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Austria’s Long-Term Care System: Challenges and Policy Responses


Birgit Trukeschitz ,

Vienna University of Economics and Business (WU), AT
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August Österle,

Vienna University of Economics and Business (WU), AT
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Ulrike Schneider

Vienna University of Economics and Business (WU), AT
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Approaches to design comprehensive support systems for people in need of long-term care (LTC) have appeared on the policy agenda of European countries from the 1990ies. Austria was one of the first to implement such a system separate from health care. In this last significant expansion of its social protection system, the country established a universal and tax-funded LTC system, departing from Austria’s Bismarckian tradition while carrying along the familialist logic and federalist structure in this policy field. Thirty years later, Austria now joins other countries in creating solutions to important contemporary challenges by discussing another major revamp of its LTC system. This paper renders a country case study to explain the development of Austrian LTC policies in greater depth and from a dynamic perspective. The two-step approach, starts with presenting the logics and major building blocks of Austria’s LTC system, and provides an update on its benefits and services. The second part identifies and discusses a raft of current and planned measures for three areas that appear critical in terms of future proofing LTC: (i) responses to staffing challenges, (ii) policy pilots to support informal carers, and finally, (iii) the role of digital transformation for LTC in Austria. This showcase exercise fosters policy learning and thus supports innovation and refinement of LTC systems. It could also serve as a futile starting point for comparative LTC policy research that moves beyond the outer hull of care-regime typologies to explore more specific system features and policy interventions.

How to Cite: Trukeschitz, B., Österle, A. and Schneider, U., 2022. Austria’s Long-Term Care System: Challenges and Policy Responses. Journal of Long-Term Care, (2022), pp.88–101. DOI:
  Published on 24 Mar 2022
 Accepted on 04 Feb 2022            Submitted on 31 Jul 2021

1 Introduction

From the 1990s, member countries of the Organisation for Economic Co-operation and Development (OECD) have intensified efforts to address the social risk of long-term care (LTC) (Colombo, Llena-Nozal, Mercier & Tjadens, 2011; Spasova et al., 2018). Demographic, economic, political and social changes, however, are affecting these LTC systems, even more so in the aftermath of the 2008 financial crisis and the ongoing COVID-19 pandemic (European Commission 2021a). The resulting changes in preferences, coverage gaps, inequities, ineffectiveness and inefficiencies call for policy responses to ensure reliable and sustainable support for some of the most vulnerable groups in society. While attempts to cluster LTC systems (Ariaans, Linden & Wendt, 2021; Fischer, Doetter & Rothgang, 2022; Kraus et al., 2010; Nies, Leichsenring & Mak, 2013) can help identify groups of countries with similar LTC (policy) characteristics, these typologies cannot provide details on the inner structure and workings of a country’s policy approach. Hence, there is value in tracking such changes for single countries to learn how LTC systems address contemporary challenges. Not least, the experiences and implications of the COVID-19 pandemic will further intensify a growing interest in understanding and learning from LTC system characteristics, practices and reform efforts in other countries. Austria can contribute to these endeavours as a country that strongly builds its LTC system on a cash-for-care scheme, and it represents a country with 30 years of relative continuity in the LTC system design. A major exception is the growing role of live-in migrant care work, as the development of this important source of LTC provision was politically unintended and was later incorporated into the system.

This case study aims to provide a detailed account of Austria’s LTC system, its development over time and selected cross-cutting fields of action. It employs a two-step approach to report on Austria’s LTC policy. First, we will focus on the history and logic of Austria’s LTC policy that led to today’s system of benefits and services for care-dependent people and their informal carers. Based on this, we will describe the cornerstones of Austria’s LTC policy and provide an update on benefits and services. Second, with a view to the most recent major LTC reform process (Taskforce Pflege) (Rappold et al., 2021), we will reflect on both the current state and a raft of planned measures for three main Austrian LTC policy areas—responses to staffing challenges, policy pilots to formalise informal care and, finally, the role of digital transformation for LTC. Taken together, this paper provides comprehensive insights into the Austrian LTC policy and the routes taken to tackle contemporary challenges.

2 Historical Roots and Logics of Austria’s Public Long-term Care System

As in many other European countries, up until the 1990s, Austrian public (co-)funded LTC provisions were primarily social assistance-based, dispersed among different policy areas and with different sorts and levels of support for different groups in need of LTC. LTC was strongly perceived as a family responsibility. The Scandinavian countries and the Netherlands were the first European countries with national reforms addressing LTC more comprehensively. From the 1990s, several other European countries started to move beyond the traditional scattered system of benefits and support to introduce new, more comprehensive LTC systems.

Austria was one of the first European countries to implement such comprehensive LTC reform in the 1990s, which established LTC as a distinct social policy field. A political debate—strongly driven by representatives of disability groups—lasted many years and resulted in the formation of the cornerstones of the Austrian public LTC system in 1993 (Österle, 2013). Different from the 1995 reform in Germany, Austria abandoned its tradition of social insurance orientation and established a tax-funded system. In terms of provisions, the Austrian reform built on two main cornerstones. First, a system of universal LTC allowances paid to those in need of care was established. From an international comparative perspective, this system of LTC allowances is generous regarding benefits and personal coverage (Ranci, Österle, Arlotti & Parma, 2019). Second, the reform also created an agreement between the national and provincial (Laender) levels to extend existing structures of residential and home care services. Political parties and other stakeholders reached broad consensus over the 1993 LTC reform, but they did so for different underlying rationales that still prevail today: recognition of and support for family care; freedom for users and their families to choose care arrangements; and support for market-driven developments in the LTC system (Österle, 2013).

In 2022, the Austrian LTC system is still heavily reliant on family care, cash for care and services. Despite their importance for the LTC system, reforms over the past 30 years did not deviate from this reliance (Österle & Heitzmann, 2020). One major example of reform is the so-called 24-hour care (migrant care work in private households), which was regularised in 2006–2007. Around national elections, the political pressure became very strong, and the respective change occurred abruptly. Similarly, prior to a national election in 2017, recourse to assets of users (Pflegeregress) when moving to a care home was abolished. Over time, the cash-for-care system has also seen several adjustments to its eligibility criteria, benefit levels and organisation. The LTC allowance system has become the sole responsibility of the central state since 2012, which reduced both legal and administrative complexities (Trukeschitz & Riedler, 2019; Trukeschitz, Schneider, & Czypionka, 2013). In addition, a series of measures addressed family carers. In what follows, the next section provides more detail on the current state of the Austrian long-term care system before discussing major ways forward in section 4.

3 Long-term Care Benefits and Services in Austria

3.1 Key Figures on the Austrian Long-term Care System

Public support for LTC in Austria encompasses the LTC allowance scheme (Bundespflegegeld), home care (mobile Pflege), residential care (stationäre Pflege), 24-hour care (24h-Betreuung) and family care. Before detailing the development, aims and characteristics of the respective programs in the next sections, this overview briefly describes their respective dimensions (see also Table 1).

Table 1

Long-term care in Austria: Benefits, users, care workers and public expenditure (2019(1)).


Recipients of care allowance by benefit level(2):
Level 1 (EUR 165.40): 131,637
Level 2 (EUR 305.00): 99,614
Level 3 (EUR 475.20): 85,269
Level 4 (EUR 712.70): 68,747
Level 5 (EUR 968.10): 52,672
Level 6 (EUR 1,351.80): 20,342
Level 7 (EUR 1,776.50): 9,471
Recipients in total: 467,752
Public expenditure: EUR 2,645 million
Residential care
Users (3): 70,312
Care workers (FTE)(4): 35,972
Public net expenditure (5):
EUR 1,933 million
Informal carers(8)
home care setting: 801,000
residential care setting: 146,000

Home care
Users (end of 2019)(3): 98,589
Care workers (FTE)(4): 12,654
Public net expenditure(5): EUR 459 million
Carer support measures
Pension and sickness insurance
Respite care (support payments)
Hospice leave (hardship comp.)
Care leave allowances
Information and counselling
Public expenditure(9): EUR 110 million

Other services(6)
Public net expenditure(5): EUR 91 million

24-hour care
Users: 30,000
Care workers: 60,123
Public expenditure(7): EUR 158 million

Public expenditure for LTC (2019)
EUR 5,396 million


(1) 2019 for expenditure data, end of 2019 for the other figures.

(2) The benefit is for 2022 (monthly payments), the number of recipients for the end of 2019 (to allow for comparison with service users).

(3) Users for whom services are publicly (co-)funded.

(4) FTE: full-time equivalents.

(5) Public gross expenditure minus user contributions from cash-for-care benefits and minus income-related co-payments.

(6) Including day care, assisted living arrangements, short-term relieve services, case and care management.

(7) Public expenditure for the means-tested 24-hour care benefit (see below), which was paid to a monthly average of 24,837 beneficiaries in 2019.

(8) This estimate refers to primary family caregivers as well as people who supported others in this role.

(9) Does not include spending for (small-scale) programs offered at the level of the Laender.

Sources: BMSGPK (2020); Statistik Austria (2021b); Statistik Austria (2021c); BMF (2020); WKO (2021).

A total of 467,752 individuals (5.3% of the Austrian population) qualified for the LTC allowance by the end of 2019 (Statistik Austria, 2021c). About half were enrolled in the two lowest levels of the benefit system (see Table 1). The LTC allowance recipients in residential care accounted for 15% of all recipients, or about 70,000 people, and 20%, or about 99,000 people, used home care. About 36,000 care professionals (full-time equivalents) work in residential care and almost 13,000 (full-time equivalent) in home care (Statistik Austria, 2021b). In the latter sector in particular, part-time work is widespread. In addition to residential and home care, about 30,000 people in need of care used 24-hour care. Approximately 60,000 self-employed 24-hour care workers live and work in private households in two or more weekly shifts to provide care for this group (WKO, 2021).

More than half of LTC allowance beneficiaries are exclusively cared for by family members or other informal networks. An estimated 10% of the Austrian population (roughly 950,000 people) takes on informal care responsibilities for persons receiving LTC allowance, i.e. for persons with a need of at least 65 hours of care per month (Nagl-Cupal et al., 2018).

Applying a very broad definition for dependency, the European Commission (2021b) estimated coverage rates for LTC services and cash benefits for the dependent population aged 65 or older in 28 European countries. For Austria, coverage with cash benefits was estimated at 60% in 2019, which substantially exceeded the EU average (33%). Accordingly, Austria ranked 4th in coverage with cash benefits (after Poland, Finland and Sweden). Austria’s coverage rates for home care (12%) and institutional care (9%) were substantially below the EU average (26% and 15%, respectively). Austria ranked 22nd in each LTC setting (home care and institutional care), close to Germany and Poland. These estimates, however, neither account for the amount (or quality) of services received nor do they reveal any within-country variation. In addition, these LTC service coverage rates are much lower than LTC service coverage rates published in Austrian reports (Rechnungshof Österreich, 2020), as these national reports define the dependent population much more narrowly (LTC allowance beneficiaries, i.e., persons of all ages needing at least 65 monthly care hours) and provide only combined coverage rates for both LTC service settings.

Austria’s public LTC expenditure is in line with the EU average, below the level of the Nordic countries, but above the respective levels of Southern and Eastern Europe (OECD, 2020a; Eurostat, 2021). In 2019, the total public expenditure for LTC allowances was EUR 2,645 million (0.7% of GDP). Residential care, day care, home care and other LTC-related services require users to co-pay from their pension or other income and from the LTC allowance (see the section on LTC services). Public net expenditure for these services is another EUR 2,483 million (0.6% of GDP; Pratscher, 2021).

3.2 LTC Allowance

The LTC allowance, implemented in 1993 as a tax-funded cash benefit, aims to enable care-dependent people to organise their care themselves by increasing their purchasing power. It was designed as a lump-sum contribution to partly cover the costs of care. Today, two (parafiscal) social insurance bodies manage the LTC allowance: the Austrian Pension Insurance Agency and—in case of an occupational disease or accident—the Austrian Workers’ Compensation Board.

In 2019, 467,752 people (i.e., 5.3% of the Austrian population) received an LTC allowance (Statistics Austria, 2021a). It is a nationwide monthly cash benefit for people in persistent need (more than six months) of a substantial level (more than…) of care, personal support and/or nursing. Access to and levels of the LTC allowance are granted on a care-needs basis only (i.e., do not depend on other personal characteristics, such as age, income, wealth, region, cause of care dependency or the availability of informal care (‘carer-blindness’)). The LTC allowance is paid to people living in Austria. Under certain conditions, it can be transferred to eligible recipients in countries of the European Economic Area (EEA) or Switzerland. People meeting the eligibility criteria have a legal entitlement to the benefit and are able to appeal any negative decision.

As Table 2 shows, the LTC allowance features seven benefit levels reflecting differing degrees of care need. Up to level 5, the benefit level is only determined by the care hours needed to cope with the limitations. From level 5 on, distinctive care characteristics are also taken into account. A needs assessment, conducted by a physician (first assessments) or a registered nurse (reassessments), considers the time needed for (instrumental) activities of daily living. An additional lump sum of 25 hours is added for people with severe mental health conditions, dementia in particular. People with specific needs, however, are automatically assigned to a certain minimum level, for example, wheelchair users to level 3 to 5 (according to diagnoses and limitations), severe visually impaired (level 3), blind (level 4) and deaf and blind people (level 5). The LTC allowance is paid directly to the care-dependent person living in place, if not hospitalised. Where the cash benefit’s purpose cannot be achieved, the LTC allowance is replaced by an in-kind benefit or service of equal value. For people living in care homes, up to 80% of the LTC allowance is transferred to the care home provider.

Table 2

LTC allowance levels (2022).


Level 1 More than 65 hours EUR 165.40

Level 2 More than 95 hours EUR 305.00

Level 3 More than 120 hours EUR 475.20

Level 4 More than 160 hours EUR 712.70

Level 5 More than 180 hours and extraordinary care efforts required EUR 968.10

Level 6 More than 180 hours and care cannot be coordinated in terms of time or permanent presence of a carer required EUR 1,351.80

Level 7 More than 180 hours and unable to move EUR 1,776.50

Source: (no date). Translation by the authors.

In 2005, the Home Visit and Counselling Programme (HVCP) was established to monitor the quality of care in private households receiving LTC allowance (Trukeschitz, 2010). A registered nurse arranges an appointment (on a voluntary basis) to provide LTC allowance recipients and their informal carers on site free advice and support tailored to their specific needs. In 2018, obligatory home visits were introduced for households claiming support for 24-hour care. In 2019, a pilot tested unannounced visits in two provinces (Vienna and Tyrol). More than 20,000 LTC allowance recipients received a visit as part of the HVCP in 2019. On top of the HVCP, informal carers of LTC allowance recipients have been able to request a series of up to three talks with a psychologist or social worker (Angehörigengespräche) since 2016. These talks aim to maintain or improve informal carers’ health and quality of life by providing advice and information. (BMSGPK, 2020)

3.3 LTC Services

The Austrian Constitution assigns competences for LTC services to both the central state and the Laender. The central state is responsible for framework legislation of social welfare and nursing homes. Each of the nine Laender has the right to issue their own laws to implement LTC services and is obliged to support LTC service provision financially. As a result, regulation, funding, supply, service names, prices and use of LTC services vary substantially across the nine Laender (for details, see Trukeschitz & Schneider, 2012). Article 15a of the constitution allows governmental levels to negotiate agreements to specify competences. For LTC services, such an agreement was reached in 1993. It requires each of the Laender to provide for specific types of LTC services and to maintain a minimum quality of LTC services according to its regional requirements and development plans (Bedarfs-und Entwicklungsplan). In addition to the Laender, but without legal competences, important players are also districts (Bezirkshauptmannschaften), communities (Gemeinden) and other public bodies, such as communities joining for providing care and support (Sozialhilfeverbände). (Trukeschitz et al., 2013). In Austria, public and private (for- and non-profit) agencies provide LTC services, with public and non-profit organizations serving as the main providers of care homes and non-profit organizations serving as the predominant institutional form for home care service provision.

LTC services for people in need of care include home care (including care, support with (instrumental) activities of daily living, long-term nursing care (Hauskrankenpflege) and end-of-life care), residential care and day care as the most important services. In addition, short-term care in care homes, case and care management, alternative housing and relief services are available to promote and maintain a self-determined lifestyle (BMSGPK, 2020). Short-term nursing home care (medizinische Hauskrankenpflege), however, differs from other LTC services, as costs are fully covered by social health insurance for a limited number of days (Trukeschitz et al., 2013).

In line with Austria’s federalist system, the Laender are responsible for ensuring LTC service quality, guided by a rough set of national minimum standards issued in 1993. LTC quality regulations on the national and Laender level mainly address structural aspects (e.g., workforce and infrastructure characteristics) and some process-related aspects (e.g., requirements to record care activities) but hardly any outcome-focused aspects. Recently, the Austrian Court of Audit (Rechnungshof Österreich, 2020) recommended developing nationwide definitions and objectives of LTC process quality and outcomes, including related indicators.

Two nationwide initiatives aim to support providing good quality of LTC. On the one hand, the National Quality Certificate for Care Homes (NQZ), awarded in 2009 for the first time, also facilitates self-regulation of service provision in care homes (Trukeschitz, 2010). Care homes may receive a subsidy to prepare and implement the NQZ. In 2017, the Laender were obliged to assure that 50% of care homes use a quality management system by 2021. On the other hand, the national Home Visit and Counselling Programme (HVCP), piloted in 2009, offered on-site counselling and improved the database on living conditions and LTC quality in care-dependent community-dwelling people. Since 2012, the HVCP also collects data on care outcomes using an adapted version of the Adult Social Care Outcomes Toolkit (ASCOT) (BMSGPK, 2021).

In 2019, the gross expenditure for LTC services (excluding nursing home care) was EUR 4.2 billion. Of the expenditures, 36% resulted from out-of-pocket payments of LTC service users, the Laender and municipalities covered 59% and 5% was paid by other public means, such as the health fund of a province or a VAT refund. Gross expenditures increased by over 25% from 2014 to 2019, with Laender and communities increasing their contributions by 88% (Statistik Austria, 2020, own calculations).

In response to growing concerns with increasing costs for LTC service provision, the LTC fund (Pflegefonds (PFG), the ‘Care Fund Act’) was implemented in 2011. Two ministries (Social Affairs and Finance) administer the LTC fund. By granting earmarked financial transfers via the LTC fund, the central state supports the Laender and communities to improve and expand their LTC services, and it seeks to better align the supply of LTC services across Austria by providing targets of service coverage. In 2021, the Laender should aim to provide LTC services (including 24-hour care) to 60% of all LTC allowance recipients (Richtversorgungsgrad). At the same time, the Care Fund currently restricts the Laender’s annual increase of LTC service-related gross expenditures to a maximum of 4.6%.

The Austrian Court of Audits (Rechnungshof Österreich, 2020) recently reported the LTC service coverage rates for LTC allowance beneficiaries for 2016. Across all LTC services, regional coverage rates ranged from 63% (Burgenland) to 86% (Vorarlberg) and thus met the target of 60% (Richtversorgungsgrad). However, the Austrian Court of Audits also criticized such data as not suitable for monitoring, as they do not account for different types of LTC services. According to their own calculations, in 2016, some 16% received institutional care for an entire year; 6.3% received 24-hour care at home (see next section). Due to lack of data, no coverage rates could be calculated for other community-based LTC services, such as home care.

In 2011, the LTC fund provided up to EUR 100 million; the financial means available increased every year with the exception of 2016 and 2017. In 2021, EUR 417 million are available. The LTC fund deducts parts of the tax revenues charged by the central state (Vorwegabzüge) before they are shared with other levels of government (gemeinschaftlichen Bundesabgaben). From 2017 to 2021, additional funding of up to EUR 18 million was provided to expand end-of-life care. For this LTC service, equal parts of funding come from the central state, the Laender and the social insurance agency.

3.4 24-hour Care

From the late 1990s, private households in Austria started to employ migrant care workers from neighbouring Central and Eastern European countries for the provision of LTC. Two care workers stayed as live-ins in the private household of the users and replaced each other in two or more weekly shifts. This mode of caregiving was soon more widely used, leading to a growing market for migrant care work in the early 2000s. However, the market initially developed outside labour and social security regulations, becoming an openly accepted grey economy of care. It became a major political issue before the 2006 national elections, when these arrangements were found to be illegal. Soon, there was broad political consent on the urgent need to regularise the arrangements without endangering the availability of this source of caregiving. After the election, respective legal changes were implemented.

A central part of the 2007 reform was a new national law regarding personal care work in private households (Hausbetreuungsgesetz), which established the possibility for migrant care work in private households to be categorized as self-employment (alongside the possibility to establish an employer-employee relationship, an option not taken up in reality). Self-employment allows flexibility in work schedules; furthermore, it allows for a continuation of two to more weekly shifts. Therefore, it is not bound to specific regulations typical for employer-employee relationships (e.g., minimum wage or sick leave regulations). To cover at least a portion of additional costs arising with the regularisation, a new financial support scheme for 24-hour care was introduced. The means-tested benefit (which depends on income rather than assets) reaches a maximum of EUR 550 per month in the case of two self-employed care workers on rotational shifts.

By the end of 2019, around 60,000 self-employed care workers from Central and Eastern European countries were active in Austrian households. The majority originate from Romania and Slovakia. An estimated 30,000 households use this care arrangement, in which two care workers per household usually alternate two or more weekly shifts. In the political discourse, the relevance of 24-hour care to recipients of the LTC allowance is often assessed as small scale. However, in contrast, the number of 60,000 migrant care workers is greater than the total number of care workers (in full-time equivalents) in the residential and the home care sector combined (Österle, 2018).

The Austrian approach to regularisation of migrant care work in private households is successful in terms of take-up but has weaknesses in certain areas. Despite 24-hour care becoming an additional pillar of the Austrian LTC system, it remains a mode of care provision that is very weakly integrated into the overall system. The Austrian case further shows that legality does not systematically ensure quality of care work and of care work arrangements (Aulenbacher, Schwiter & Lutz, 2021; Österle & Bauer, 2016; Schmidt et al., 2016). Migrant care work in private households remains a highly precarious arrangement, with vulnerabilities on the side of the user and of the care workers. In practice, the quality of the arrangements and of care work is co-determined by the role of intermediaries (Leiber, Rossow, Österle, & Frerk, 2021), but registration and a voluntary quality certificate for intermediaries remain the only systematic measures of quality assurance in this market. The implications of the COVID-19 pandemic have further aggravated these vulnerabilities (see section 4; Leiblfinger et al., 2020; Leichsenring, Schmidt & Staflinger, 2021).

3.5 Policies in Support of Informal Care

Family caregivers form an explicit target group in Austrian LTC policy (Bundeskanzleramt, 2020), both as co-producers of care and as co-clients who share knock-on effects of care dependency. The LTC allowance and improved access to care services first address care recipients but also benefit their families (Pallinger & Pfeiffer, 2013, p. 284). In addition, family carers can obtain support in their own right, given their care-related risks in terms of physical and psychological health, forgone labor market and career opportunities and medium- and long-term financial well-being (Schneider, Sundström, Johannson, & Tortosa, 2016).

Austria’s carer support policy has evolved at a very slow pace and in a piecemeal fashion. The 1993 reform legislation initially focused on family carers’ access to social insurance. It took policymakers until 1997 to address pension insurance coverage (subsequently expanded in 2005, 2007, 2009 and 2015). This was followed by legal underpinnings for family hospice leave (2002), respite care (2004), improved sickness insurance coverage (2009), care leave and part-time work options (2014), psychosocial support and counselling (2015) and legislation to strengthen consideration of family caregiving in inheritance matters (2015). In expenditure terms, social insurance coverage is the single most important measure, with EUR 86 million spent in 2019 (80% of monetary support for family carers).

Four points stand out in the development of carer support policies in Austria. First, eligibility rules for most benefits are tight, targeting high-intensity family carers. Access to the vast majority of measures is limited to family carers of LTC allowance beneficiaries in need of at least 120 hours of care per month. For some benefits, additional eligibility rules apply (e.g., qualifying periods, social hardship). As a result, family carers of some 50% or less of all LTC allowance recipients are eligible for support from the central government. The actual count of beneficiaries is lower by far, suggesting moderate take-up.

Second, supporting parents who care for disabled or severely ill children and—more recently—dementia caregivers seems to assume high priority. Carers for severely ill children were first to benefit from provisions related to social insurance. Support for this group of carers tends to be more generous and taps into a ring-fenced funding source for family support.

Third, until recently, policies (pre)supposed that care is the predominant activity for a key family carer. With the introduction of care leave legislation in 2014 and changes in eligibility rules for social insurance benefits in 2015, a new policy approach to combining work and caregiving has emerged, allowing families to share caregiving responsibilities.

Fourth and last, while family care amounts to about 70% of all care provided (Famira-Mühlberger & Firgo, 2019, p. 151), it still appears to be taken for granted. There is no systematic and regular statistical tracking of this group. In 2019, total public spending on LTC reached EUR 5.2 billion, of which 110 million—about 2.1%—went into supporting family carers in their own right (see Table 1).

4 Long-term Care in Austria: Recent Policy Responses and the Way Forward

After outlining the current system of LTC in Austria, in this section, we discuss ways forward to strengthen LTC policies and practices for people in need of LTC, their families, care workers and care organisations. The topics chosen for this section represent LTC policy areas that are core for creating a sustainable LTC system and approaches repeatedly addressed in policy documents, in stakeholder opinions and in broader public discourses nationally and internationally. Not least, in early 2020, the Austrian government announced a major LTC reform process and started a strategy process involving LTC stakeholders (Task Force Pflege, ‘Task Force Long-term Care’). The resulting report was published in spring 2021 (Rappold et al., 2021). This policy reform process started just before the outbreak of COVID-19. The pandemic has since had huge implications for the policy process, but above all for those in need of LTC (Rocard, Sillitti & Llena-Nozal, 2021), for informal carers (e.g., Eurocarers/IRCCS-INRCA, 2021), for migrant care workers (e.g., Leiblfinger et al., 2020), for staff in nursing homes and mobile services (Schmidt et al., 2020) and the steering and coordination of LTC systems (e.g., Leichsenring, Schmidt & Staflinger, 2021). Building on this context, our discussion focuses on three main fields of action: policy approaches to combat staff shortages, empower informal care and strengthen the role of digital transformation for LTC in Austria.

4.1 Addressing Staff Shortages in LTC

Across the OECD world, the care workforce is a main concern for LTC policies (e.g., OECD, 2020b; Eurofound, 2020; or a special issue in the Gerontologist, see Meeks & Degenholz, 2021). Debates involve current and future staff shortages but also fighting undeclared work or precarious working conditions. Underlying concerns about impediments to attracting workers into LTC jobs and retaining workers in these jobs include issues of pay, workload and conditions of work, skills gaps and a lack of resources and support. Austria is no exception. Staff shortages are identified in several Austrian studies (Famira-Mühlberger & Firgo, 2019; Rappold & Juraszovich, 2019), and workforce issues are repeatedly emphasised in the public discourse that further intensified during the COVID-19 pandemic. The LTC Taskforce agenda (Rappold et al., 2021) identified three aims to address professional care work shortcomings, including making professional care work more attractive, motivating and training young individuals for careers in care work and improving conditions for care work.

In practice, Austria has started to establish a variety of new opportunities to (re-)enter care work. In 2016, a new two-year program for care assistants was established. From 2020, upper secondary schooling (for three or five years) with a major in social care became available in several pilot programs. The Austrian labour market service offers several financial support schemes for (re)qualification in health and long-term care, in regular educational programs and in programs addressing unemployed persons (Auer et al., 2021). Another proposal (Pflegelehre, apprenticeship in care work and nursing) follows successful vocational training programs in other areas linking schooling and working in the job. In general, these training programs are designed to begin at the age of 15, which is a major critique among several stakeholders, including representatives of care workers. Finally, a recent pilot allowing family carers to be employed formalizes family care while also promoting a pathway into paid care work (see next section).

Another bundle of policy proposals addresses working conditions and pay. These include debates about a general work-time reduction to 35 hours per week as well as an announcement in one Austrian province (Tyrol) to harmonise wages of professional care workers in nursing homes to those in the hospital sector. While there are many calls to make LTC more attractive and to improve the image of care work, there are also measures that might constrain these endeavours and lead to supporting ‘cheaper’ care work options. Whenever there is a discussion about how to fight long-term unemployment, care work is presented as a job opportunity, which for many is just another sign of the devaluation of care work in society. Similarly, financial support for migrant care work in private households is support for care work that is regularised in the Austrian context (different from many other European countries). But a lack of qualification requirements and minimal measures of quality assurance in this sector undermine the demands for further professionalization and decent work in the care sector. (Aulenbacher et al., 2021; Österle, 2018) While there is broad consensus about workforce issues, policies and practices are hugely challenged by cost containment efforts in LTC.

4.2 From Empowering to Formalizing Informal Care

As discussed above, the scope of support for informal care in Austria has increased considerably over the past decades in terms of social rights, time rights and access to cash support. Le Bihan, Da Roit and Sopadzhiyan (2019) pointed to three factors explaining the expansion of carer support policies in seven European countries, including Austria. First, interest in family care increased due to efforts to contain public spending on LTC. Second, to increase female labour market participation, there was a political push towards better reconciliation of work-and-family responsibilities. Third, caregivers’ organizations (established in 2009 in Austria) contributed to advancing support policies and empowering informal carers. The one element still not featured in federal support for informal carers in Austria is a carer allowance (i.e., a monthly compensation for informal care that contributes to formalizing informal care).

A recent policy innovation on the Laender level is addressing this very gap. Since October 2019, one of the Laender (Burgenland) has spearheaded the development of a model which permits family carers to be hired (Land Burgenland & FH Burgenland, 2019). Burgenland’s pilot program avoids a direct employment relationship between the person in need of care and a family carer. It employs family carers through the publicly owned non-commercial company Pflegeservice Burgenland GmbH (PSB). The pilot will be assessed in 2022, after two years in operation. Oberösterreich will follow suit in summer 2021 (Gerstorfer, 2021), Vorarlberg (AK Vorarlberg 2021) as well as Kärnten and Vienna (Scherndl, 2020) explore a similar move. Because of this bottom-up rollout, Austria could formalise a noticeable number of (predominantly high-intensity) family care arrangements.

Burgenland’s employment scheme (Anstellungsmodell) is directed at working-age family carers who provide care to an LTC allowance beneficiary with an assessed care need of level 3 or higher. As displayed in Table 3, the scheme offers fully socially insured part-time employment to family carers of LTC allowance recipients in level 3 or 4 and full-time employment for recipients with higher care needs (levels 5 to 7). Accordingly, monthly net income ranges between EUR 1,022 and EUR 1,700. The employment offer to family carers is conditional on their taking 100 hours of free basic training within the first year of the contract. The province offers financial support to train as a home help (Heimhilfe), a qualification requiring 200 hours of theoretical instructions and 200 hours of mandatory practical training. (Land Burgenland & FH Burgenland, 2019; Pflege Service Burgenland GmbH, 2020).

Table 3

Burgenland’s employment models for family carers.


1 Level 3 90% of care allowance + income exceeding social assistance ref. rate1) 20 hours/week EUR 1022.21 1 per month

2 Level 4 80% of care allowance + income exceeding social assistance ref. rate1) 30 hours/week EUR 1,442.29 2 per month

3 Levels 5 to 7 Level 5: 80% of care allowance + income incl. exceeding social assistance ref. rate 40 hours/week EUR 1,750.49 Level 5: 2 per month
Levels 6 and 7: 60% of care allowance + income exceeding social assistance ref. rate Levels 6 and 7: 1 per week

Notes: (1) Social assistance reference rate for single persons (EUR 949 in 2022).

Source: Pflege Service Burgenland GmbH (2022), translation by the authors.

The cost of the informal carer’s employment is shared between the care recipient and the Land. Care recipients in need of level 3 contribute 90% of their LTC allowance; those in level 4 or higher contribute 80%. In addition, care recipients’ income will be claimed up to Burgenland’s social assistance reference rate for single persons (EUR 949 per month in 2021). However, households opting into the scheme can use neither home care services nor 24-hour care (to avoid double subsidy). The projected annual public cost after the end of the build-up phase is estimated at EUR 13 million for 600 employment contracts (Land Burgenland & FH Burgenland, 2019)—more than 10% of the amount currently spent on carer support at the federal level (see Table 1).

In a summary assessment, Burgenland’s pilot could avoid social risks known from other models of employing family carers–different kinds of income risk, loss of social security entitlements and being financially dependent on other family members (Frericks, Jensen & Pfau-Effinger, 2014)—and may safeguard care quality. The net income in the full-time-employment variant corresponds to the collectively agreed upon entry-level salary for home helpers and exceeds the median net income of employees in the health and social services sector. The according contributions to social security reduce potential long-term losses in pension entitlements. The option to train as home help addresses the income insecurity associated with the random end of their family caregiving spell. Finally, care quality protection is stronger than in non-formalized, family-only, care arrangements, as support visits and basic training are mandatory.

The LTC-Taskforce has identified and sketched out a raft of further potential improvements to supporting family carers in Austria (Rappold et al., 2021). Most suggestions concern better access to existing support and relief services, particularly in terms of availability, affordability and (spatial) accessibility. This includes establishing regional contact points for family carers (to better deliver information and counselling or outreach services). The Taskforce report gives specific attention to working family carers and young carers. It proposes making care leave accessible for non-cohabiting family carers, suggests care leave periods of up to one year with improved dismissal protection and recommends accounting for caregiving spells in the pension system. Support for caring children and adolescents should be (i) identified earlier on, (ii) rights-based, (iii) embedded in daily life and (iv) explicitly considered in the training of pedagogical and social professions.

4.3 Digital Transformation of LTC in Austria

In many industries, digital transformation is changing production, distribution processes, business models and competition (OECD, 2018) at an increasing pace. In particular, for personal service industries with a high level of co-production, such as long-term care (LTC), digital technology could affect service provision profoundly (Lember, Brandsen & Tõnurist, 2019). Assistive technologies, tele-health and tele-care tailored to needs and processes are expected to facilitate scaling-up support, attract young people into care work, improve workflows and ensure quality of care (OECD, 2020b). However, digital transformation also comes with challenges for LTC. Sensor technologies that automatically transfer data to medical or care experts as well as robots and chat-bots may reduce the interaction between staff and patients (Lember, Brandsen & Tõnurist, 2019); data protection issues arise for one of the most vulnerable groups of society, prompting debates on trade-offs between safety and privacy.

While other Austrian industries increasingly benefit from digital technologies, LTC seems to lag behind (Peneder, Firgo & Streicher, 2019), particularly home care. Although most Austrian home care organisations use specialised software for customer management, accounting and tour planning (e.g., MOCCA ONE, CareCentre), care records software has been less frequently implemented, and care networks still lack digital tools commonly used in other service industries (e.g., digital communication platforms). The development and testing of Active and Assisted Living (AAL) technologies is co-funded by national and European programs to increase the availability of new technologies for older people and care ecosystems and to enhance digital literacy and support self-determined living in place. The first Austrian pilot regions (Ates et al., 2017) and European projects (with Austrian participation) tested bundles of technologies to increase comfort and security for older people with no or low care needs and to introduce them to tele-care and tele-monitoring systems and social inclusion applications. More recently, Austrian projects also focus on care-dependent people in general or with specific needs, their carers or care ecosystems (e.g., AMIGO, Care about Care, CARUcares, CiM, LICA-App). Others seek to improve data flows within care networks and between LTC and health care by both linking different LTC data sources and combining them with ELGA, the Austrian electronic health record (e.g., Linked Care project).

The Austrian LTC-Taskforce Report (Rappold et al., 2021) explicitly addresses the role of new technologies for the upcoming LTC reform. It presents digitalisation as an opportunity for LTC, which should be expanded on via two approaches: by promoting and financially supporting assistive technologies as a means for the secure and self-determined life of care-dependent people and by expanding applied research and testing of digital and assistive technologies, with room for discussion of critical aspects, such as data protection, personal rights and ethics. In addition, new technologies are also perceived as a resource to support a further three core aims of the reform: (i) providing reliable care and increasing safety, (ii) improving care quality and (iii) promoting social coherence and reducing loneliness.

The current COVID-19 pandemic has not only revealed the limits of today’s care arrangements but also shown new ways and potential benefits of implementing new technologies into care settings. ICT offers approaches to improve information exchange, coordination and care management while also raising challenges in how to deal with big data, personal data and rights. Taken together, Austria as well as European societies have to re-think the role of digital tools for LTC, which will change LTC as we know it today.

5 Discussion

In Europe, the 1990s mark a turning point for organising public support and benefits for people in need of LTC and informal carers. Although different in their characteristics, these LTC systems face similar challenges resulting from population aging, economic pressures, societal changes and, recently, global health crises. This paper set out to provide details on the Austrian LTC policy approach, including its historical roots and the current policy instruments in response to the risk of dependence on personal help and support. In the second part of this paper, we discussed three areas of LTC—staff shortage, informal care and digitalisation—provided an overview of the current developments and an outlook to options for policy responses as part of the LTC reform process.

Austria’s LTC policy design differs from other policies addressing social risks in Austria. Social protection against the risks of sickness, unemployment and retirement is organised as social insurance and mainly funded by the contributions of employees and employers. In contrast, LTC benefits and services are tax-funded. Legal and administrative competencies for the LTC cash benefits (LTC allowance and 24-hour care support) are with the central state and competencies for LTC services with the nine Laender, with no or little national coordination. This resulted in a high degree of regional variation in eligibility criteria, quality criteria, co-payment levels, wages and working conditions, which challenge providers, people in need of LTC and their families. People in need of both health care and LTC experience service gaps, unnecessary readmissions to hospitals, administrative burdens and reduced quality of life (Ilinca, Leichsenring & Rodrigues, 2018) caused by the logics and workflows of the two systems. So far, initiatives to improve policy coordination in general have not shown enough effect, as reported by the Austrian Court of Audit (Rechnungshof Österreich, 2020). Thus, the report on the planned LTC reform (Taskforce Pflege) (Rappold et al., 2021) also calls for a better policy collaboration and coordination. It specifies the need for common strategies for governance of LTC service provision; suggests better planning of needs and benefits, including minimum standards and data management; and identifies the need for a common framework (e.g., guidelines). This implies that sustainable changes in governance structures require the reallocation of legal and administrative competencies and their alignment with financial flows.

In Austria, monitoring, evaluating and (re-)designing LTC policy is substantially limited by insufficient availability, accessibility and quality of LTC data. Data on total LTC spending, covering both public and private spending, is lacking, as is a systematic account of the origin and use of public funds. Data reported for the country’s Care Services Statistics (Pflegedienstleistungsstatistik) are incomplete and insufficient to assess the extent to which needs are being met. Thus, there is a clear need to improve the LTC data infrastructure to better inform the design of LTC benefits and their financing, which also includes better data access for researchers and the general public. The Ministry of Social Affairs pledged to coordinate efforts towards a revision of the Care Services Statistics but relies on the nine Laender to provide accurate and complete data. Further progress can be expected from passing the planned Freedom of Information Act (Informationsfreiheitsgesetz IFG) and following the implementation of a new Austrian Micro Data Centre of Statistics Austria in summer 2022. For both planned improvements, the required investment in data infrastructure is not just a matter of affordability but presupposes a more profound change in the mindset of the administration towards evidence-based policymaking.

The broad stakeholder involvement to set up a comprehensive LTC reform has identified further aims and measures in a number of areas of LTC (Rappold et al., 2021), which are now waiting to be decided on and implemented. While policymakers have found it difficult to allocate enough funds to initiate comprehensive LTC reforms over the last decades, the COVID-19 pandemic has shown how quickly public funds can be shifted to reduce societal pressures in many areas of life. At the same time, the COVID-19–related additional budgetary burdens for public budgets will also place the Austrian LTC policy at a crossroads. Policymakers could opt to either profoundly overhaul the LTC system or continue in a piecemeal path. The former would require substantial investment in care infrastructure (e.g., staff, new service models, support for informal carers and digitalisation), and the latter would impel low-wage care provision, which would potentially cause increasing gaps in service provision. With the aging of the baby boomers, policy decisions are needed to invest in Austria’s LTC system and enable sustainable support for all groups of the current and future LTC ecosystems.

Competing Interests

The authors have no competing interests to declare.


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