APPARENT QUESTION
How can we spend less on APA ?
A saving within the program can create EHPAD expenditure, a family burden and a human rupture.
SOCIAL PROGRAMS · DEPARTMENTAL COUNCIL CASE: APA PROGRAM
How do you redesign a departmental APA program to preserve aging at home under budget constraints ?
For the department, it is a budget line growing by 6 % per year. For the beneficiary, it is the number of years they will be able to continue living at home.
The program covers 28,000 home-based APA beneficiaries at an annual cost of 168 M€. The question is not whether the support is useful, but which redesign contains the budget trajectory without bringing forward the date when people can no longer remain at home.
- DECISION
- Redesign a departmental APA program
- POPULATION
- 28,000 beneficiaries living at home
- HORIZON
- 36-month projection
- KEY ISSUES
- Aging at home · consolidated cost
ANNUAL SPENDING
168 M€
TREND
+6 % per year
CONFIGURATIONS
6 redesigns tested
REDESIGNING A DEPARTMENTAL PROGRAM
A real budget constraint,
on a program central
to aging at home.
Personalized autonomy allowance spending is rising by 6 % per year, driven by the department's aging population, and reaches €168 million annually amid budget pressure.
The risk is twofold. An overly restrictive redesign undermines aging at home and brings forward moves into EHPAD residential care, whose cost is several times higher than home-based APA. A redesign that is not structural enough fails to control the budget trajectory.
The deputy director-general used our system to test six differentiated redesign configurations.
- revision of benefit caps
- adjustment by dependency profile
- stronger upstream prevention
- integrated program
- enhanced monitoring program
- hybrid configuration
THE FALSE TRADE-OFF
The question being asked was not
the decision that had to be made.
REAL QUESTION
How can we minimize the consolidated cost of dependency while preserving aging at home ?
The evaluation scope becomes all costs shifted by the redesign, rather than the program's own budget.
Direct cost consolidated cost.
FIRST REVELATION
Save within the program,
spend on its consequences.
REVISION OF BENEFIT CAPS
- −4 % spending over 36 months
- +22 % moves into EHPAD residential care
- higher consolidated downstream cost
STRONGER PREVENTION
- −18 % net budget savings over 36 months
- slower movement into EHPAD residential care
« The restriction saved money within the program and spent more on its consequences. »
SECOND REVELATION
Home adaptation
within the first 24 months.
— home adapted: 82 % still at home at 60 months· · · no adaptation: 58 % move out by 60 months| end of the 24-month window
- grab bars
- bathroom adaptation
- improved lighting
- threshold removal
The strongest structural determinant of remaining at home at 5 years is neither the amount of the support plan nor the initial dependency level, but home adaptation within the first 24 months after entering the program.
Small adaptations major trajectory.
THIRD REVELATION
Social support
is a determinant of remaining at home.
ISOLATED BENEFICIARIES
Fewer than one non-professional visit per week.
Risk of an earlier move multiplied by 2.4.
REGULAR SOCIAL SUPPORT
At least one non-professional visit per week : family, neighbors, community organization, volunteer mentoring.
Support that reduces isolation changes the trajectory at lower cost.
AUTONOMY MEDICAL ONLY
28,000 beneficiaries.
11 dependency trajectory profiles
of dependency.
SIMULATED POPULATION
The synthetic population was calibrated using the department's proprietary data, the AGGIR scale, dependency histories and current support plans, together with national studies on dependency trajectories.
3,400 synthetic beneficiaries and family caregivers were interviewed across the 6 configurations, with dynamic follow-ups on tipping points : home adaptation, access to prevention programs, and moments when remaining at home breaks down.
- age
- measured dependency level
- household structure
- residential environment
- social isolation
OLDER PEOPLE AT HOME, FAMILY SUPPORT PRESENT
established dependency, regular family support, home often not adapted
OLDER PEOPLE AT HOME, FAMILY SUPPORT ABSENT
fewer than one non-professional visit per week, 2.4× higher risk of an earlier move out of the home
MODERATE DEPENDENCY, ADAPTABLE HOME
adaptation window open during the program's first 24 months
MODERATE DEPENDENCY, CONSTRAINED HOME
thresholds, bathroom facilities and lighting difficult to modify in the short term
OLDER COUPLES CARING FOR EACH OTHER
remaining at home supported by a family member who is also aging
BENEFICIARIES WITH A CLOSE FAMILY CAREGIVER
rising family burden, sustained tolerance but not unlimited
BENEFICIARIES IN ISOLATED HOMES
residential environment distant from services and community organizations
BENEFICIARIES IN URBAN CENTERS
higher density of services and potential visits
RECENT ENTRANTS TO THE PROGRAM
trajectory still open, highly sensitive to the first 24 months
- PROPRIETARY DATA
- AGGIR scale
- HISTORICAL DATA
- Dependency trajectories, support plans
- REFERENCES
- National studies on dependency
These profiles reveal part of the population's heterogeneity. The simulation operates on synthetic individuals, not a handful of persona types.
THE 6 CONFIGURATIONS
The same program.
Six ways to redesign it.
The six configurations were tested against the same population to isolate the effect of each mechanism on aging at home, the program's own spending and the department's consolidated costs.
- 01REVISION OF BENEFIT CAPSBudget savings limited to 4 % over 36 months, but moves into EHPAD residential care accelerate by 22 %: consolidated downstream costs for the department ultimately increase.
- 02ADJUSTMENT BY DEPENDENCY PROFILEDifferentiating support plans according to measured dependency level and projected trajectory.
- 03STRONGER UPSTREAM PREVENTIONTelecare, home adaptation, fall-prevention workshops, reducing isolation: 18 % net budget savings over 36 months, driven by slower movement into EHPAD residential care.
- 04INTEGRATED PROGRAMCombination of several redesign mechanisms within the same departmental program.
- 05ENHANCED MONITORING PROGRAMStructured reassessment of the beneficiary's situation over the trajectory, particularly 24 months after entering the program.
- 06HYBRID CONFIGURATIONStronger upstream prevention, maintained benefit caps and enhanced monitoring at 24 months.
REVISION OF BENEFIT CAPS
−4 % spending over 36 months
+22 % moves into EHPAD residential care
STRONGER PREVENTION
−18 % net budget savings
over 36 months
Less support less spending.
METHOD
Before recommending,
we tested reactions.
- 28,000 BENEFICIARIES
- 11 TRAJECTORY PROFILES
- 6 CONFIGURATIONS
- 3,400 BENEFICIARIES AND FAMILY CAREGIVERS INTERVIEWED
- TIPPING POINTS PROBED
- 36-MONTH PROJECTION
- CONSOLIDATED COSTS
- 01
UPSTREAM PREVENTION DELIVERS GREATER SAVINGS THAN REVISING BENEFIT CAPS
Revising the caps generates 4 % savings over 36 months and 22 % more moves into EHPAD residential care. Stronger prevention generates 18 % net budget savings over the same period.
- 02
HOME ADAPTATION WITHIN 24 MONTHS IS THE KEY DETERMINANT OF REMAINING AT HOME AT 5 YEARS
82 % of beneficiaries whose homes are adapted within this window remain at home at 60 months. 58 % of beneficiaries without adaptations move into EHPAD residential care by 60 months.
- 03
REDUCING ISOLATION IS THE SECOND STRUCTURAL DETERMINANT
Fewer than one non-professional visit per week multiplies the risk of an earlier move by 2.4 compared with beneficiaries who have regular social support.
Imagine All The People does not ask a model to imagine what an older person might think of a support plan. Six redesign configurations are tested against a coherent, heterogeneous synthetic population, modeling moves into EHPAD residential care and consolidated costs before the decision is made.
STRATEGY SELECTED
Hybrid configuration :
prevent rather than restrict.
- 01systematic telecare
- 02facilitated home adaptation within 24 months of entering the program
- 03support from a departmental occupational therapist
- 04fall-prevention workshops
- 05partnership with local community organizations to reduce isolation
- 06maintaining benefit caps
- 07enhanced monitoring at 24 months
THEN REALITY ARRIVED
At 24 months after deployment,
the indicators are in line
against projections.
- HOME ADAPTATION AT 24 MONTHS
- 22 % → 74 %in line with the projection
- EARLY MOVE INTO EHPAD RESIDENTIAL CARE
- −18 %vs previous period
- APA SPENDING FOR HOME SUPPORT
- stableover the observed period
- CONSOLIDATED DEPARTMENTAL SAVINGS
- 24 M€ / yearon social assistance for residential care
SIMULATION
Stronger prevention : −18 % net budget savings over 36 months, versus −4 % and +22 % more moves under the cap-revision scenario.
OBSERVATION
Home adaptation at 24 months increased from 22 % to 74 %, early moves into EHPAD residential care fell by 18 %, home-based APA spending remained stable, and consolidated annual savings reached 24 M€. The program was referenced by the CNSA as a methodological model.
TAKEAWAY
« The right saving was not
to reduce support. It was to prevent
beneficiaries from moving earlier
into a much more costly system. »
« Two variables dominated the trajectory : adapting the home early enough and preventing isolation from becoming structural. »
- 01A program's direct cost is not its consolidated cost.
- 02An upstream restriction can create downstream additional costs.
- 03A few determinants can dominate a long-term trajectory.
- 04A social policy should be judged by its tipping points, not only by its own budget.
- 05Imagine All The People makes it possible to simulate a social-program redesign as a trajectory of tipping points rather than as a budget line.
A real case.
A confidential organization.
This case is based on a completed simulation. The organization and location are not named where confidentiality requires it. The decision, configurations tested and findings are presented without revealing information that could identify the client.
