of elderly residents in rural areas showed an inability to perform basic activities of daily living, and the need for long-term care was more common in more than one in three people surveyed [22]. It is worth noting that prolonged waiting times for professional help in inpatient or home long-term care threaten the patient’s health and life and affect the family’s care capacity.

Based on the data from the National Plan for Reconstruction and Increasing Resilience developed by the Ministry of Health in 2022, it was presented that in 2019, the demand for inpatient long-term or geriatric care amounted to 47,900 places, compared to 31,000 current beds in 2019 [9]. The data indicates the need to transform facilities and create additional spaces for long-term care patients. The largest nominal number of beds to be converted comes from internal medicine, general surgery, and obstetrics-gynecology departments. The most significant transformation potential of the base number occurred in Kuyavia-Pomerania, Lower Silesia, West Pomerania, and Lubusz. The lowest transformation opportunities exist in the provinces of Lesser Poland and Świętokrzyskie. It turns out that the most significant difficulties in converting existing wards and creating new patient places are observed in areas where the current queue of patients is the largest, including the Lesser Poland province. The most significant potential for adding new beds is in the Lower Silesia province, where the current patient queue is also one of the longest in the country [9].

Policymakers face many challenges regarding organizational changes, financing, and access to long-term care. As demographic and epidemiological forecasts confirm, the demand for this form of care will grow.

Conclusions

Recommendations for nursing practice

Post-graduate training of nurses in long-term care nursing is needed to provide qualified medical staff, resulting in a high level of care. Numerous challenges also await those organizing long-term care to make it more accessible.