LATEST FINDINGS

Ongoing InCARE survey on long-term care: we need you!

Please help us collect a large number of contributions to the InCARE survey on attitudes, experiences and expectations on long-term care. The aim of the survey is to understand how people view care for older people with support needs and how they assess long-term care systems.

Findings from this study will be used to raise awareness of the challenges faced by older people with care needs and their families, to advocate for policies that can support them, and to help design better support systems for older people, their families and communities.

You can help ensure as many people as possible are given the opportunity to express their views:

  • By filling out the survey here. This should take no more than 20 minutes of your time!
  • By disseminating the survey in your professional and personal network. Everyone is, or will be affected at some stage in their life by a need for long-term care support, and each contribution counts. You can simply share this link, or disseminate the survey via Twitter, or Facebook.

Ensuring all those who need it have access to high quality, affordable long-term care, in particular home-care and community-based services, is a major challenge throughout Europe and at the global level. Policy debates are ongoing on how to shape long-term care systems in the future: it is essential that people are given a voice and this survey will contribute to it. More highlights

Risk and preventive factors in juvenile delinquency studies

Interventions shall address several social institutions that can influence the life-course of young people. As young people tend to drift and shift between different social environments there are a number of opportunities to initiate turning points in family life, at school, in sport clubs, and in the local community.

Source: Stummvoll 2021

Interventions should be designed with creativity to

  • establish a strong attachment with positive role models
  • elaborate social programmes that allow juveniles to be committed to an accumulation of achievements in life
  • involve young people in meaningful activities other than "hanging around"
  • influence their moral convictions that guide their actions.

Social programmes need to make an offer in various local settings such as schools, sports, music, religion, arts and craftwork to support adolescents to better cope with stress, status frustration and stigmatisation. Read more

Loneliness and social isolation among older people in Europe

Loneliness and social isolation have a negative impact on quality of life and well-being. They also affect older persons much more than other age groups. The COVID-19 pandemic increased public attention to loneliness and social isolation, but more is needed to enhance knowledge about these phenomena and to promote public initiatives in this area. In our Policy Brief, we aim to raise awareness of this important issue. We present empirical evidence on loneliness and social isolation among older European citizens and provide a summary of existing interventions from across Europe.

Based on European comparative surveys, we find significant cross-country variation in the prevalence of loneliness and social isolation. Older persons in Eastern and Southern Europe are more likely to report frequent loneliness and fewer social contacts than in the Northern and Western parts of Europe.

Share of people aged 65 and older reporting feeling lonely (in %, 2016)

Share of people aged 65 and older reporting feeling lonely (in %, 2016)

Source: Own calculation based on EQLS 2016

The identified measures to tackle loneliness at old age include both top-down and bottom-up strategies, smaller-scale initiatives and complex interventions. Very few countries in Europe have nationwide strategies addressing issues of loneliness, social isolation and ageing in a comprehensive way. Read more about the results & examples hereMore findings

Study on Intergenerational Fairness

Our findings in the recently published Study on Intergenerational Fairness show that young adults (18-24) in most European Union countries experienced the strongest decline in disposable income during the economic and financial crisis from 2007-2014 while older generations (65+) saw the strongest relative income growth. The decline in young adults’ income was primarily driven by a drop in employment (market) income which was only marginally counteracted by automatic stabilisers like unemployment benefits or policy changes.

In addition, we used microsimulations to analyse what effects of different policy reforms would have had on the intergenerational distribution of income during this period. We find that an unemployment benefit for young adults with no qualifying period would have counteract the unequal growth in income. The combination of a tax on top income earners and financial support for households below the at-risk-of-poverty rate would have strongly reduced poverty and inequality while redistributing income from the prime-working age population (25-64) to younger and older age groups.

FutureGEN: Launch of the Data Navigator

On 12 May 2021, the FutureGEN team launched the Data Navigator, an open-access tool that allows the user to compare gender and socioeconomic differences in health and long-term care use for community-dwelling older people in Europe.

The Data Navigator uses data from the Survey on Health, Ageing and Retirement in Europe (SHARE) on individuals aged 65+ within 4 care regimes (Northern, Continental, Southern and Eastern care regime) from 2004 to 2017 and presents 5 health and long-term care related indicators: prevalence of individuals with ADL limitations, with IADL limitations, receiving formal care, receiving informal care, and providing informal care.

The Data Navigator can be used in research and advocacy work to understand the macro level trends in health and care taking place across care regimes, as well as for comparing how gender and socioeconomic inequalities have evolved over time. The Data Navigator is available here.

4 key principles for promoting social innovation in LTC

Our recent Policy brief shows that local innovators should shift focus away from 'best practice' initiatives and towards defining the 'best fit for purpose' initiatives. We highlight the need to match investment in social innovation design and development with investment in scale-up and sustainability of social innovation approaches, in order to increase societal impact. We propose four key principles that can guide social innovators in long-term care:

4 key principles for promoting social innovation in LTC

 

More about the InCARE project

Key findings on the use of formal and informal care in Slovenia and Austria

In Det_Caremix: Determinants of use of care in Slovenia and Austria, we compared two familialistic countries which rely heavily on the family in long-term care (LTC) provision. Key findings include:

  • 4 different pathways into caregiving that are influenced by reciprocal exchanges in the family, parallel life transitions (e.g. divorces, retirement), accumulation of disadvantages and the life trajectories of siblings.
  • Ideals of care among dyads practicing a care-mix in Austria reflect a strong role for the family but go beyond this and include e.g. involvement of care users in decision-making
  • Different types of unmet needs of care users as well as needs of informal carers exist despite the combination of informal and formal care. These pertain to how care is provided (e.g. timing of care, quality of care) and the possibility to develop caring relationships.  
  • Familialistic long-term care systems reinforce gender and socio-economic inequality in care provision and use, and we found no evidence that generous cash benefits have a sizeable effect in counteracting such inequalities
  • Higher socio-economic position for both households and individuals confers more choice with respect to care arrangements
  • Informal care provision interacts with other public policies, namely increasing statutory retirement age, although this interaction depends on carers’ socio-economic position.

Our policy briefs on the balance between formal and informal care provision, on gender and income inequalities shaping service use and on unmet care needs for long-term care provide further information on results (also in German). 

Key findings to tackle homelessness

The project ‘Mapping trends and policies to tackle homelessness in Europe’  aimed to provide a comparative assessment of national policies within corresponding social and health systems to prevent and address homelessness. We first developed a framework to measure relevant policies (read the Policy brief & see graph below):

Subsequently, we conducted a comparative analysis with the following key findings:

  • Not all European Union countries acknowledge the right to adequate housing as an individual enforceable right. And even if the right is acknowledged, the rights frequently do not generate effective policy outcomes for people who are at risk of homelessness or already homeless.
  • From a systemic policy perspective, homelessness is characterized by insufficient resources allocated by governments to abandon it and by subjective as well as objective access barriers for people to benefits and service. This results in inadequate coverage and/or non-take up of benefits and services.
  • Important findings furthermore include that access to adequate housing frequently is also restricted for vulnerable groups, mainly due to limited supply. Absence of reliable funding and sufficient affordable housing supply hinder a more widespread use of ‘housing first’ approaches.
  • While inadequate minimum income benefits represent a major problem for homeless people, housing allowances lose their preventive function if inadequate compensation for real housing costs is provided.
  • Despite wide-ranging health services for homeless people across Member States, barriers remain in utilizing these services. Improving access to healthcare will require addressing access barriers in mainstream healthcare services (e.g. eligibility conditions, lack of address). Read the Info sheet

Findings of the Con3Post project

The findings of the Con3Post project investigating mobility and posting flows between third countries, EU-sending and EU-receiving countries indicated that immigration of third country national (TCN) workers is driven largely by economic discrepancies and wage disparities between the third countries and EU countries, as well as political and economic instabilities in the third countries. We found that

  • some companies have become quite active in the wider European markets providing services through posting of TCNs, which has in many cases become a business model for profit maximisation;
  • the intersection of the migration and employment regimes may enhance the vulnerabilities of posted TCN workers, who tend not to defy or report their employers, on whom they depend not only for employment but also for the renewal of their work and residence permits in the sending country;
  • despite the mechanisms for control and enforcement of national/EU standards, the vulnerability of TCN posted workers persists due to the cloaking effect of the posting employment characterised by subcontracting, cross-border mobility and temporary service provision.

 

Interreg Austria-Hungary: Age-Friendly region finalised

“Age-friendly Region” (AFR) aimed at developing new care models so older people can live longer at home with the best possible quality of life, including:

  • Tailored case & care management 
  • Interregional cooperation among organizations in Styria & Western Hungary 
  • Evaluation by the European Centre 

A pre-post survey of 100 health and care experts indicated that networking and collaboration improved during AFR. Also, 230 older clients reported their health status, which they assessed about 3% higher at the end—compared to older people without AFR services (e.g., on the EQ-5D visual analogue scale).

The evaluation points to a positive direction of AFR effectively addressing growing LTC needs, and recommends:

  • Making services participative, integrated & interdisciplinary,
  • Considering regional differences, and
  • Continuing AFR sustainably. 

 

 

 

AFR was funded by the European Regional Development Fund. More details at here

Prevention Practices on Polydrug Use among Youth in Criminal Justice Systems

The project EPPIC (Exchanging Prevention Practices on Polydrug Use among Youth in Criminal Justice Systems) has come to an end. At the closing conference, researchers from 6 partner countries presented research findings:

  • Trajectories of young people who use drugs and who have come in contact with the criminal justice system.
  • Legal and socio-cultural contexts for the provision of interventions.
  • A set of newly developed quality standards to guide the development of services for this target group in the future.
  • Knowledge exchange and transferability were discussed among stakeholders from EPPIC partner countries.

In this project, funded by the 3rd Health Programme of the European Commission, project partners from 6 countries collaborated to gather knowledge, exchange best practice, and identify transferable innovations & principles of good practice on interventions to prevent illicit drug use, the development of polydrug use, and use of NPS among young people in touch with the criminal justice system.

Read more: Policy Brief and www.eppic-project.eu

Successful completion of the social services project in Kosovo

The project Support for better social services for the most vulnerable groups in Kosovo was successfully completed, as co-implemented with Save the Children and financed by the European Union and SIDA. To navigate the decentralization process, the project contributed to the effective transformation of the social service system, focusing on improved quality, availability and sustainability of social community-based service delivery for vulnerable people living at social risk.

The project engaged central, municipal and non-state actors to collaborate on delivering community-based social services. The European Centre team supported municipalities in developing local action plans for service provision. They led the situation analysis of municipal social service provision, capacity building of stakeholders such as social workers, and the development of a financial allocation model. The funding model considers particular vulnerabilities of each municipality and will guarantee sustainable financing of social services throughout Kosovo.

Institutional Capacities for Implementing the Posting of Workers Directive in the Western Balkans: A Needs Assessment

The assessment of the institutional capacities and needs of the four candidate countries of the Western Balkans: Albania, Montenegro, North Macedonia and Serbia, to implement the Posting of Workers Directive (96/71/EC) was conducted in the context of the policy process cycle and in terms of six interdependent domains: legal framework, institutional arrangement, inter-agency cooperation, human resources, stakeholder engagement, and public governance. Findings indicate that

  • the Directive has been only partially transposed in the Western Balkan countries and the existing legislation does not include all the elements of the Directive and the Enforcement Directive,
  • other relevant mechanisms such as bilateral agreements on social security coordination and health care are incomplete,
  • institutions responsible for the implementation of the Directive are either partially or not established,
  • liaison offices for interagency cooperation and information dissemination have not been established,
  • more training and information on posting are needed by human resources,
  • trade unions, employer organizations, Chambers of Commerce and NGOs have not been actively involved in the process in the Western Balkan countries, except partial consultation.

To address the needs identified, candidate countries must complete the legal framework and establish protocols of intra-agency cooperation, mandate public authorities and build their capacities on posting, as well as include social partners more actively in the process. Read more here.

Taking a human rights-based approach in monitoring policies for older people in Europe

The research team of the European Centre developed two tools that can contribute to monitoring legislation and policies and their outcomes for older people in Europe:

  • the Rights of Older People Index (ROPI) on Structure and Process Indicators and
  • the Scoreboard on Outcome Indicators.

These tools are building on the conceptual framework, created also part of the project, building on the achievements of the disability rights discourse. Categorized under the 10 domains of the conceptual framework, the ROPI Index includes 35 indicators and the Scoreboard includes 17 indicators, relevant for the rights of older people with care and support needs. Together, the ROPI and the Scoreboard fill an important gap, as multi-dimensional tools to monitor the situation of older people with care and support needs, based on a human-rights approach and highlight gaps in legislation and the implementation of policies, as well as gaps in data. Read more here about the results of the ROPI.

Some key findings:

ROPI:

  • In the ROPI, Sweden has the highest overall score, Finland positions itself second, slightly ahead of Slovenia, Ireland and Austria. Switzerland, Italy and Poland have the lowest index score.
  • Even in front-runner countries in the ROPI there is a substantial room for improvement. There is no obvious geographical clustering in the overall ranking results.
  • Areas where countries performed well in the ROPI by having legislation and policy frameworks to protect older people in place, included: Participation & social inclusion and Freedom of expression, freedom of thought, conscience, beliefs, culture and religion.
  • Areas where the need for improvement seems to be especially pressing include Life, liberty, freedom of movement & freedom from restraint; Privacy & family life; Adequate standard of living and Remedy & redress.

 

Key recommendations by the Employment Thematic Network (ETN) for improving European Social Fund (ESF) policies

The Thematic Network Employment (ETN) helps EU Member States to improve their ESF policies for public administration. The goal of the network is promoting good practice and mutual learning through meetings, transnational exchange and cooperation. The European Centre and its project partner AEIDL (European association for information on local development) implement transnational cooperation through the ETN. Anette Scoppetta is the thematic expert for the Thematic Network Employment. Read more about the project.

The ETN presents the following key recommendations for improving ESF policies of this year:

Job carving and job crafting

  • is a useful HR management tool to tailor jobs according to people’s talents.
  • can prevent unhealthy work practices. It can be used for people with (temporarily) reduced work capacity, and it creates meaningful and productive employment for all people. Read more here

Socially Innovative Entrepreneurship

  • Public administration should build ‘enabling ecosystems’ for socially innovative entrepreneurs to introduce new products, services or practices. It should also develop policy frameworks that reflect the varying requirements of vulnerable groups when starting a business.
  • ESF should increase offers for coaching and mentoring for entrepreneurs. Read more here

Labour market transitions in the Future of Work

  • Public administration should adjust polices towards increased labour market transitions and the coverage of new forms of employment.
  • Public administration should enhance equality between people with migrant backgrounds and the ‘working poor’. It should eradicate gender bias that exists in many policies. Read more here

More findings

Falling through the social safety net? The case of non-take-up in Austria

Using the tax-/benefit microsimulation model EUROMOD/SORESI based on Austrian EU-SILC data the European Centre carried out an up-to-date analysis of the extent and social determinants of non-take-up of minimum income benefit and monetary social assistance in Austria. Within the system of benefits of last resort minimum income benefit replaced monetary social assistance in 2010/11. The study was supported by funds of the Oesterreichische Nationalbank. More

Overview of analyses and datasets

Extent of non-take-up

  • 2003 monetary social assistance: 61,000 households/ 49%; 150 million EUR/ 39%
  • 2009 monetary social assistance: 114.000 households/ 53%; 423 million EUR/ 51%
  • 2015 minimum income benefit: 73.000 households/ 30%; 328 million EUR/ 30%: with the new benefit statistically significant decrease of non-take-up
  • in case of 100% take-up in 2015 the at-risk-of-poverty rate would drop by 0,7 pp

Determinants of (non-)take-up (socio-demographic characteristics of households rather taking-up; for personal characteristics: main earner in household)

  • Higher poverty gap (2003, 2009)
  • Renting of dwelling (no home ownership) (2009)
  • Lower education level (2003, 2009, 2015)
  • Unemployed, inactive (2003, 2009)
  • Lone parent (2009)
  • Vienna/ larger residential municipality

Exchanging prevention practices on polydrug use among youth in criminal justice systems

 

Best practice examples on prevention of polydrug use among young people in the CJS:

189 interviews with young people in 6 European countries were conducted to learn about drug use trajectories and factors of onset, persistence and desistance. This information was used to identify key points for intervention and to obtain perceptions and experiences of interventions to prevent or reduce drug use:

  • Early drug consumption is rooted in a combination of social milieu, opportunity and sheer curiosity and inquisitiveness.
  • Young people in the criminal justice system (CJS) show multiple problems, including needs in physical and mental health, criminal activity, broken family relationships, educational problems, and social deprivation. Prevention responses shall look beyond drug use or criminal activity and include personality traits, and social circumstances of clients.
  • Specific challenges arise in interventions delivered in custody: Uncertainty of length of stay (remand prison); short sentences impinge on the effectiveness of interventions; reluctance to admit drug use in prison settings; motivation of young people to participate in trainings; transition from youth to adult services at age 18.
  • Funding: Many interventions for drug prevention in Europe are funded on a short-term basis (1-4 years). Outside the prison system, projects often lack sustainability and face inadequate resource allocation.

Read more about the project and see the project page.

Findings of the POOSH comparative report

The findings of comparative analysis based on the results of the nine country reports (namely: Austria, Belgium, Croatia, Germany, Italy, Romania, Slovakia, Slovenia, and Spain) indicate that the temporary, mobile and transnational character of posting affects the health and safety of posted workers in multiple ways and involves several different aspects:

  • economic vulnerability and dependence on the employers make workers comply to poorer working and living conditions;
  • cases of injury reveal various irregularities to posted workers' health insurance and care;
  • while each country has complex systems of OSH providing for both prevention and protection of workers, posted workers do not necessarily take advantage of the existing mechanisms.

This is partly due to their lack of knowledge on host countries OSH structures and mechanisms, and partly because of their hesitation to go to the authorities, but it is also partly because of the inadequate response of enforcement organizations. Furthermore, lack of or limited access to collective representation lowers workers' level of protection and language barriers limit their access to information which has a wide range of implications – from exercising their employment rights, including health and safety rights, to accessing healthcare and housing and managing their daily lives. Aware of the challenges, stakeholders demand more coordinated and cohesive action. More

Notes: Full dots indicate language barriers identified by informants as a problem for workers posted to the respective countries, while empty dots highlight specific aspects of language barriers. In the case of Romania, the information relates to language barriers for workers posted from Romania working in international road transport.

 

POOSH country report in Austria

Posting is an important form of transnational temporary labour mobility for Austria. With a total of 108,627 of PDs A1 issued in 2015 for posted workers coming to Austria, the country ranked 4th in the EU after Germany, France and Belgium. The temporary migration and employment status affect the situation of EU and TCN workers posted to Austria in multiple way.

  • Firstly, employers pay less attention in terms of OSH training towards them;
  • secondly, their temporary status marks them as workers who are easier to exploit and pressure to accept unsatisfactory working/OSH conditions;
  • thirdly, it also influences posted workers’ behavior in so far as due to their short-termed stay, they tend not to inform themselves sufficiently about their rights and the regulations in Austria.
  • The last point is caused by a lack of integration and a feeling of not belonging of posted workers themselves into the Austrian system, which again are caused by the temporariness of their stay.

National competent authorities and agencies in Austria have made great attempts early on after the transposition of the Posting of Workers Directive (96/71/EC) to protect posted workers from increased OSH-related risks. Yet, data from our research suggest that vulnerabilities still persist. Read more

 

Working conditions of the long-term care workforce in Austria

The results of the NORDCARE survey show manifold insights into the working situation of the long-term care workforce in Austria. Overall, long-term care workers, particularly in the residential care sector, have experienced a deterioration of working conditions over the last years. On the one hand this can be related to the increasing demands and needs of people in need of care, on the other hand time limitations and staff shortages add to such experiences. Long-term care workers are therefore confronted with numerous burdens and demands at the workplace. While the application of individual coping strategies partly helps to deal with such burdens, high levels of psychological and physical constraints nevertheless result in a subjectively perceived bad health status. Despite organizational characteristics it is thus the health status that significantly impacts on the future considerations of the workforce to continue working in the sector. In order to secure sustainable human resources for the long-term care sector, prevention and health promotion measures as well as developments in work organization such as autonomous and person-centered forms of work are key factors in improving working conditions. More...

Old age carers (80+) more likely to be men in European countries

Share of young people not in education, employment or training

Source: WHO/Europe (2018) The health and well-being of men in the WHO European Region: better health through a gender approach, based on data from SHARE (wave 6)

Caregiving has traditionally been associated with feminine values, but recent data point to a gender role inversion in later life. It is well established that men are less likely to engage in unpaid work and provide filial care or care to older family members during adulthood, when a large proportion of men are engaged in remunerated work activities. Even once they reach older age, a lower proportion of men, with respect to women engage in care provision in virtually all European countries. However, while the proportion of men carers decreases with age in later life, it does so slower than is the case for women, leading to a situation where a greater share of men in the oldest age groups act as informal carers than women. Informal care provided by older men is generally concentrated on care for their spouses and takes place within the household. The higher prevalence of carers among older men is closely linked with differences in living arrangements, which are in turn closely related and sensitive to changes in, the health, marital and socioeconomic status of the older population. More...

Decentralization of social services has been a continuing challenge for Kosovan municipalities

Source: Own illustration based on the latest Census data (2011) and interviews with municipal staff conducted in 2017

A specific budget line for social services from the Ministry to the municipal government does not exist yet, which has led to inadequate staffing, facilities and service provision. Other sources of income from private or nongovernmental donors have been fluctuating. The formerly centrally governed Centres of Social Work have not been fully incorporated into the municipal structures.

Inadequate funding is further aggravated by its uneven distribution across municipalities. As shown in the graph, the ratio between social services staff and the population is markedly different among municipalities of similar size. While larger municipalities tend to employ fewer social services staff per population, some larger municipalities such as Ferizaj/Uroševac not only manage a better ratio, but also cooperate with NGOs in providing social services.

For 2019, a specific budget line for social services is planned. Detailed account of decentralizing social services delivery in Kosovo can be found in the original Situation analysis prepared by the European Centre and Save the Children Kosovo and a policy brief by Rahel Kahlert and Sonila Danaj. More...

 

Housing remains costly and unaffordable for many European households

Source: Own illustration based on data from European Central Bank Statistics, OECD National Accounts Statistics and Eurostat Database, EU-SILC.

Housing affordability has become a central issue in recent years as some population groups find themselves priced out of the housing market in some European countries or cities. Although the financial crisis depressed housing prices, these have in the meantime recovered in most countries. Disposable income however, particularly among lower income households, has yet to increase significantly, with housing costs representing nowadays a significant financial burden on low income families. The share of households "overburdened" by housing costs (i.e. the latter represent more than 40% of disposable income) ranges from between 33%-34% in Hungary and Italy, to 42-43% in the UK and the Netherlands. Countries have implemented housing allowances to alleviate this problem, and although these allowances overwhelming target the poor, their poverty reducing impact is somewhat limited. Detailed account of why this is the case, further results and policy implications can be found in the original research note and in a policy brief by Eszter Zólyomi and Katarina Hollan.

Long-term care in Europe: Socio-economic inequity in utilization of formal and informal care services

The use of both formal (home-based care services) and informal care across Europe is unequally distributed among income groups, with poorer individuals using significantly more long-term care. In the case of home-based care, differences in utilization basically reflect differences in needs: less affluent older people have, on average, poorer health. Only in Denmark and Estonia (both pro-poor) and Italy and Spain (both pro-rich) is the distribution of home care use inequitably distributed across income groups. For informal care, however, there is strong evidence (9 out of the 15 countries considered) that poorer older people disproportionately use this type of care even after accounting for different needs. This may suggest financial barriers in accessing home care services. Detailed results and a discussion of policy implications can be found in the original research articles by Ricardo Rodrigues and Stefania Ilinca (and Andrea E. Schmidt) in EuroHealth, the International Journal of Environmental Research and Public Health and Health Economics.

A framework for a human rights-based approach to care & support for older people

The framework outlines what the fulfilment of universal human rights necessitates when applied to the case of older people with care and support needs and is organised according to three key domains:

  1. Desired outcomes: fulfilment of rights;
  2. Enabling processes: monitoring and enforcement; and
  3. Structural conditions: legal recognition.

These correspond with three areas across which the implementation of fundamental rights can be measured: results (outcome indicators); effort (process indicators); and commitment (structural indicators). The framework was developed as part of the ongoing project, 'From disability rights towards a rights-based approach to long-term care in Europe: Building an index of rights-based policies for older people'. More...

A framework for a human rights-based approach to care & support for older people

Five tension points in dementia community care

Our framework attempts to capture the complexities and interdependencies inherent to the organization of community-based dementia care along the disease trajectory, recognizing the roles played by the various actors involved. Furthermore, we include the socio-cultural, economic, and legal and governance context of community care for people with dementia in our framework.

5 Tension Points in Dementia Community Care

While we do not develop each of these dimensions in depth, we emphasize instead how each interacts with and affects the organization and quality of community-based care by linking them with 5 core tensions, or ‘Tension Points’ within the system. More...