13Artículo 321.- Los Ayuntamientos con adeudos contraídos con el Gobierno del Estado o con

In Germany, the nursing organizations can be subdivided into ambulant and inpatient in- stitutions (§71 SGB XI). Ambulant nursing care institutions are the facilities that care for the elderly in their home and provide household care (§71 Abs.1 SB XI). Inpatient care in- stitutions (nursing homes) are the facilities where people in need of care received services on sites. In such institutions, elderly people can be accommodated and catered for all day long or only during the day or only at night, which is called semi-stationary (§71 Abs.2 SB XI). Both ambulant and inpatient care institutions are economically independent, under the constant responsibility of a trained nursing expert (§71 Abs.1 und 2 SGB XI). According to the Federal Statistical Office, there are in total 13,596 inpatient institutions in Germany

in 2015, including 11,164 with full stationary nursing care. The total number of ambulant institutions in Germany is 13,323 in 2015. Table 4.3 shows the amount development of ambulant and inpatient institutions in Germany from 2001 to 2015.

Table 4.3: Development of nursing institutions in Germany from 2001 to 2015[93].

For both ambulant or inpatient institutions, German nursing organizations can be clas- sified into three types of carries (Träger): private, non-profit and public. The public carriers only take a very small portion. At the end of 2015, among the total 13,300 approved am- bulant care institutions, the majority were privately sponsored (8,700 or 65 percent). The proportion of non-profit carriers (e.g. DIAKONIE or CARITAS) was 33 percent. According to the priority of the other carriers according to the SGB XI, public providers had a share of only 1 percent. Meanwhile, national wide there were around 13,600 fully or partially inpa- tient nursing homes approved by SGB XI. The majority of nursing homes (53 percent and 7,200, respectively) were in non-profit sponsorship (e.g. DIAKONIE or CARITAS). The pro- portion of private nursing homes was 42 percent, which is lower than in the ambulant area. Public agencies, as in the ambulant sector, have the lowest proportion, which is 5 percent [93]. Compared with 2013 [160], the amount of inpatient care institutions showed overall growth. The number of nursing homes increased by 4.3 percent or around 600 institutions.

The number of nursing homes with inpatient permanent care increased by 2.0 percent or around 200 facilities. The total number of beds approved increased by 2.9 percent corre- sponds to 26,000 beds. The beds for inpatient permanent care increased by 2.2 percent associated with 18,600 beds. For day care, 7,800 beds were added with a growth rate of 18.0 percent. The number of 1-bed rooms is continuously gaining importance and increased by 5.6 percent or 29,500 beds for permanent care. In Table 4.4, the development of nursing homes and available beds from 1999 to 2015 is revealed.

Table 4.4: Nursing homes and available beds in nursing homes in Germany from 1999 to 2015, data source: Health report of the Federal Government (Gesundheitsberichterstattung,GBE)

The cost of care services in the nursing institutions is covered partially with a flat rate payment by nursing insurance fund based on the identified care levels. The uncovered cost have to be paid by the residents themselves. Usually, the cost for general nursing service, social care and medical treatment care are covered by LTCI. The residents have to pay for the accommodation and foods on their own [161]. This regulation is determined at the time of the construction of corresponding laws and is aiming to make the living cost of the people receiving care service at home and at stations fair and balanced, in order to avoid incorrectly motivating the people who need nursing care to make decisions of choosing nursing stations.

SUPERVISION AND EVALUATION OF NURSING INSTITUTIONS

The nursing institutions are monitored and controlled in a proper way in Germany to keep the market transparent and open. It is regulated by Bundestag, to prevent a closed market for authorized nursing institutions, to keep access to the care market open to new, innova- tive service providers and, thus to promote competition among care institutions [162, 163]. The pricing standards of nursing institutions are not determined by supply and demand but by a joint decision of LTCI, health insurance, welfare agency and carriers of nursing homes based on the care rate negotiation (Pflegesatzverhandlungen) (§ 82 SGB XI), be- cause it is believed that the market and competition can not bring ideal solutions to the nursing services [164].

In Germany, the elderly can evaluate and select a nursing institution through the fol- lowing public ways or channels:

• Nursing notes of the annual quality inspection according to §114 SGB XI (national

wide). Since 2009, the quality of care service in all ambulant institutions and all nurs-

ing homes would be checked (regular check). Once a year, the quality of ambulant and inpatient care institutions in the form of grades between "very good" and "poor" rated. On this basis, the nursing insurance fund create a transparency report for each nursing home institution and publish it on the Internet.

• Reports of the home inspection authorities (state wide). It is published by the higher national inspection departments supervising these nursing institutions. The insights gained by inspection department must be summarized in a standardized report and published in the authority’s internet portal. The inspection department go to nursing homes in certain time interval e.g. every two years; In addition, they can respond to complaints of the elderly people. Home-based supervision not only prepares reports on the home situation, but may also close deficient facilities.

• Non-profit project heimverzeichnis.de. Heimverzeichnis.de is a project of the so- ciety for the promotion of the quality of life for elderly people and those with dis- ability. Around 60 carefully trained honorary experts are traveling nationwide for the home directory. They check institutions that voluntarily register for an assessment according to the criteria of self-determination, participation and human dignity. The

inspections are consistently carried out from the consumer’s point of view, meaning that the appraisers only consider the interests of the people who live in a nursing home or senior residence.