The JDC-Brookdale Institute had conducted two censuses of long-term care institution residents in the past: in 1983 and 1990. These censuses were conducted with the full cooperation of the institutions, and consequently were an effective and useful tool for policymakers. The census data served three principal purposes:

1. They revealed the unique characteristics of the institutional population.
2. They examined changes in the characteristics of the institutional population over time.
3. They created a basis for forecasting institutional care needs, by providing an accurate, current picture of the patterns of institutionalization of various population groups.

• According to data from the Ministry of Social Affairs and the Ministry of Health, at the beginning of 2000, the period during which the census was conducted, close to 370 long-term care institutions were in operation. These included old age homes, hospitals for the chronically ill, and nursing care wards in general hospitals, kibbutzim and sheltered housing frameworks.
• The number of beds licensed for long-term care in these institutions was 27,130, 12,460 (46%) of which were under the supervision of the Ministry of Social Affairs (6,010 for semi-independent elderly and 6,440 for frail elderly), and 14,680 (54%) of which were under the supervision of the Ministry of Health (12,190 for nursing elderly and 2,480 for mentally frail elderly). At the beginning of 2000, the long-term care bed rate was 45 beds per thousand persons age 65 and over in the population: 21 for semi-independent and frail elderly, and 24 for nursing and mentally frail elderly.
• The occupancy rate, which expresses the number of residents relative to the number of beds, was 94%. This rate was identical to those found in the 1990 and 1983 censuses. The occupancy rate by type of ward reflects the percentage of beds occupied by residents whose functional status was appropriate to the types of bed in the ward. The occupancy rate in semi-independent and frail wards was 93%, and that in nursing and mentally frail wards was 96%.
• The institutionalization rate reflects the percentage of elderly in the population who reside in institutions – that is, the tendency of the elderly population to use institutional services. According to the census, the institutionalization rate of people age 65 and over was 4.1% at the beginning of 2000. The institutionalization rate by functional status was 0.9% semi-independent, 1.8% frail, 1.8% nursing and 0.4% mentally frail elderly. By comparison, the institutionalization made in 1983 was 3.6%, and the distribution by functional status was: 1.5% semi-independents, 0.8% frail, 1.1% nursing and 0.2% mentally frail elderly.
• The institutionalization rate of elderly women was nearly double that of elderly men: 5.1% versus 2.7%, respectively. The institutionalization rate increases sharply with age: Consequently, the institutionalization rate of people age 75 and over is ten times greater than that of people ages 65-74: 8.3% versus 0.8%, respectively. This rate reaches 19.7% among those age 85 and over.
• There is no uniformity in the institutionalization rates of principal population groups. The institutionalization rate of elderly non-immigrant Jews (exclusive of immigrants from the former Soviet Union who arrived in or after 1990) was 4.9%. The institutionalization rate of immigrants from the former Soviet Union was 2.1%, while that of Arab elderly was 0.7%. Among non-immigrant Jews, the institutionalization rate of those born in Europe-America was double that of those born in Asia-Africa: 6.3% versus 3.2%, respectively. The institutionalization rate of elderly born in Israel was particularly low: 2.4%.
• Elderly who are unmarried tend to use institutional services six times as much as do married elderly: Their institutionalization rates were 7.8% and 1.3%, respectively. Elderly who live alone have a four times greater chance of entering an institution than do elderly who do not live alone (institutionalization rates of 8.2% and 2.2%, respectively).
• The population of institution residents (age 65 and over) differs from the total elderly population: 72% of institution residents are women, compared to 57% of the total elderly population. Institution residents are older than the total elderly population: The median ages of these populations are 84 and 73, respectively.
• The breakdown of population groups among residents of institutions differs from that in the total elderly population: 89% of institution residents are long-time residents of Israel (hereafter, non-immigrants), 10% of them are immigrants from the former Soviet Union, and 1% of them are Arabs. The parallel breakdown among the total elderly population is 75%, 19%, and 5%, respectively. The percentage of married elderly among institution residents is one-third that of married elderly in the total elderly population: 18% versus 57%, respectively. More than half (56%) of the institution residents lived alone before entering an institution, compared to one-quarter of the total elderly population.
• There is usually a correlation between functional status and type of ward in which the resident has been placed. The census data indicate that 94% of the residents who were in wards for the mildly disabled were indeed defined as being mildly disabled (that is, as being semi-independent or frail). Similarly, 95% of residents of wards for the severely disabled were defined as being severely disabled (that is, as being nursing or mentally frail). A certain lack of correlation was found in wards for the frail (9% of whose residents were defined as being nursing or mentally frail), and in nursing care wards (4% of whose residents were defined as being frail).
• The use of institutional services changes with the increase in age: The percentage of residents of wards for the severely disabled (nursing and mentally frail) declines with age, while the percentage of residents of wards for the mildly disabled (semi-independent and frail) increases with age – although in the main, the majority of residents of all ages, reside in wards for the severely disabled. In other words, the younger elderly tend (more than the older elderly) to use institutional services that are medical in nature, due to functional impairment, while the older elderly tend (more than the younger elderly) to use institutional services that are "residential" in nature, given their need for social-environmental support. As a result, residents of wards for the mildly disabled are older than the residents of wards for the severly disabled (89% and 82% of those age 75 and over, respectively).
• Arabs and immigrants from the former Soviet Union (who arrived in Israel in or after 1990) have a greater tendency to use institutional services when an elderly person's functional impairment is severe than do non-immigrant Jews. Conversely, non-immigrant Jews have a relatively greater tendency than do Arabs or immigrants from the former Soviet Union to use wards for the semi-independent. Of the non-immigrants, a larger percentage of those born in Asia-Africa than of those born in Israel or Europe-America resided in nursing wards. Conversely, larger percentages of those born in Europe-America or Israel than those born in Asia-Africa resided in wards for the semi-independent.
• Regarding mobility, the census data reveal that about half (48%) of all institution residents can walk by themselves (with or without an assistive device such as a cane or walker), while half (52%) need the assistance of another person. As expected, significant differences were found in the mobility of residents of different types of ward. The majority (86%) of residents of wards for the mildly disabled (semi-independent and frail) can walk by themselves, although close to one-third (31%) of them need an assistive device. Ninety-one percent of the residents of nursing wards need the assistance of another person to walk, and the majority of them need complete assistance or are wheelchair-bound. More than half (55%) of the residents of wards for the mentally frail can walk by themselves.
• The census reveals that 39% of the institution residents have no impairment of cognitive functioning. Eighteen percent of the residents have mild disorientation. Forty-three percent of them suffer from more seriously impaired cognitive functioning: 20% have notable disorientation, and 23% have dementia with impaired speech and impaired daily functioning. Notable differences in cognitive functioning were found among the residents of the different types of ward: 70% of the residents of wards for the nursing and mentally frail, as opposed to 10% of the residents of wards for the semi-independent and frail, were diagnosed by staff as having particularly impaired cognitive functioning (e.g., notable disorientation, dementia).
• More than two-thirds of the institution residents entered the institution directly from their home. The remainder entered the institution from a hospital or some other housing framework. There appears to be a correlation between type of ward and the place from which the resident entered the institution: 86% of residents of wards for the mildly disabled entered the institution from their homes, compared to 55% of the residents of wards for the severely disabled.
• Sixty-one percent of the residents of wards for the severely disabled who did not enter the institution from their homes, entered the institution from a general hospital (40%) or from a geriatric-rehabilitation hospital (21%). Thirty-four percent of the residents of wards for the mildly disabled who did not enter the institution from their homes, entered the institution from a general hospital (24%) or a geriatric-rehabilitation hospital (10%). The remainder entered the institution from another long-term care institution, sheltered housing, or a psychiatric hospital.
• The census also provides data on the residents' living arrangement prior to entering an institution. An average of 56% of the institution residents lived alone prior to entering an institution, though the percentage changes with level of disability: Close to two-thirds (64%) of the residents of wards for the mildly disabled lived alone prior to entering an institution, compared to 47% of the residents of wards for the severely disabled.
• The census data reveal that 42% of the residents, together with their families, bear the full cost of residence in the institution. The more disabled the resident, the higher the cost of his institutionalization. Consequently, the percentage of residents and their families who are able to cover the cost of institutionalization decreases as the severity of disability increases: 87% of the residents in wards for the semi-independent, 39% of those in wards for the frail, and 23% of those in wards for the nursing and mentally frail bear the full cost of institutionalization. The Ministry of Social Welfare participates in paying the cost of institutionalization of 31% of the residents of wards for the mildly disabled (10% of residents in semi-independent wards and 53% of residents of wards for the frail). The Ministry of Health participates in paying the cost of institutionalization of two-thirds of the residents of wards for the severely disabled.
• The average length of stay, measured from entry into the institution until the time of the census, was 43 months. Residents of wards for the semi-independent and frail remained in an institution for an average of one year more than did residents of nursing and mentally frail wards: 50 versus 38 months, respectively.
• The supply of beds differed in different areas of the country. The bed rate for the semi-independent and frail was relatively large in the Sharon, Acco, and Hadera Sub-district and the Jerusalem District, and relatively small in the Southern District (especially the Ashkelon Sub-district) and in the Ramla, Jezreel, Safed and Kinneret Sub-districts. The bed rate for the nursing and mentally frail was relatively large in the Petah Tikva, Safed, Kinneret, Hadera and Sharon Sub-districts, and relatively small in the Southern District (especially the Ashkelon Sub-district), the Acco Sub-district, and the Tel Aviv District.
• Close to half (47%)of the residents entered an institution in their locality; 24% entered an institution in another locality in their sub-district; and 30% entered an institution in a locality outside their sub-district. On average, the distance between the resident's previous locality of residence and the locality in which the institution was located was 22 kilometers (by air). The data indicate that when the institution was in a sub-district other than that in which the resident had previously lived, the average distance was four times greater than when the institution was in the same sub-district in which the resident had previously lived: 33 versus eight kilometers, respectively.
• At the beginning of 2000, there were 25 licensed complex nursing care wards in Israel, containing 1,000 beds. The occupancy rate in these wards was 115%; in other words, the number of patients defined as needing complex nursing care was 15% greater than the number of beds intended for them. The demographic profile of patients in complex nursing care wards differs from that of patients in regular nursing care wards. Patients in complex nursing care wards are younger, more of them are men, more of them were born in Israel or Asia-Africa, a relatively large percentage of them are married, and their average length of stay (from admission to the institution until the time of the census) in the ward is relatively brief: one year.
• At the beginning of 2000, there were 11 licensed geriatric-rehabilitation wards in Israel, containing 965 beds. These wards are not part of the long-term institution system; however, the census was constructed such that it would be possible to address them, as well. The occupancy rate in geriatric-rehabilitation wards was 83%. In other words, the number of patients defined as needing geriatric rehabilitation was 17% less than the number of beds approved for such care.

Trends in the Institutionalization of the Elderly, 1983-2000

• Between 1983 and 2000, the number of institution residents doubled, from 12,700 to 25,800. Examination of changes in disability level reveals that the population of institution residents with severe disability (nursing or mentally frail) increased at double the pace of residents with mild disability (semi-independent or frail) (2.9 times versus 1.5 times, respectively). In other words, there was a correlation between an institutional population's level of functioning and its growth. Thus, while the number of semi-independent institution residents remained fairly stable, the number of frail residents increased 2.3 times, the number of nursing care residents increased 2.8 times, and the number or mentally frail residents increased 3.8 times.
• These differential rates of growth led to a change in the composition of the institutionalized population, as reflected in the functional status of the institution residents.  The percentage of semi-independent residents declined by about half, from 41% in 1983 to 22% in 2000.  Concurrently, the percentage of residents who were not semi-independent increased: The percentage of nursing care residents increased from 33% to 45%, and the percentage of mentally frail residents doubled – from 5% to 10%.  The percentage of frail residents barely changed, from 20% to 23%.
• These changes are clearly reflected in the trends in the institutional system during this period. Over time, the emphasis of the institutional system shifted to the treatment of more severely disabled elderly. Concurrently, a variety of alternative services were developed in the community for less severely disabled elderly, including sheltered housing, supportive communities, and day care centers.
• Between 1983 and 2000, the number of Jewish institution residents doubled (from 12,100 in 1983 to 24,700 in 2000). During that period, the elderly Jewish population grew by 70% (from 338,000 in 1983 to 573,000 in 2000). Consequently, the institutionalization rate of the elderly Jewish population increased by 20% – from 3.6% in 1983 to 4.3% in 2000. In other words, during this period, the number of residents of long-term care institutions increased 20% more than did the Jewish population. The institutionalization rate of non-immigrants (that is, not including immigrants from the former Soviet Union who arrived in or after 1990) increased even more – by 35% – reaching 4.9% in 2000. It should be noted that the majority of changes transpired between 1983 and 1990.  Although we do not have data for comparison to 1983 on the Arab population, it should be noted that the institutionalization rate of that population did not change during the 1990s.
• Examination of changes in institutionalization rates by age reveals that the tendency of the younger elderly (ages 65-74) to use institutional services decreased by 18% – from 1.1% in 1983 to 0.9% in 2000. In contrast, the tendency of the older elderly (age 75 and over) to use institutional services increased from 8.3% in 1983 to 8.7% in 2000. The rate of increase was particularly sharp among those who were not immigrants (that is, who did not immigrate from the former Soviet Union in or after 1990): Their institutionalization rate had reached 9.6% by 2000. The rate of increase was 5% among all older elderly and 16% among non-immigrants. Consequently, the institutional population aged: The proportion of those age 75 and over among all institution residents increased from 81% in 1983 to 89% in 2000, and the proportion of those age 80 and over increased from 58% to 73%.
• The institutionalization rate of elderly women was double that of elderly men in both 1983 and 2000. However, the institutionalization rate of women increased at a lower rate (by 14% between 1983 and 2000) than did that of men (by 23%). (The rate of increase was 31% among non-immigrant women and 37% among non-immigrant men.)
• Examination of changes in the institutionalization rate by marital status reveals that the institutionalization rate of unmarried elderly was six to seven times that of married elderly, at both points in time. Over time, this gap lessened somewhat, as the institutionalization rate of married elderly increased by 37% – from 1.0% in 1983 to 1.4% in 2000 – while the institutionalization rate among the unmarried elderly increased by only 6% – from 7.4% in 1983 to 7.9% in 2000. It may be assumed that this gap lessened in part because the number of nursing and mentally frail residents – a relatively large percentage of whom are married – increased more rapidly than did the number of semi-independent and frail residents.
• Examination of changes in the institutionalization rate by country of birth reveals that the use of institutional services increased in particular among non-immigrants who were born in Europe-America, by 63% – from 3.9% in 1983 to 6.3% in 2000. The institutionalization rate of elderly people born in Asia-Africa increased by 24% – from 2.6% in 1983 to 3.3% in 2000. Interestingly, the institutionalization rate of elderly people born in Israel decreased by half during the period in question – from 4.6% in 1983 to 2.4% in 2000.

Many factors affect changes in institutionalization patterns: the increase in disability rates among the elderly (due mainly to changes in the elderly population’s composition, such as the aging of that population); the supply of beds; public financing arrangements for bed occupancy; and the development of community services such as those provided under the Community Long-term Care Insurance Law and day care centers.

It may be assumed that the rapid development of community services during the period covered were in part responsible for the lack of change, beyond what was found by the census, in institutionalization rates. Both demographic changes and the policies that will be instituted regarding the development of community and institutional services will have implications for patterns of institutionalization in the future.

This census is one link in a chain of systematic collection of data on the system of services for the elderly, in general, and on institutional services, in particular. It has provided data on the elderly's patterns of use of long-term care institution services. Following conclusion of the census, the relevant data were disseminated to agencies in the social and health systems, and the principal findings were presented to various public committees and used in planning. Given the sizable interest in the topic, a decision was made to publish a summary version of the findings.

In brief

Research Report (Hebrew)

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