The chapter examines how countries are promoting a continuum of long-term care options between home and institutional care. There is a strong focus on understanding how day care for older people contributes to healthy ageing and what the landscape of adult day care is in terms of access, services, and funding. The chapter looks at the different communal solutions that are available to ensure people‑centred care and services as people age. It describes the advantages of co-housing and intergenerational solutions, and challenges to promoting such living arrangements. The chapter finally discusses assisted living, which is a residential option for people who start needing care services, to understand how countries fund it and ensure quality standards.
The Economic Benefit of Promoting Healthy Ageing and Community Care
Abstract
Adult day care appears to have many benefits for older people and to be cost-effective but is often underused. In many countries, options for community care are limited: the number of day-care users is below 1% of the population aged 65 or above. The use of adult day care is limited by a shortage of supply and transportation options, lack of awareness, and high costs, with 17 countries highlighting that out-of-pocket payments were required. Maintenance of personal hygiene, provision of meals and group activities are often the mandatory services provided. More than 40% of countries have no specific requirements or only require registration to operate. Quality monitoring relies mostly on quality standards while only nine countries have quality indicators and only seven countries have external audits
Innovative shared living arrangements have benefits for older people but remain limited. Collaborative housing, such as co-housing or co‑operatives, was reported in about one‑third of OECD countries, similarly to intergenerational housing models. Both have been found to have potential in reducing loneliness and social isolation. Developing such options is sometimes constrained by legal challenges as well as conflict and privacy concerns. Retirement villages have grown in the United States, Australia and some European countries but are mostly privately financed from membership fees.
Assisted living facilities are common across OECD countries (24 out of 26 countries), with varying degrees of funding and quality regulations. While often private, half of OECD countries reported that public funding at the national or local level is used to finance assisted living facilities. Quality monitoring is less developed with requirements on what and how to monitor being less strict than for nursing homes. For instance, auditing is available in only six countries, and quality indicators are used in three countries.
Policy options
Improve access to adult day care, the health services offered and quality regulation. Adult day care services appear to have substantial benefits with reduced social isolation, improvement in health outcomes such as physical health and functional status and a reduction in emergency attendance and hospital admissions and can also delay nursing home admission. To better reap the benefits of adult day care, incentivising access and improving the offer of health services is paramount. Improving referral and addressing transportation challenges are important points to address barriers: The Netherlands has introduced a specific transport budget for day care for that purpose. In Japan, health screening is a mandatory service in adult day care.
Promote innovative housing models for older people. France is considering options for co‑operative housing and intergenerational housing whereby people could benefit from the allowance for LTC and there is also a special allowance for inclusive housing, the so-called “allowance for shared living” (aide à la vie partagée). Tax credits, such as in Canada (Québec), providing a legal status to such housing options to benefit from subsidies, as in France, as well as offering co‑operative or intergenerational housing through rental options appear to have an impact on the development of innovative housing models.
Ensure that funding options and sufficient quality monitoring are available for housing options with care services. Regulations on staffing competences might be needed to ensure the needs of a more dependent population, as well as recording adverse events. In New Zealand, audits are conducted regularly, similarly to the Netherlands, where public reporting of results is available. In the United States, Green House care facilities include Medicaid and Medicare residents and offer small home‑like environment with higher quality of care, resulting in lower hospitalisation rates. Considering how to provide public funding for emerging living arrangements and assisted living facilities could be beneficial in reducing overall health expenditures.
Day care for older people provides a series of activities and services in a supervised community setting which can consist in a variety of medical, functional and social types of support. It differs from clubs or centres which are more focussed on recreational and leisure activities but largely lack support measures in terms of care. It is also different from outpatient health services which are more focussed on rehabilitation and other forms of health treatment and less on functional and social support, and where staff is more likely to consist of health workers. As such, day-care centres across OECD countries target individuals who need some form of care because of their health and dependency status. Depending on the country, they focus on older adults (e.g. 65+) or are open to a wider range of age groups. Adult day-care attendance is associated with several positive outcomes for both family carers and their care recipients. Although it is often difficult to quantify and price these positive outcomes, most research indicates that public investments in day care are generally cost-effective, as it can prevent and reduce other health system burdens (Caiels et al., 2010[1]; Knapp, Iemmi and Romeo, 2013[2]).
Most evidence on the benefits of adult day care is focussed on its impact in providing respite to family carers. A review of studies highlights that by providing respite to family carers, day care reduces caregiver burden, at least when the day care programme includes a caregiver-support dimension (Vandepitte et al., 2016[3]). When the care recipient attends day care, the family caregiver’s mental well-being improves and anxiety diminishes, their caregiving competencies develop, and the relationship between the family carer and the relative receiving care improves (Lunt, Dorwick and Lloyd-Williams, 2018[4]; Tretteteig, Vatne and Rokstad, 2017[5]; Klein et al., 2016[6]). For people with dementia, day-care attendance contributes to limiting family caregiver stress and increasing the motivation to continue living together and providing care at home, thus delaying admission to a nursing home (Maffioletti et al., 2019[7]).
In addition, adult day care can serve a social purpose and improve the quality of life and well-being of people receiving care, especially for those living alone or more isolated. By engaging people in social and recreational activities as well as exercise, adult day care can reduce the risk of social isolation and contribute to mental well-being (Iecovich and Biderman, 2012[8]; Orellana and Samsi, 2024[9]). Older people often experience network shrinkage as peers their age begin dying or becoming increasingly disabled, and many day care attendants report new friendships with people their age as a main benefit (Hagan and Manktelow, 2021[10]). Activities organised at adult day-care centres can also contribute to improved social outcomes and give older people a sense of purpose and belonging. This not only improves quality of life but also has important public health benefits: A randomised controlled trial on psychosocial group rehabilitation services in day care centres found significantly reduced mortality among participants as well as improved subjective health and less need of health services, with almost EUR 1 000 lower healthcare costs per person in the year after the programme (Pitkala et al., 2009[11]). A Finnish randomised controlled trial also found benefits of socially stimulating group interventions in day care centres on the cognition and mental function of lonely older people (Pitkala et al., 2011[12]).
Social functioning and well-being are improved by attendance at adult day care centres. Based on 24 papers, a scoping review focussing on people with dementia finds that adult day care improves various aspects of social functioning, including connecting with others, increased interaction and participation (Tuohy et al., 2023[13]; Rokstad et al., 2019[14]; Österholm et al., 2023[15]). Particularly activities based on bodily senses, such as music, art, multisensory, robotics and animal therapy, would facilitate the ability of people with dementia to connect to others. According to a review, more than 80% of studies show positive effects on quality of life and well-being for adult day care users (Benedetti, Sancho and Hernández, 2024[16]). Some of the strongest evidence on the benefits of day care emerged when centres were closed due to COVID‑19, with several studies finding decreased independence, worsened physical and mental health outcomes and dementia symptoms where applicable, and increased caregiver stress due to day care facility closures during lockdown (Borges-Machado et al., 2020[17]; Wong et al., 2022[18]; Teramura et al., 2021[19]).
Adult day care also generates beneficial health outcomes, fosters autonomy, and facilitates older people staying in their own environment. Day care can have a medical focus, providing physiotherapy and other healthcare, and the provision of meals can ensure sufficient nutritional intake for those who might find it challenging to cook or eat their meals in isolation. This can result in improved physical health and functional status (Benedetti, Sancho and Hernández, 2024[16]; Orellana, Manthorpe and Tinker, 2020[20]). For older people with long-term conditions, research indicates improved psychological, physical, and general health and better functioning and quality of life among day care attendants, though the strength of the evidence is mixed (Lunt, Dowrick and Lloyd-Williams, 2021[21]). Marquet et al. (2020[22]) find that day care attendance increases physical activity for relatively younger and older female participants, but not for other groups. Some countries or facilities offer targeted interventions to tackle specific health outcomes, often with meaningful results. For example, a fall-prevention programme held twice a month over three years in a Japanese day care centre significantly improved mobility and reduced falls among participants, compared to the control group (Yamada and Demura, 2014[23]). Day-care attendance is also associated with a reduction in emergency attendance, hospital admissions and days in hospital (Kelly, 2015[24]), as well as reductions in pain and fatigue and improvements in gait speed (Lunt, Dorwick and Lloyd-Williams, 2018[4]). There is some more limited evidence from randomised studies of day care being associated with improved psychological health, lower depression and better cognition (Ellen et al., 2017[25]; Femia et al., 2007[26]). Honjo, Ide and Takechi (2020[27]) conclude that day care use significantly improves cognitive function of Alzheimer’s patients, and person-centred care strategies used in day care can also help manage other behavioural and psychological symptoms of persons with Alzheimer’s and Alzheimer’s Disease Related Dementias (Boafo et al., 2023[28]).
The potential for adult day care to promote healthy ageing appears to be wide but it is unclear whether it is currently fulfilling its potential. Previous research has highlighted heterogeneity in the organisation of adult day care across countries, with a different target groups and different types of providers, coming from public, private for profit and not for profit and operating in different types of building, either independent or attached to a nursing home. At the same time, information remains limited in terms of services offered, funding and regulation, especially with services being provided at the local level in many countries. This section attempts to fill this gap by surveying these topics based on a questionnaire and providing evidence from the literature.
6.1.1. A number of barriers limit adult day care use
In most OECD countries, adult day care services cover a minor percentage of people in need of care, generally well below the coverage of home and institutional care which amounts on average to 7.6%. Currently, less than 1% of older people aged 65 or above have access to and use day care services, compared to over 20% who have low (13%) and moderate (8.5%) needs (OECD, 2024[29]). The rates of unmet need for day care vary across the country. In Chile, it is estimated that adult day care covers only 3.5% of the target population (Pontifica Universidad Catolica Chile, 2022[30]). In Israel, adult day care was used by 2.2% of older people in 2012, compared with 16.5% who would be in need; however, this represents more than a doubling of attendants since 1994 (Iecovich and Carmel, 2011[31]; Resnizky et al., 2012[32]). Respite day care use among carers was also rare, with 89% of primary carers of people with dementia never using respite care (Du Preez et al., 2018[33]). The utilisation is particularly low in the early stages of dementia.
One reason for the limited coverage of adult day care is the low supply of services. People are often waitlisted due to a limited number of days or hours of entitlement, or there may be no facility in the area. According to responses to the OECD questionnaire, the total availability of places in adult day care remains limited in many countries. In France, adult day care falls short of meeting the high demand although several strategies have been implemented to promote their development, resulting in a 93%-increase in availability between 2008 and 2016. In Ireland, the amount of time a person can spend in adult day care may be reduced if local demand exceeds the number of available places, even after initially waiting up to five months for a place (Donnelly et al., 2016[34]). In a British survey of day care users, most respondents only attended adult day care once or twice a week but 26% said that they would like to go more frequently than they did (Caiels et al., 2010[1]). Some rehabilitation- and reablement-focussed day care programmes in Northern Ireland are time‑limited, usually running for a period of 6‑12 weeks, and have left some participants who wished to continue attending day care after the programme without sufficient long-term options and guidance (Hagan and Manktelow, 2021[10]).
Cumbersome application processes may constitute a second barrier to day-care use for older adults. Most countries require a needs assessment to be eligible for adult day care services, except for four countries that accept a referral from the general practitioner (or a public nurse). While the needs assessment should help ensure fairness and targeting based on a comprehensive measure of needs, such assessments can take a long time to perform, and their administrative procedure might deter some eligible users. In England, there are almost 250 000 people waiting for an assessment, of which 33% wait for longer than six months (Schlepper and Dodsworth, 2023[35]). In some countries, available places in day care remain unfilled: In Israel, daily occupancy rates were 73% while in France it varied between 47% and 50% (EHESSP, 2019[36]; Iecovich and Carmel, 2011[31]).
Third, a lack of awareness of available services is also limiting overall demand and use. In addition to families, general practitioners or specialists from whom a referral is needed to access adult day care might not always be aware of day care as an option. A study in Spain carried out by providers highlighted that 65% of people believe that the main reason older people did not use day care was because they did not know about the existence of such services and 14% did not receive any information from a health or social professional about them, while most of them received a recommendation either from social services or from relatives or friends (STIMA, 2023[37]). Information about providers is fragmented, and it is not always clear what services are available to potential users nearby. In Israel, about 60% of older people who did not attend day care indicated that they were unaware of its existence, and 78% said that they would not know how to go about joining a day care centre (Resnizky et al., 2012[32]). Negative perceptions about attending day care or its use for respite care are possible obstacles to increasing the use of available services. In addition, there is a certain stigma or poor image associated with it, especially if day care is offered within a nursing home. In France, 86% of day care is offered within a nursing home, and older people are concerned that this means the first step into institutionalisation (EHESSP, 2019[36]). In England, research indicates that while day care is not stigmatised, awareness about it is low (Orellana, 2018[38]).
Fourth, physical barriers might prevent access to adult day care. Travel time has been found to be a deterrent to attending an adult day care centre. Geospatial analysis from Ireland shows that this affects 18% of people with dementia who do not live within 15 km of their nearest day care centre. There is high variability in the availability of adult day care centres throughout the country and low population density areas tend to have less availability (Pierse et al., 2020[39]). Across several countries, there appear to be geographical disparities in the availability of day care, with rural and peripheral areas experiencing greater access challenges (Vitman-Schorr and Khalaila, 2022[40]). In the United States, another study using geospatial analysis found that many rural counties had a higher percentage of older adult populations but did not have adult day care services within one hour’s drive distance (Li et al., 2023[41]). In France, while transport solutions are offered in 90% of the cases, only 36% offer sufficient reimbursement of such transport costs (EHESSP, 2019[36]). The centre can arrange transportation in three ways: through its own vehicles, by contracting an external provider, or by compensating families for the cost of transporting their family members, but the state caps the publicly subsidised amount that centres receive for transportation services. In the Netherlands, partly to incentivise its use and address barriers, transport costs have been largely reimbursed since 2021, and many providers offer specialised and integrated transport services for patients (HollandZorg, 2025[42]). As adult day care attendants commonly have mobility impairments, using public transport to travel to the facility is often complicated and time‑consuming (Du Preez et al., 2018[33]).
Finally, the supply of services is not always aligned with people’s needs in terms of flexibility of hours. Hours might also not suit family members. For instance, in Israel, most adult day care centres operate 5 to 6 hours per day, 5 days a week. While all centres offer organised transportation services, these usually only run once a day in each direction, meaning that attendants have to be there on time. This inflexibility seriously inhibits participation, with around 40% of respondents in a survey of non-users stating that they would be interested in attending day care, but would like to go at a later hour or attend afternoon services instead (Resnizky et al., 2012[32]). A study from Montreal, Canada, showed that regular adult day care attendance is much more likely if users stay the full day rather than just half a day. This is probably because caregivers associate a burden with getting the recipient ready for day care and potentially transporting them there, which only pays off if they then stay for longer (Savard et al., 2009[43]). Other countries also highlight that adult day care remains closed on weekends and holidays, and opening hours exclude early mornings or late afternoons and open for a maximum of 8 hours per day, which can be challenging for informal/family carers who work (Tretteteig, Vatne and Rokstad, 2017[5]). In Greece, adult day care centres (KIFI) often operate from 08:00 to 15:00, excluding weekends when they are closed.
6.1.2. There is room for improvement in securing adequate financial and human resources for adult day care
Expenditures on adult day care constitute a small fraction of overall long-term care spending. Expenditures range between less than 1% to 5% of total long-term care spending in most countries. In Spain, Costa Rica, Japan and Brazil, day care is an important element as part of the overall LTC policy as it makes up more than 10% of all long-term care expenditures. In Japan, this could be explained by having a high number of recipients compared with other OECD countries while in Costa Rica, the relative importance of day care in total expenditures is driven by a strong focus on home and community care, which were, previously to the creation of a new care network, the only parts where public funding was available as residential care was primarily in the private sector (Medellín, 2020[44]). Since 2015, the share of day care in total long-term care spending has only increased significantly in Germany, Korea and Lithuania, with most countries showing a decline or stagnation (OECD, 2023[45]).
In many countries, day care is a very small component of total long-term care spending, with less than 1% of expenditures: this is the case in Romania, the United Kingdom, Australia, Croatia, Poland, Slovenia, Switzerland, Iceland, the Netherlands, Belgium and Austria. In a number of countries, low unit or hourly costs for day care partially explain low expenditures. For instance, in the Netherlands, hourly costs for day care are lower than for both home and institutional care. In England, some reports suggest that when there are reductions in local authority funding, day care can be particularly affected and that between 2009 and 2014 the number of day care or day services clients 65+ declined per week (Bennett et al., 2023[46]). Data suggests that its share as a fraction of total long-term care has been declining since 2015 in the United Kingdom (Orellana et al., 2024[47]). Low funding may affect staffing and its composition. In Chile, adult day care relies on centres having temporary funding for short periods and signing an agreement (often yearly). A study has found that this led to instability for the staff in the centres as some had to temporarily close until resources were renewed or people were asked to work without income (Rubio and Miranda, 2018[48]).
Day long-term care (health) expenditure as a share of long-term care expenditure, 2022
Note: The information in this document with reference to “Cyprus” relates to the southern part of the Island. There is no single authority representing both Turkish and Greek Cypriot people on the Island. Türkiye recognises the Turkish Republic of Northern Cyprus (TRNC). Until a lasting and equitable solution is found within the context of the United Nations, Türkiye shall preserve its position concerning the “Cyprus” issue.
The Republic of Cyprus is recognised by all members of the United Nations with the exception of Türkiye. The information in this document relates to the area under the effective control of the government of the Republic of Cyprus.
Data from 2017 for Colombia, 2019 for Brazil, 2021 for Australia, Lithuania, Romania and Sweden.
Source: OECD Health Statistics (2023[45]), “Health Expenditure and Financing”, https://data-explorer.oecd.org/s/2vw.
As a result of limited expenditures, costs or eligibility requirements limit access to adult day care. Out of 28 OECD countries which provided information in the OECD Survey on Healthy Ageing and Community Care, 17 highlighted that out-of-pocket payments were required, although they most often constitute the second source of funding, after public funding. In Spain, 57% of adult day care centres were private in 2022, but 64% of available spots received public financing, with 22% of the price paid by users, amounting to over EUR 2 200 per year on average across the country in terms of user copayment (IMSERSO, 2022[49]). In the United States, 57.4% of adult day care centres are for-profit, according to the Centre for Disease (2024[50]). Costs of adult day care may vary between USD 25 and 100 per day, and Medicare does not pay for day care, leading to such centres being unaffordable for many who would attend regularly. The most common way for Medicaid to cover adult day care is through a Home and Community Based Services (HCBS) Waiver. HCBS Waivers have a limited number of enrolment spots, and once those spots are full, additional applicants may be placed on a waitlist1 that can last months. In Poland, the fee for participation in adult day care is established by the government, but, depending on the participant’s individual (or family) annual income, the fee can be partially or fully covered by the social welfare services (Mazurek et al., 2020[51]).
While all countries for which data is available do provide at least some support for day-care use among older adults, financing arrangements differ across countries (Table 6.1). In Luxembourg, while costs of medical and care services are covered by insurance, a fee for meals and other costs of EUR 25.60 per day needs to be paid. Fees for meals are also expected in other countries, such as Iceland and Latvia, while the Netherlands also requires a fee to access the services. In other countries, out-of-pocket costs depend on eligibility criteria and individuals with higher income will bear a higher fraction of the costs. For instance, in Ireland, 10% of the costs are paid by users but those with higher income contribute 20 to 30% of the costs. In the United States, only people eligible for Medicaid receive a reimbursement for day care and it depends on their assets and income. Means-testing is used in four countries and might reduce the number of eligible participants. For instance, in Chile, people entitled to day care must belong to one of the first four sections of the socio-economic qualification of the Social Registry of Households.
Countries by the level of out-of-pocket payment for adult day care
Note: The data for Canada refer to New Brunswick. * In Latvia, municipalities determine the pricing of day-care services, although typically services are free or with minimal co-payment, with the exception of the meal. In New Zealand, in addition to public services, which provide day care free of charge, some support is available to people purchasing private day-care services depending on eligibility. In the United States, adult day care is a responsibility of the states, but Medicaid programmes typically include some targeted support for day-care services.
Source: OECD Questionnaire on Healthy Ageing and Community Care (2023[52]).
A number of countries have given impetus to day care over time. In Norway, day care for people with dementia was highlighted as an essential part of the country’s care strategy in the 2015 and 2020 National Dementia Plans, which also provided additional funding for day care services to the local authorities offering them. However, the focus is strongly on dementia patients, and despite increased availability, day care utilisation remains low (Rokstad et al., 2019[14]). In Japan, the 1983 Health and Medical Services Act for the Aged first established a consistent healthcare framework for older people, ranging from prevention to rehabilitation, including at day care facilities (Nakamura, 2018[53]). The implementation of the Community-Based Integrated Care System and the 2015 reform of the Long-term Care Insurance Act then led to a broader approach targeting the whole community of older people and their caregivers rather than just high-risk individuals (Saito et al., 2019[54]). These reforms place greater emphasis on home care and adult day-care and strengthen their seamless integration with healthcare services, and have been shown to decrease the proportion of bedridden people and long-term medical care costs in regions where they were first implemented (Hatano et al., 2017[55]). In Germany, adult day care is part of the mandatory care insurance, meaning that it covers costs, including transportation to the centre, up to certain maximum amounts for people with at least moderate care needs. However, the maximum insurance coverage is often insufficient, meaning that in practice, most recipients also have to make out-of-pocket payments (Siegl, 2025[56]). There is social assistance for people who do not have care insurance or who cannot afford the out-of-pocket expenses (Rosenberg, 2025[57]).
Funding for adult day care was recently improved in Ireland, and Chile has continued to expand beneficiaries. To improve funding for adult day care and Meals on Wheels community care services, Ireland just announced EUR 10 million in additional funding in 2024. Approximately 400 service providers, around 300 of which also offer adult day care, across the country are eligible to apply for up to EUR 25 000 each in increased funding for improving their service provision. For example, they may use the money to purchase new equipment or upgrade their kitchens and other facilities, thus expanding and enhancing their care capacities. In total, the government invested around EUR 730 million in home support services in the last year, which includes day care and other measures to reduce and delay hospital and residential care admission (Grants and Funding, 2024[58]). In general, older people in Ireland are referred to day care services by their doctor or nurse and need to pay a small fee for transport (for centres which offer transport solutions) and meals (Citizens Information, 2024[59]). Chile launched the adult day care services in 2013 with 1 200 people attending only in the capital, while in 2023, this number reached 12 500 people, with 2024 seeing an increase by 14.5% of the budget in order to create 20 new centres and reach 52% of municipalities in the country (Ministerio de Desarrollo Social y Familia de Chile, 2024[60]).
Nurses and social workers, together with volunteers, are the most often reported professionals in adult day care. Doctors are not often employed in adult day care: only four countries report having doctors (Chile, France, the Netherlands and the Slovak Republic). In France, only 30% of adult day care establishments had a doctor on site and for a limited time (0.4 full-time equivalent) (EHESSP, 2019[36]). Nurses, social workers and nurse assistants are the most common staff, together with physiotherapists. In Chile, initial evaluations of the adult day care centres suggested a need for better training about gerontology and teaching self-care. Many countries rely heavily on volunteers: 10 OECD countries cite them as part of the workforce in the questionnaire. Adult day care facilities face similar workforce shortages as the rest of long-term care due to poor salaries and working conditions such as temporary contracts (OECD, 2023[61]), although day centre staff and volunteers seem to have higher job satisfaction and lower employee turnover than most other parts of the health and care sectors (Orellana, Manthorpe and Tinker, 2021[62]).
Which of the following professionals are available in adult day care centres?
Note: The data for Canada refer to New Brunswick.
Source: OECD Questionnaire on Healthy Ageing and Community Care (2023[52]).
6.2.1. Services offered in adult day care often lack a health component
Across countries, adult day care services tend to focus on the provision of essential services for older adults (Table 6.2). Maintenance of personal hygiene, provision of meals and group activities are provided across all countries which responded to the survey and cited as mandatory in 60% of the countries. For instance, a study from Poland highlighted that adult day care services which are mostly offered in the social sector tend to focus on social isolation and sense of loneliness prevention, and maintenance of social activity (Mazurek et al., 2020[51]). On the other hand, health and rehabilitation services are important yet not always offered, and if they are, they are not often mandatory. Health screening and medical care are available in 56% of countries, and mandatory in 22%. Rehabilitation services are offered in a slightly higher share, with 65% countries providing them, but less so on a mandatory basis (13%). Similarly, mental health services are available in 60% of countries, while only in 22% of countries are such services mandatory. Legal help is less likely to be mandatory, with only 20% of countries having it mandatory, but they are also offered in half of the countries.
Lack of national legislation or guidelines underpins this variability in the provision of services. Voluntary services will be included depending on the region, local authority, or type of provider in different countries. For instance, in the United States, Alabama requires only two services for adult day care, which are health monitoring and social services, while in Washington D.C., assistance for activities of daily living, health education and counselling, medication administration, nursing services, social services and transportation are required. D.C. also stands out positively through its Adult Day Health Program (ADHP), which provides a range of medically supervised adult day services to residents with chronic health problems (American Council on Aging, 2025[63]). Services are determined based on individual needs, and the day care team consists of licensed professionals, including registered nurses and nutritionists. Additionally, the programme is covered by Medicaid and several private insurance schemes, limiting out-of-pocket costs for recipients (MBI Health Services, 2024[64]). In Poland, there are no unified guidelines or coherent standards for day care (Mazurek, et al., 2020). In Spain, while there is a national legislation that includes adult day care as a service for older adults, regions are responsible for the provision and agreements on minimum standards nationwide have focussed on the ratio of professionals and the obligation to design a personalised plan for attendees, but not on the detailed services provided (Ministerio de Derechos Sociales y Agenda 2030, 2022[65]). Some regions, like Castilla y Leon have enacted legislation to ensure that certain services are included across the region, while others leave it to the responsibility of local authorities to decide (Comunidad de Castilla y Leon, 2024[66]).
Evidence highlights the strong health needs of attendees for adult day care centres. Older people attending day care centres tend to have significant health limitations and be at risk of social isolation. In the United States, for instance, over three‑quarters needed assistance with at least one activity of daily living and 64% needed assistance with three to six ADLs, with bathing, dressing, walking, toileting and eating being among the most common. Participants also often had chronic conditions, especially high blood pressure (51%), diabetes (30%) and dementias (28%) (Lendon and Singh, 2021[67]). In the United Kingdom, all attendees reported health conditions or disabilities impacting their life, while half reported at least two and two‑thirds were at risk of isolation or depression (Orellana, Manthorpe and Tinker, 2020[68]). In France, 80% of users had Alzheimer’s and had moderate levels of dependency, indicating their need for assistance for bodily functions and meals (EHESSP, 2019[36]). Similarly, a study of informal caregivers in Bavaria, Germany, found that it is mostly informal carers who wish to use day care as a form of respite care and, as a result, use tends to be more likely for recipients having dementia and high care needs (Bösl et al., 2024[69]). Data from Israel pinpoints that those more likely to be socially isolated tend to use day care. At the same time, compared with non-users, attendees are often younger, more likely to be unmarried, live alone and have fewer functional limitations; it is thus likely that those with more severe limitations receive care at home (Iekovich and Carmel, 2011[70]). Resnizky et al. (2012[32]) confirm that adult day care users in Israel are more likely to be socially isolated, but according to them, 77% of users do suffer from problems of daily functioning, with 43% having serious disabilities. In Japan, although the need for social participation was the most important factor for people attending adult day care, 64% also listed hygiene and health needs as a key factor (Naruse and Yamamoto-Mitani, 2021[71]).
Adult day care is often seen as mostly relevant to people with moderate care needs. However, Germany’s pilot programme “Dying where you live and are at home”, which ran from 2020 to 2023, aimed to develop the availability of day care services in hospice and palliative care to support people in staying at home until the end of their life. As these people generally have severe care needs, the initiative required comprehensive integration of day care and other healthcare services, and the centres are often located in healthcare facilities such as hospitals or residential care homes (Ponz and Schoenmaeckers, 2021[72]). The German long-term care system also offers specific day care facilities for people with dementia and other cognitive impairments, with trained specialists and other targeted healthcare services on-site (Siegl, 2025[56]). Generally, the medical costs of day care are covered by health insurance, while recipients have to pay an out-of-pocket fee for meals, transportation, and specific investment costs (Federal Ministry of Health, 2025[73]). Day care centres offer health screening services and there is stringent quality monitoring for inpatient long-term care facilities. The regularly published care quality reports of the Federal Medical Service (Medizinischer Dienst Bund) contain a separate chapter on quality inspections in day care facilities.
A limited offer of health services in adult day care might result in limited impact on outcomes. In Israel, day care use did not result in lower health utilisation in terms of visits to specialists, hospitals, etc. This was possibly related to the lack of health and rehabilitation services, as only around half the day care centres offer physiotherapy and occupational therapy services and their supply is very limited, and although 83% of centres had a nurse on hand, they were on average only present for 11 hours a week (Iecovich and Biderman, 2013[74]; Resnizky et al., 2012[32]). On the other hand, responses from the users of day care in Chile showed that it led to significantly lower healthcare expenditures (60%) due to lower consultations and medicine use (SENAMA, 2020[75]). In Poland, a study of adult day centres highlights unmet needs with respect to health monitoring, such as blood pressure and sugar levels, due to a lack of nurses (Mazurek et al., 2020[51]).
Adult day care in Japan now consists of four interconnected pillars, namely social participation, hygiene and health, exercise and eating habits, and family support. Studies investigating the relative importance of these four pillars for day care attendants found social participation to be most important, with 75% of respondents having needs in that domain, followed by health and hygiene with 64% (Naruse and Yamamoto-Mitani, 2021[76]). Clients spend a significant share of their time at the day care facility on rehabilitation and health-related activities, and there must always be trained staff with professional qualifications in nursing and rehabilitation, among other areas, present to ensure that their high healthcare needs can be met. Adult day care services offer medical screenings and are co‑ordinated with other health institutions, including hospitals, outpatient care, and home‑visits by healthcare professionals (Naruse and Kobayashi, 2022[77]). Japan also pioneers the use of technological innovations in care for older people, integrating telemedicine and remote monitoring with in-person day care services (TechSci Research, 2024[78]) and employing assistive robotics to aid with meeting clients’ healthcare needs (Takanokura et al., 2023[79]).
Innovative solutions need to make adult day care more attractive and adapted to future needs. Studies have cited flexibility, personalisation and choice as important areas of improvement. Having more personalised attention and targeted health services, especially with respect to activities targeting cognitive and physical functioning, are perceived by professionals and users as particularly attractive. Working with a variety of other community organisations might facilitate having a diverse set of cultural, physical and artistic activities (Orellana et al., 2024[47]; Bennett et al., 2023[46]). Better co‑ordination with healthcare is important to help people manage their chronic conditions and to deliver preventive programmes. Providing adequate care and support for users with dementia would be of particular importance as previous OECD work (OECD, 2018[80]) highlighted shortcomings in the availability of specialised day care for such older adults. For this, partnerships with specialised dementia associations might be helpful. More involvement of users and even co-design for the activities and organisation are also discussed as options for the future of day care to become more targeted, especially as some users describe day care services as paternalistic, with activities and offers decided by a top-down approach (Hagan and Manktelow, 2021[10]; Wang et al., 2022[81]). In addition, another needed enhancement is finding solutions for transport or addressing proximity to users, particularly to ensure access in underserved areas. For instance, in the United States (Georgia), mobile day care enables rural communities to have their own day care programme while “sharing” staff, which will travel between locations and sites that are open one to three days per week (Georgia Department of Community Health, n.d.[82]).
Note: m=mandatory, v=voluntary. Data for Poland includes the social sector only, not health.
Source: OECD Questionnaire on Healthy Ageing and Community Care (2023[52]).
6.2.2. Quality regulation is lagging behind in adult day care
Most countries have put in place regulatory practices to avoid abuse of older people in adult day care, although this tends to be more incipient than for institutional care. Two countries require no formal process of accreditation, licensing, registration or authorisation for the operation of day care providers (France, Ireland). The most widely used mechanism is a simple authorisation from the Ministry of Health or Social Services (Canada (New Brunswick), Colombia, Costa Rica, Japan, Türkiye) or registration (Czechia, Latvia). In Luxembourg, the Ministry for Family, Solidarity, Living Together and Reception of Refugees is in charge of the accreditation of the day care provider (agrément) while the National Health Fund (Caisse Nationale de Santé) concludes a contract with the providers allowing them to be reimbursed. Licensing is required in five countries while accreditation is in place in six and three countries require both. In the United States, requirements vary by state: 26 states require licensing only, 10 states require certification only, 4 states require both and 11 states do not require any. Both licensing and accreditation are usually more stringent regulatory practices in terms of quality than authorisation. Licensing requires that providers meet certain standards and that a public body authorises the provision of services for that provider. Accreditation involves an evaluation process that assesses the quality of care and services provided in LTC and gives recognition that providers are competent, comply with the regulations and meet certain quality standards in their services. The purpose of accreditation is to encourage quality and safety through a mix of compliance and quality elements, which can extend to continuous quality improvement. National accreditation bodies are often independent authorities (O’Keeffe and Siebenaler, 2006[83]).
Regulatory practices for adult daycare centres across OECD countries, by type
Note: The data for Canada refer to New Brunswick.
Source: OECD Questionnaire on Healthy Ageing and Community Care (2023[52]).
The most common policy approach to safeguard and control quality in OECD countries focusses on having minimum acceptable standards with respect to the environment and minimum qualifications. This is the case for safety and the environment in 14 countries while minimum qualifications are required in 13 countries. Colombia has quite detailed guidelines in a resolution (Resolución 00 024 – 2017 Ministerio de Salud y Protección Social). Day care centres, in addition to complying with the sanitation, environmental and fire guidelines of the Law 9 of 1979, have minimum space requirements for the activity rooms and eating areas (1.5 m2 per user), as well as specific requirements regarding accessibility and minimum sanitation facilities. With respect to the qualifications, there is a need to have people trained for emergencies and one qualified person for food preparation (per 20 older people). Similarly, there needs to be at least one qualified person responsible for cognitive stimulation and social interaction, one for physical activity, and one for cultural and recreational activities per 30 people. In Hungary, the Decree 1/2000 (I.7.) of the Ministry of Social and Family Affairs on the professional duties and operating conditions of social institutions providing personal care requires that day-care centres should be easily accessible by public transport, that the buildings should be barrier-free, and that the furniture and the institution is suitable for providing day care if it has rooms for community living, recreation, personal hygiene, personal laundry, and meals. In the United States, virtually all states have both orientation and initial and ongoing training requirements, but they are minimal. However, in-service training sessions of 4 hours per quarter for a total of 16 hours per year are required for all direct care staff. In Portugal, there must be a team with a technical director, activity leaders, drivers, and helpers, with minimum qualifications for the technical director and activity leaders.
Staff-to‑user ratio requirements are less common in adult day-care, but many countries regulate the type of professionals and training. Four countries have indicated that they have official staff-user ratios. Colombia requires a minimum of one personal carer/nurse assistant per 20 older people (who are expected to be independent functionally and cognitively). Similarly, Hungary requires two caregivers (or nurses) for 50 users, according to Annex 2 of Decree 1/2000 of the Ministry of Social and Family Affairs. In Canada (New Brunswick), a minimum ratio of 1 to 12 must be maintained. In Luxembourg, day care centres require a minimum of 3 FTE staff for carers and if there are more than 12 users, an additional half-time equivalent staff member is necessary for every four users.2 While not directly mandating specific ratios, requirements on the type of professionals that must be available often lead to similar minimum personnel requirements in other countries. In the United States, for instance, most states specify minimum staff-to-participant ratios ranging between one to four and one to ten while some states require lower ratios when serving participants with greater needs but allow providers to self-determine what level of need requires the lower ratio. Japan requires at least one full-time manager, one social worker, one care worker (two or more if the number of care recipients is more than 15), one full-time or part-time nurse if the facility size can host more than 10 care recipients (if not at least one social worker or nurse). In Ireland, in addition to the requirement to have one full-time consultant and nurse, there needs to be one caregiver per 15 users and an additional 0.2 person if there are more than 15 users.
All but two countries impose sanctions if the minimum requirements are not fulfilled (Chile and Türkiye). In many countries, the sanction is severe and implies the loss of authorisation to operate, contract termination, or funding. This is the case in Canada (New Brunswick), Iceland, Ireland, Luxembourg and New Zealand. In Costa Rica, it implies the closure of the establishment. In other countries the sanction depends on the nature of the infringement: In Colombia, it can range from a verbal reprimand to suspension of authorisation or closure and there are yearly inspections. This is also the case in Hungary but there is also a time limit given to remedy the deficiency in terms of standards before moving to more severe sanctions.
Quality control regulations across OECD countries in adult daycare, by type
Note: The data for Canada refer to New Brunswick.
Source: OECD Questionnaire on Healthy Ageing and Community Care (2023[52]).
6.2.3. Quality monitoring in adult day care could be improved
Countries use a variety of mechanisms for the quality assurance of adult day care, with quality standards being most frequently reported. Twelve countries report having quality standards, while four of them also have a quality framework (Luxembourg, the Netherlands, New Zealand, the Slovak Republic) and Slovenia only has a framework. In the United States, standards require that unannounced visits be made either at specified intervals or at any time to ensure compliance with rules or to investigate complaints. In addition, many states require day care providers to have an internal evaluation process. Seven countries have in place a system of external auditing. This includes Germany, which regularly publishes quality requirements that day care centres must meet, such as providing adequate transportation and meals, minimum opening hours of 6 hours a day for 5 days a week, always having a qualified nurse on site, and more. It also outlines the aims of day care, which include meeting users’ social, emotional, and cognitive needs and enabling them to age autonomously and with dignity (GKV-Spitzenverband, 2023[84]).
Nine countries collect quality indicators for adult day care. In terms of indicators, most of them focus on organising surveys for collecting information on user satisfaction (Iceland, Latvia, Luxembourg, Slovenia, the Slovak Republic, Sweden). While it is important to monitor the users, such indicators might be constrained by low response rates and might not always be informative if carried out internally (Cès and Coster, 2019[85]). In addition, analysis of the correlation of user satisfaction with indicators of the quality of long-term care suggests that family and user satisfaction correlate only slightly with quality-of-care indicators, based on user outcomes on autonomy and patient safety and any quality-of-life deficiencies (Palimetaki, Woutersen and Pot, 2023[86]). In Japan, user outcomes are monitored in terms of their condition and facilities need to keep the response to complaints as well as have monitoring mechanisms for abuse. In Luxembourg, every two years an evaluation report is published monitoring user outcomes including pressure ulcers, falls, nutritional follow-up and pain.3
Public reporting is rare and only available in a few countries. In Latvia, Regulation No. 3384 (13 June 2017) specifies that there should be reporting on user satisfaction and the provider’s self-assessment. Public reporting of long-term care indicators has been associated with improving quality over time (Poldrugovac et al., 2022[87]). In Poland, legal provisions do not specify the standards and principles of the functioning of day-care centres, including, for example, required infrastructure, qualifications of the personnel, and standards regarding the number of attendees per worker. Day-care centres also do not have a formalised way of assessing their functioning (Mazurek et al., 2020[51]). In Luxembourg, while the reports on outcomes are published highlighting the share of users experiencing adverse events, there is no disaggregated information by provider.
Mechanisms for the quality assurance of adult day care across OECD countries, by type
Note: The data for Canada refer to New Brunswick.
Source: OECD Questionnaire on Healthy Ageing and Community Care (2023[52]).
Across the OECD, evaluation of adult day care centres is scarce and focussed on structural indicators. Over half of the countries focus on structural indicators. Colombia requires reporting that the building complies with safety standards, the qualifications of the director and staffing levels in total and their shifts and sends an annual plan for centres to be inspected. In addition, the resolution includes reporting on users that have a care plan, which should be reviewed every six months and reporting any changes to the healthcare sector and on evaluations on the functional capacity of users to be carried out on a yearly basis. One‑third of countries do not perform regular evaluations of day care. Close to 40% of countries have an evaluation of structural indicators. Only three countries perform an evaluation of user satisfaction (Latvia, Portugal, Slovenia). This can be challenging given the growing desire from users to ensure the responsiveness of services and more people‑centredness. Just under 30% of the countries perform evaluations of user outcomes. Such outcome indicators would be desirable as they represent changes in health status and conditions (physical and cognitive functions) attributable to care provided or not provided and can give directions for desirable results of care provided to residents and beneficiaries. In the United States, a study of adult day care centres shows that they collect clinical data infrequently and less than 20% collect quality of life indicators while just over a third indicated that the state required them to collect data on cognitive impairment (Sadarangani et al., 2022[88]). On the other hand, autonomy levels are measured often with 88.1% reporting that they screened for users’ abilities to carry out activities of daily living and 72.3% screened for instrumental activities of daily living, with just under half being state‑mandated (Sadarangani et al., 2022[88]). A large proportion (74.6%) screened for fall risks, but most did not track actual falls, while depression was screened for in just under half and pain level in over a third (Sadarangani et al., 2022[88]).
Adult daycare centre evaluation across countries, by type of indicator(s) used across OECD countries
Note: The data for Canada refer to New Brunswick.
Source: OECD Questionnaire on Healthy Ageing and Community Care (2023[52]).
In addition to individual homes, residential buildings can be designed and adapted to help older people maintain independence and age in place. OECD countries are developing a number of innovative living arrangements which include small-scale living, shared housing arrangements, intergenerational living, senior villages, the Green House model, and dementia villages (Brouwers et al., 2023[89]). Such innovative models of living aim to create small-scale and/or homelike environments and overcome the shortcomings of nursing homes in terms of being impersonal. One of the underlying ideas is that the physical, social, and organisational environments of living arrangements is important for achieving positive outcomes for residents. In addition, such living arrangements also have the goal of supporting autonomy, potentially delaying greater care needs, and improving quality of life for older people. Across OECD countries, different innovative housing models are emerging across countries and Table 6.3 reports which countries include intergenerational housing, community-led housing initiatives, and assisted living for older adults.
Note: *=at subnational level.
Source: OECD Questionnaire on Healthy Ageing and Community Care (2023[52]).
6.3.1. There is renewed interest for people‑centred settings with promising results in terms of health and quality of life
Shared living arrangements such as co-housing or co‑operatives were reported in about one‑third of OECD countries. In co-housing or co‑operative programmes, people live in residential buildings with common areas shared by all tenants, where social activities are organised to support tenants and to involve them in the social life of the building. Services can include support with housekeeping and activities to socialise with other tenants, which can be particularly helpful for older people who might have limitations and be particularly exposed to the risk of loneliness. They exist at the national level in France, the Netherlands, Portugal and the Slovak Republic, and at the subnational/local level in Austria, Denmark, the Netherlands, New Zealand, the Slovak Republic and Sweden (OECD questionnaire, 2023). The programmes are often led by the third sector and civil society, but public subsidies are available to fund such initiatives. In France, Portugal, the Slovak Republic and Sweden, there is public funding for the organisation of services and social activities within community-led housing options. Additionally, in Portugal and the Slovak Republic, public funding is also available to provide financial support for less privileged groups, to incentivise their participation in such programmes (OECD questionnaire, 2023).
While they constitute a small share of living options for seniors, there is renewed interest in such forms of living. In Denmark, there are 250 co-housing communities exclusively for older people and, in co‑operation with municipalities, most of the facilities (55%) were established as rental social housing and tend to have around 20 dwellings in the form of cluster houses with a common house kitchen and a combined dining and living room (Pedersen, 2015[90]). In comparison, there are 19 established co-housing communities in the United Kingdom and over 600 in Germany (Quinio and Burgess, 2019[91]). In the Netherlands, the Ministry of Housing and Urban Planning issued specific guidelines on co-housing or so-called clustered housing options, anticipating a growing demand for senior housing and with the ambition to have 80 000 of such housing for seniors (Platform 31, 2023[92]). Grants are available in the Netherlands to develop such construction and the guidelines point to the need for developing social spaces.
Co-housing has several benefits, but developing such solutions has been hampered by a number of challenges. Combatting loneliness is often found to be one of the main benefits associated with co-housing, along with improved mental and physical health. Studies also found a positive association with social support and emotional and economic security, although none of the studies had causal evidence (Carrere et al., 2020[93]). Some of the challenges are that a certain involvement of all residents is expected in the running and maintenance of common areas, residents can run into conflicts or suffer from a lack of privacy, and many decisions usually require consensus. Developing co-housing projects for tenants, as it is the case in some countries such as Germany, the Netherlands and Sweden appears to favour the inclusion of less socially privileged seniors (Labit, 2015[94]). Finding solutions to provide care support as residents age is also important, as they can help prevent people from leaving due to growing dependency needs (Platform 31, 2023[92]).
Administratively, there might be a lack of funding, an inappropriate legal framework and support for developing such solutions (Quinio and Burgess, 2019[91]). A research project Collaborative Housing in a Pandemic Era (CO-HOPE) looked at such solutions in Austria, France, Spain and Sweden and found that without adequate policy support, groups wanting to establish such co‑operatives required lots of hours to secure funding and physical space and that many groups in society lack the resources to undertake such projects. Because of the lack of a legal definition, co‑operatives cannot access certain benefits such as reduced interest rates or subsidies, particularly to finance common spaces. In France, the law ALUR of 2014 created a legal status for collaborative housing and AGIR-ARRCO can subsidise common spaces for retired people (CO-HOPE, 2025[95]).
Intergenerational housing options can be defined as residential solutions designed to host people of different ages, which often host older adults and younger residents (e.g. students), with the goal of fostering interaction and support across different generations and reducing isolation. There are different types of intergenerational housing, based on the number of spaces that residents share, which can span from gardens, garages, dining rooms and laundry rooms, to most of the housing environment. The type of intergenerational housing also varies in terms of ownership, with some initiatives being public (e.g. social housing), others being provided by private companies, and others being community-led. As older people often experience loneliness and isolation when living alone in their homes, existing evidence has shown that intergenerational housing arrangements can provide older adults with more social contacts and support a sense of community, reducing loneliness and isolation (Van Gasse and Wyninckx, 2023[96]; Weeks et al., 2019[97]; Pedersen, 2015[90]). Older people can also benefit from living in intergenerational housing by receiving help with daily tasks such as household chores and transportation (Put and Pasteels, 2021[98]) while younger people benefit from the low-cost accommodation (Quinio and Burgess, 2019[91]).
Nevertheless, challenges also arise in the setting of intergenerational housing. Privacy concerns and cultural differences among residents have been highlighted by recent literature as possible concerns to consider when planning for intergenerational housing (Van Gasse and Wyninckx, 2023[96]). There have also been concerns regarding the acceptance of the concept of intergenerational housing among the general population, which may have represented a barrier to the establishment of such projects (Weeks et al., 2019[97]). Decision making processes sometimes also create difficulties, as they can become complex and time‑consuming due to the higher number and variety of people involved in the residential environment (Leviten-Reid and Lake, 2016[99]). Finally, older people tend to develop additional social and health needs, which might in some cases pose challenges within the residential environment over time, putting a heavier burden on the younger residents (e.g. people developing dementia, severe depression or other forms of mental or physical health issues requiring more intense and professional support) (Weeks et al., 2019[97]).
Examples of multigenerational housing exist in several countries and are growing in recent years. For instance, in Austria (Tyrol), intergenerational housing schemes have been established in many places to bring together older and younger generations: the Housing for Help (Wohnen für Hilfe) project, for instance, promotes shared accommodation, mutual assistance and intergenerational dialogue (OECD questionnaire, 2023). Intergenerational housing also exists in France, often in the form of social housing where students, young workers, families and older adults share common living areas. One example of intergenerational housing is the “Cayol residence” (Résidence Cayol), a residential building that aims at fighting isolation and loneliness while providing affordable housing to residents of different ages. A dedicated webpage has been set up on the website of the French Government to provide information on the opportunity of living in intergenerational housing (French Government, 2024[100]). Since 2021, there has been additional government support for inclusive housing, which includes intergenerational housing facilities, in the form of the Shared Living Assistance (Aide à la Vie Partagée, AVP). This aims to support older people with some care needs to remain more independent and retain a home environment while benefiting from high-quality and long-term support on-site and building intergenerational ties outside of their family. In total, EUR 20 million in funding was set aside for around 600 projects during the first phase (Ministère du Travail, 2021[101]). In the Netherlands, numerous multigenerational social housing projects exist, with older people and young students living in the same buildings, supporting each other and enabling each other to be independent. For instance, the Humanitas retirement home in Deventer hosts students and older people. Students are allowed to live in apartments rent free, in exchange for spending 30 hours helping older residents and keeping them company. Another multigenerational social housing programme in Beekmos allows older people and young mothers to live together and support each other in affordable housing. The social housing is located in the city centre to allow older people to easily reach the services they need (International Observatory on Social Housing, 2023[102]). In Canada, HomeShare is available in several cities and matches older adults over 55 years-old with a spare bedroom with post-secondary students.
Intergenerational houses are particularly well-established in Germany with around 530 establishments across the country with significant support and funding from the federal programme for multigenerational houses enacted in 2021, especially for structurally weak regions. Eligible facilities can get federal funding of up to EUR 40 000 annually from 2021 to 2028 for material and personnel costs (Bundesministerium für Familie, 2020[103]). However, the German multigenerational houses usually do not qualify as housing facilities but primarily serve as community spaces for facilitating structured and unstructured intergenerational exchanges through various projects and events.
Data on the number of multigenerational housing projects, the number of people living in them, and the funding systems are not widely available. Among the 29 countries that participated in the OECD Questionnaire on Healthy Ageing and Community Care, only four countries reported information on the funding systems (Germany, Japan, Poland, the Slovak Republic), reporting that in most cases, intergenerational housing programmes rely on subsidies to fund such projects (OECD questionnaire, 2023).
Retirement villages are another form of communities built to cater to the needs and lifestyles of older people, enabling residents to live independently while enjoying a sense of community and having access to a range of services. Villages tend to require a membership fee and tend to be self-funded, although there are some donations, while services are run by a mix of volunteers and staff, allowing for free or low-cost services (Hou and Cao, 2021[104]). They have been found to improve well-being, a sense of purpose and reduce social isolation (Hou and Cao, 2021[104]). The first village model opened in the United States, which is the country with the largest number of retirement villages in the world, with around 18 810 communities, followed by the United Kingdom with 3 366; Australia with 2 200; and New Zealand with 488 (Russell, McIndoe and Schulze, 2024[105]). Ownership forms for retirement villages include some form of an outright purchase model, like in Australia, the licence to occupy model (common in New Zealand, Australia, and the United Kingdom), and a rental model (common in Canada, the United States and Germany) (Russell, McIndoe and Schulze, 2024[105]). Sustainable long-term financing appears to be a challenge as it relies extensively on membership fees (Scharlach, Graham and Amanda Lehning, 2012[106]). Promoting other forms of acquiring access (loans, leases, company options), having better building standards and support for the rights of older people navigating disputes with retirement village operators have been recommended in Australia (Travers et al., 2022[107]). In Canada (Québec), tax credits are available for such options to pay for services (meal preparation or delivery services, nursing care services, home and personal care services) (Wyonch, 2024[108]).
6.3.2. Assisted living for older adults is widely available, but it often requires out-of-pocket contributions
Among OECD countries, assisted living facilities are quite widespread. Assisted living refers to housing options where older people can receive help with activities of daily living and instrumental activities of daily living. Many countries have such an option available, with 24 out of 26 OECD countries reporting the existence of assisted living as of 2023. The services received can vary based on needs and on the fees paid by residents. Among the services available in assisted living facilities, help with care and medication, maintenance of personal hygiene, provision of meals, and group activities are the most common, with between 66% and 83% of OECD countries reporting the availability of such services in assisted living facilities. Services related to physical activity and rehabilitation, mental health, and support with legal and administrative tasks are less common, with less than 50% of OECD countries reporting such services in the OECD Questionnaire on Healthy Ageing and Community Care. In general, assisted living is a more cost-effective solution for people with moderate care needs who do not require the degree of care offered by nursing homes and allows residents to maintain a higher degree of autonomy, but it is still often unaffordable for the low-income older people (Christiansen and Sompayrac, 2015[109]).
There is a growing demand for assisted living facilities across OECD countries. In Canada, there appears to be a steady growth over time: for instance, the number of licensed assisted living facilities (mostly private for profit) increased in Ontario from 383 in 2012 to 768 in 2020 (Manis et al., 2022[110]), with 37% of people 75 and above living in a residence for senior citizens (Hou and Ngo, 2021[111]). In the United Kingdom, there are more than 500 000 units for supported living properties and by 2040, it is expected to require an additional 167 329 units (Ryeder et al., 2024[112]). In Spain, senior living has 70 types of resorts, with 3 650 places, targeting not only seniors near big cities but also the coastal areas for foreigners wishing to retire in Spain and forecasting high growth in this sector (Observatorio Sectorial DBK, 2023[113]). In the United States, more than 900 000 people are in assisted living (Zimmerman et al., 2024[114])., up from 800 000 10 years ago and projected to continue increasing (Fabius et al., 2022[115]). Assisted living is also quite prevalent in Germany but there is no general register of facilities or people living in them, also because a clear definition is lacking. Rothgang et al. (2018[116]) estimated around 300 000 assisted living units (i.e. individual rooms or flats) and 3 891 assisted shared houses across Germany, with large differences between regions. These numbers are likely to have increased, since a significant share of providers reported planning to expand their assisted living offers. For assisted shared housing, a large share of the offer is targeted towards people with dementia, meaning that there are only a few facilities for older people with other care needs. (Klie et al., 2017[117]).
In some cases, national and local governments are developing legislation and guidelines to incentivise and improve the provision of assisted living facilities. In Ireland, the 2022 Framework Toolkit, How to Develop a Housing with Support Scheme for Older People, has been published to share insights from the Dublin City Age Friendly project. It serves as a guide primarily for social housing providers, including local authorities and approved housing bodies, while also being a resource for private developers interested in adopting this model. The goal of the ongoing project is to reduce the number of admissions to residential care facilities by offering a safe, affordable, and community-integrated alternative for those with lower care requirements (OECD questionnaire, 2023). In Austria, assisted living is available and several recent initiatives have aimed at making assisted living facilities more accessible and safer for older people. In some cases, for instance, homes have been provided with ambient assisted living systems, namely technological tools able to support older people to freely move around the housing environment (OECD questionnaire, 2023).
Number of countries providing a given type of services in assisted living facilities
Note: N=24.
Source: OECD Questionnaire on Healthy Ageing and Community Care (2023[52]).
While options for assisted living are often private, public funds can be used for staying in such facilities in several countries. Among 24 OECD countries providing information on the funding methods for assisted living facilities, 12 reported that public funding at the national or local level is used to fund assisted living facilities. In most countries (15 out of 24), out-of-pocket spending is required to receive services in assisted living facilities, while only five countries reported private donations among the funding sources for such services (OECD Questionnaire, 2023). While there are some subsidised or NGO-run facilities specifically for low-income people and they report good outcomes in terms of health and residents’ functioning, demand for affordable assisted living far exceeds the supply (Fonda, Clipp and Maddox, 2002[118]; Jenkens, Carder and Maher, 2005[119]). In Colombia, for instance, all assisted living facilities are privately provided by construction companies (OECD questionnaire, 2023). In the United States, most residents finance it out of their private resources (Fabius et al., 2022[115]). Medicaid does not cover board and lodging, but the states have waivers that can be used to pay for support services in assisted living facilities. In France, people can use their benefit to fund the services of assisted living (Allocation Personnalisée d’Autonomie) and can also apply for a special housing subsidy. At the same time, the majority of facilities (residences autonomie) are public with only 29% being private out of 2 260 residences with availability for 114 120 people in 2019 (DREES, 2023[120]). In Germany, while private contributions are required for assisted living, the exact price for users depends significantly on the type of offer, and social security also often covers a significant part of the cost. Estimates suggest that on average, assisted living requires out of pocket payments of EUR 1 368 per month, which is similar to nursing home care but significantly higher than traditional home care. Generally, most assisted living providers use their own funds and various aids, particularly from the federal states and the central insurance association (GKV-Spitzenverband) to cover start-up costs. Running expenses are largely financed by patients’ out of pocket contributions as well as care and health insurance and social service proceeds, with some subsidies (e.g. for shared living facilities) (Kremer-Preis and Mehnert, 2019[121]). While there is often public support available, the complex landscape of grants, aids, and subsidies across Germany and the many different types of assisted living without a clear definition or grouping can make it difficult for providers to know which resources they qualify for and how to get them.
Type of funding for assisted living facilities, across OECD countries
Note: The data for Canada refer to New Brunswick. N=24.
Source: OECD Questionnaire on Healthy Ageing and Community Care (2023[52]).
Monitoring and enforcement of quality might be a challenge due to the governance and funding arrangements for assisted living. A lack of quality monitoring is becoming a challenge in many countries because well-trained staff are in short supply to meet the increasing number of people in assisted living facilities who have complex needs. In the United States, 70% of the residents of assisted living facilities have cognitive impairment and three‑quarters need assistance with bathing, while only 71% of facilities assist with nursing (Zimmerman et al., 2024[114]). People in assisted living facilities have a much higher rate of hospitalisations, odds of death, falls, and emergency visits than people living in the community, thus calling for significant geriatric expertise (Bartley et al., 2018[122]). To strengthen the quality, in France, a study issued a number of recommendations: reinforce the competences of the staff to be able to prevent and detect autonomy loss and adverse events, enhance the co‑ordination with doctors for people developing cognition problems and pathologies, strengthen social links inside and outside the facility and evaluate the impact of concrete actions to foster social connectedness (Anesm, 2018[123]).
Most OECD countries have quality mechanisms in assisted living facilities, but the type of mechanisms varies across countries (OECD questionnaire, 2023). Among the 24 OECD countries reporting information on the quality mechanisms, quality standards (Canada, Costa Rica, Hungary, Japan, Luxembourg, the Netherlands, New Zealand) and mechanisms for external or internal audit (Canada, Japan, Latvia, New Zealand, Portugal, Türkiye) are the most common. Other quality mechanisms are less common, including quality frameworks and public reporting (e.g. mandatory quality reports) available in four countries, and quality indicators in three countries (OECD questionnaire, 2023).
The absence of an agreed framework adds the challenge of controlling the quality of assistive living. In the United States, it appears that regulation for assisted living was often the responsibility of several agencies. There are few processes in place, little in terms of public information related to data requirements of adverse events, and of offering assistance to providers to understand regulations (Kaskie et al., 2021[124]). In Germany, the wide variety of different types of assisted living and lack of a uniform definition makes quality monitoring and evaluation difficult, but efforts towards more consistent quality standards and enforcement are being made (Schölkopf, 2024[125]). There are often quite stringent regional quality requirements or for specific kinds of assisted living, but a uniform, nationwide quality framework is missing (Rothgang et al., 2018[116]). The “Freiburg model”, a network of assisted living communities for people with dementia and care needs, developed a quality framework based on the seven principles of citizen engagement, shared responsibility, openness, central values (dignity, self-determination, social participation), equal standing of the professions, community focus and domesticity. While members of the network are obligated to apply this framework and many other assisted living providers use it, it is far from universal (Klie et al., 2017[117]). In August 2025, the federal cabinet approved a law which contains new regulations for long-term care in assisted living arrangements. The law’s aim is to create attractive and legally secure options for operators to provide outpatient nursing care in a variety of new living arrangements. In some countries, a more structured approach is undertaken. In New Zealand, audits are required for certification which is reassessed between one and four years. The audits are undertaken by agencies designated by the Ministry of Health using 50 quality standards and risk ratings are granted as well as corrective action if necessary. In the Netherlands, the same quality framework applies to nursing homes and assisted living facilities and inspections are undertaken by the Health and Youth Care Inspectorate (Inspectie Gezondheidszorg en Jeugd) which reports their outcomes on their website.
In addition to traditional assisted living facilities, the Green House model is available and can function as a small, personalised form of assisted living or nursing home. The model was introduced in the early 2000s in the United States with the goal of a more person-centred approach and has proved successful at identifying clinical changes of residents and improving their mental well-being. Green House model facilities are small-scale designs with private rooms, an open kitchen, and shared dining and outdoor space, where staff have more direct engagement with residents and promote independence (Waters, 2021[126]). According to the Green House project website, there are about 400 such houses in the United States. Adoption of Green House models is also associated with reductions in Medicare spending for hospital costs and stays in skilled nursing facilities (the THRIVE Research Collaborative, 2016[127]). In addition, several studies reported improved quality outcomes for residents of Green House facilities which are likely to impact overall costs and staff monitoring: residents in Green House facilities had a lower fall rate and a lower likelihood of pressure ulcers (1.9%) and using catheters (Williams and Joshi, 2023[128]).
Those alternative living arrangements have proven to be particularly suitable for people with dementia. Promising results were found on the physical functioning, social participation, and quality of life for older adults living in small-scale home‑like facilities compared to those living in conventional nursing homes (Krier et al., 2023[129]). People with dementia displayed less aggressive behaviour in such settings and there was a lower use of antipsychotics, which can have a significant impact on care costs (Verbeek et al., 2014[130]). Dementia villages and promoting people with dementia to live at home and at the community are important elements of a people‑centred approach. A study of an innovative dementia-friendly support in the community in Ireland showed that personalised care in the community resulted in lower costs than using residential care (O’Shea and Monaghan, 2016[131]). The Netherlands are another good practice example regarding dementia villages, which are self-contained communities that replicate real towns but provide 24/7‑supervised care specialised for people with dementia. Hogeweyk, near Amsterdam, was the world’s first dementia village in 2009 and today houses 152 residents with severe dementia, with two carers per inhabitant who are dressed in everyday clothing to reduce stigma and make it feel more like any other village (Dementia Village Associates, n.d.[132]). While the construction costs of EUR 19 million were mostly covered by the Dutch Government, residents still need to pay the usual costs of staying in a nursing home of up to EUR 5 000 per month. However, considering the unique setting and high satisfaction of inhabitants and workers, it is still largely considered more cost-efficient than standard nursing homes (Godwin, 2015[133]).
Foster care for older adults aims at providing older adults with the possibility to live in a family setting receiving personalised support, and it can be an alternative to nursing homes or assisted living facilities for care recipients with moderate‑to-severe long-term care needs. The foster family is usually approved by the local government or other institutional actors and receives a fee in exchange for supporting and hosting one or more (e.g. a couple) older people and involves them in their family life. Foster care for older adults is available in a limited number of OECD countries. Only Canada, Costa Rica, France, Germany and the United States reported having such opportunities, out of 21 countries that replied to the question as part of the OECD Questionnaire on Healthy Ageing and Community Care. In Portugal, while such programmes are currently not available, planning is underway to offer foster care for older adults (OECD questionnaire, 2023).
Developing foster care for adults has come with challenges. For instance, in France, the government has attempted to expand foster care services for the older people, though with limited success. A brief report in 2008 proposed several directions for improvement, highlighting significant challenges, particularly the undervalued image of the sector, the difficulty in finding substitutes to allow caregivers time off, and recruitment issues. Among its recommendations, the report suggested establishing a support structure (potentially a public entity, possibly in partnership with NGOs and the private sector), utilising “Chèque emploi service universel”-vouchers, and accelerating the validation process for family caregivers. Additionally, it advocated for the creation of a quality label for foster care (Rosso-Debord, 2008[134]).
Some country-specific experience can also represent a helpful learning opportunity. For instance, in the United States, recruitment efforts have proven most effective when targeting individuals with similar characteristics. Therefore targeted recruitment towards specific professions, groups or geographical areas were implemented (Casey family programs, 2014[135]). Key recruitment strategies also involve hiring programme co‑ordinators to lead community-based recruitment teams and designating staff specifically to engage with family members. Agencies frequently collaborate with NGOs to locate foster caregivers (United States Joint Economic Committee, 2020[136]). In the United Kingdom, local authorities have partnered for advertising campaigns, with mixed levels of success (Baginsky, Gorin and Sands, 2017[137]).
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← 2. Staffing requirements are under Article 46 of https://legilux.public.lu/eli/etat/leg/loi/2023/08/23/a562/jo.