Assessing Care Dependency and Long-Term Care Needs in Viet Nam: Building a Practical Needs-Assessment Framework for Safe, Equitable and Person-Centred Care
MEASUREMENT, IMPLEMENTATION & LEARNINGLONG-TERM CARE QUALITY
Assessing Care Dependency and Long-Term Care Needs in Viet Nam: Building a Practical Needs-Assessment Framework for Safe, Equitable and Person-Centred Care
MEASUREMENT, IMPLEMENTATION & LEARNING, LONG-TERM CARE QUALITY
Last reviewed: October 2026
Two older people can be the same age, have many of the same diagnoses and still need very different kinds of care. One may live with diabetes, hypertension and osteoarthritis but continue to cook, bathe, manage medicines and move around the community independently. Another may have fewer diagnoses but need help getting out of bed, using the toilet and eating, while a third may remain physically mobile but require regular supervision because of significant cognitive impairment.
A diagnosis list alone therefore cannot tell us how much care a person needs. Neither can age, frailty status or one functional score.
This question is becoming increasingly important as Viet Nam develops more options for older-person care at home and in the community. The Population Law No. 113/2025/QH15, enacted on 10 December 2025 and effective from 1 July 2026, requires diversified forms of older-person care and support appropriate to older people’s level of autonomy and the needs of different groups. Article 18 recognizes self-care, care at home, community care, and care in older-person care facilities or medical facilities, while also providing for support to family members through training, counseling and technical assistance.
That policy direction raises a practical question for health, community and long-term-care services: How do we determine what support an older person actually needs, how much support is required, what is already available, and what remains unmet?
A useful answer cannot come from one score alone. It requires a practical, multidimensional and person-centred assessment.
Care dependency is not the same as frailty, disability or loss of intrinsic capacity
Several concepts used in older-person care overlap, but they answer different questions. In this article, care dependency is used as a practical assessment concept. It should not be read as a single statutory dependency category created by the Vietnamese older-person care instruments discussed below.
WHO defines intrinsic capacity as the combination of a person’s physical and mental capacities. Functional ability reflects intrinsic capacity, the environment in which the person lives, and the interaction between the two. Someone with reduced mobility may therefore function relatively well in an accessible home with appropriate assistive products and support, while another person with similar physical capacity may struggle in an unsafe environment without assistance.
Frailty describes increased vulnerability to stressors. A person can be frail but remain largely independent, although frailty may increase the likelihood of dependency after an infection, fall or hospitalization. Disability and care dependency also overlap without being equivalent: disability can affect mobility, sensory function, communication or participation without necessarily requiring continuing assistance from another person.
Care dependency asks a more operational question: how much assistance, prompting or supervision does this person need to manage everyday life safely?
WHO’s current long-term-care monitoring takes a similar functional approach. Need for LTC is identified through standardized assessment of functional limitations, typically difficulty or dependency in one or more basic activities of daily living, and may also include the need for supervision because of significant cognitive impairment. WHO also cautions that comparisons between countries are difficult because assessment instruments, eligibility thresholds and cultural interpretations of dependence differ.
These concepts should therefore not be treated as interchangeable. Frailty can identify vulnerability; intrinsic-capacity assessment can identify declines in physical or mental capacities; disability can describe important limitations; and care-dependency assessment asks what practical assistance or supervision is required. Long-term-care assessment then needs to place those requirements within the person’s clinical, social and environmental circumstances.
Long-term-care need is more than an ADL score
Activities of daily living are an essential starting point because they make dependency visible in everyday terms. Can the person move around the home, use the toilet, dress, bathe, maintain personal grooming and eat without help?
These activities are closely reflected in the ICOPE-based tool incorporated into Ministry of Health Decision No. 1976/QĐ-BYT of 1 July 2026. Its assessment includes difficulty walking inside the home, using the toilet, dressing, bathing, maintaining personal appearance and eating.
But knowing that someone needs help bathing does not yet tell us what the care plan should be. One person may need physical assistance getting safely into a shower. Another may be physically capable but forget the sequence of the task because of dementia. A third may bathe independently if grab rails and an appropriate seat are installed. Someone recovering from stroke may require substantial assistance now but have realistic potential to regain independence through rehabilitation.
Care dependency should therefore not automatically be treated as permanent. Assessment needs to ask not only what the person has difficulty doing, but why the difficulty exists, what assistance makes the activity possible, what may improve with treatment or rehabilitation, and whether the environment is increasing or reducing dependency.
Cognitive needs are equally important. An older person with dementia may still walk, dress and eat independently but become lost outside the home, use medicines unsafely or be unable to respond appropriately to an emergency. Their main need may be supervision, cueing, decision support or environmental safety rather than hands-on physical assistance. WHO’s current LTC indicator explicitly allows supervision because of significant cognitive impairment to contribute to the definition of LTC need.
The opposite also matters: cognitive impairment should not automatically be interpreted as total dependency. People may retain important abilities, routines and preferences for a long time. A good assessment should identify what the person can still do as carefully as it identifies where assistance is required.
The aim is not to label someone “independent” or “dependent” as quickly as possible. It is to understand the pattern, intensity and potentially changing nature of their support needs.
Long-term care spans health, personal care and social support
An older person may have substantial healthcare needs without being dependent in everyday life. Someone receiving dialysis, cancer treatment or complex medication management may remain independent in basic activities. Conversely, another person may need considerable daily assistance even when no acute medical treatment is required.
Long-term care therefore spans health and social care. WHO’s framework for an integrated continuum of LTC specifically aims to integrate long-term-care services within existing health and social-care systems, while its 2024 UHC package provides interventions that countries can adapt across sectors, services and care settings.
A practical assessment should consequently distinguish several questions instead of collapsing everything into one dependency score. What health problems require clinical care or monitoring? What everyday activities require assistance, prompting or supervision? Is there potential for rehabilitation or recovery? Could environmental modification or an assistive product reduce dependency? What social support is needed? Is the current caregiver arrangement sustainable? And what matters most to the older person?
Different needs require different responses. Medication review requires clinical expertise. Difficulty transferring from bed may require rehabilitation, equipment or physical assistance. Loneliness will not be solved simply by increasing nursing visits. An inaccessible bathroom may create dependency that can partly be reduced through environmental modification.
The purpose of assessment is therefore not merely to document deficits. It is to identify the right combination of healthcare, personal assistance, rehabilitation, social support, environmental modification and caregiver support for the individual person.
The person’s environment and support network are part of the assessment
Care need does not exist only inside the individual. Consider two people with the same difficulty walking. One lives in a single-level home with handrails, an accessible bathroom, an appropriate mobility aid and a family member who can provide limited assistance. The other lives alone on an upper floor without a lift and has no nearby support. Their physical limitation may be similar, but their safety risks, feasible care arrangements and unmet needs are very different.
Decision 1976 already moves beyond a purely medical assessment. In addition to personal-care needs, its ICOPE-based tool examines social-support issues such as housing, financial problems, loneliness and inability to participate in activities that are meaningful to the older person. The application then proceeds toward person-centred goals and agreed care actions.
WHO’s second edition of ICOPE, published in September 2025, follows the same broader direction: detect declines in intrinsic capacity, identify social-care and support needs, and develop a personalized care plan in primary care, including community settings.
This leads to a simple but important principle for needs assessment in Viet Nam: assess the person and the environment together.
A mobility aid is useful only if it works in the person’s home. A discharge plan that assumes family support is safe only if somebody is genuinely available, capable and willing to provide that support. A person may technically be able to remain at home but have unsafe housing, severe social isolation or caregiver circumstances that make the arrangement unsustainable.
Family support should not make underlying need disappear
This distinction is especially important where family members provide much of the day-to-day care. Suppose two older people both require substantial assistance with bathing, dressing and toileting. One lives with an adult child who currently provides that care every day; the other lives alone. Their underlying need for assistance may be similar even though the support available to them is very different.
If assessment records only whether a need is currently unmet, the first person may appear to require little support because the family is already absorbing the workload. That can make caregiver burden invisible and create inequity between people whose families differ in available time, health, finances and practical capacity.
A stronger approach separates the person’s underlying need, the support currently available and actually being received, and the remaining unmet need or risk.
WHO’s current LTC coverage indicator illustrates why this distinction matters. It measures receipt of formal LTC services but does not capture unpaid family care and does not show whether the frequency, intensity or quality of services received is adequate relative to need. WHO has also highlighted sex- and gender-related inequalities within LTC and the different burdens experienced by carers, while noting more broadly that informal caregiving responsibilities disproportionately affect women in many settings.
The caregiver should therefore be assessed as part of the care environment, but the presence of a caregiver should not erase the older person’s underlying need.
Viet Nam now has a stronger foundation for needs-based older-person care
Viet Nam’s legal and professional framework changed substantially during 2025–2026. Article 18 of the Population Law No. 113/2025/QH15 requires diversified forms of care appropriate to older people’s autonomy and needs. It recognizes self-care, home care, community care, and care in older-person care facilities or medical facilities, and provides for family support through training, counseling and technical assistance.
Decree No. 168/2026/NĐ-CP, issued on 15 May and effective from 1 July 2026, provides more concrete arrangements for home and community care. It establishes community-care clubs and a model of community day-care points for older people under commune-level health stations. These are day-care rather than residential services; they do not have separate legal personality and do not provide medical examination or treatment. They may operate at an existing commune health station, health-station site, cultural house or another suitable local location.
Decision 1976/QĐ-BYT then adds professional guidance. Professionals at commune health stations, population collaborators, village health workers, social workers and trained volunteers can conduct initial ICOPE screening and send the results to the commune-level health station. The health station is responsible for determining identified declines and the care needs of individual older people and for providing relevant care guidance or referral.
The ICOPE guidance appended to Decision 1976 also extends beyond screening. It includes personal-care and social-support needs and moves toward a person-centred goal and care plan, including goals chosen by the older person and care actions discussed and agreed with them.
Implementation has continued since July. Circular No. 34/2026/TT-BYT of 8 September 2026, which guides implementation of the National Target Program on Health, Population and Development for 2026–2035, specifically directs training and community older-person care activities to follow Decision 1976, further embedding the guidance in local implementation.
Together, these instruments create a more explicit route from screening toward individualized care in home and community settings. They do not, however, answer every question involved in determining long-term-care dependency, service intensity or eligibility.
ICOPE should not be turned into a dependency entitlement scale
ICOPE is valuable precisely because it does more than count diagnoses. WHO’s second edition sets out four steps: basic assessment, in-depth assessment, development of a personalized care plan, and implementation and monitoring. It covers intrinsic-capacity domains including cognition, mobility, vitality, vision, hearing and psychological capacity, with greater attention to social support and community-level implementation than the first edition.
But ICOPE was not designed as a national LTC entitlement scale.
A decline in intrinsic capacity does not automatically tell us whether someone needs several hours of assistance each week, daily professional home care, continuous supervision, caregiver respite or residential long-term care. Nor should declining intrinsic capacity automatically be equated with care dependency.
WHO’s separate work on LTC financing shows why this distinction matters. When countries design LTC benefit systems, the criteria and thresholds used for individual needs assessment influence how need is categorized and what intensity of service is made available.
ICOPE should therefore be seen as an important component of the assessment architecture, not the entire architecture.
A practical framework should describe what support is actually required
A useful needs-assessment framework does not need to become unnecessarily complicated, but it does need to be multidimensional. It should begin with function and cognition: what the person can do independently, where prompting or physical assistance is required, and whether memory, judgment or behavior creates supervision needs that are not visible in a physical ADL score. It should also examine clinical and recovery needs, including unstable health conditions, medication complexity, nursing care, nutrition, rehabilitation potential and palliative-care requirements.
The assessment then needs to consider the environment and support network. Is the home safe and accessible? Are suitable assistive products available? Who currently provides help, for what tasks and how often? Does the caregiver have the knowledge, health and physical capacity to continue? Can the person reach necessary services? Could environmental modification restore some independence?
Finally, assessment must include the older person’s preferences and goals. Someone may place great importance on remaining at home. Another may value social participation or reducing dependence on an exhausted spouse. Someone recovering after hospitalization may accept more intensive assistance temporarily because the objective is to regain function later.
These dimensions should lead to a care plan describing what assistance is required, for which activities, how frequently, with what level of skill, by whom, in which setting, and when the situation should be reassessed.
That is more useful than applying a category such as “mild,” “moderate” or “severe dependency” without explaining what it means in the person’s everyday life.
Assessment should guide support, not automatically determine where a person lives
A high level of dependency does not automatically mean residential care is the only appropriate option. With sufficient professional home care, caregiver support, assistive products, rehabilitation, accessible housing and clinical backup, some people with substantial needs may remain safely at home if that is their preference.
Conversely, “living with family” does not by itself demonstrate that home care is safe or sustainable.
WHO’s LTC framework emphasizes person-centred care, functional ability and an integrated continuum rather than treating one setting as appropriate for everyone with the same level of functional limitation. The appropriate setting should therefore emerge from the interaction of need, preference, environment, available services and safety, rather than from dependency alone.
This is particularly relevant as community day-care points develop under Decree 168. They add a new community-based option and can support activities of daily living, education and health-promoting activities, but the Decree explicitly excludes medical examination and treatment from their functions.
Needs also change over time. A hip fracture can abruptly increase dependency; rehabilitation may later reduce it. Delirium may temporarily increase supervision requirements. Progressive dementia can gradually increase them. A caregiver becoming unwell can destabilize an otherwise workable home arrangement overnight.
Needs assessment should therefore include reassessment triggers, rather than function as a one-time administrative event. Hospital discharge, major illness or injury, substantial functional change, new cognitive or behavioral change, completion of rehabilitation, changes in living arrangements, caregiver breakdown or movement between care settings may all justify reassessment.
Information should travel with the person, but labels should not become permanent simply because they were recorded during an acute episode.
Equity requires separating need from access
A needs-assessment system can look objective and still reproduce inequity. A person living in an area with few formal services may have the same underlying need as someone living where home care, rehabilitation and day-care services are readily available. Families also differ substantially in income, housing, work obligations and capacity to provide unpaid care.
If assessment asks only what services can currently be provided locally, genuine need can disappear from the data.
Assessment should first establish what support is required, then identify what support is available and actually being received. The remaining gap helps identify unmet need. This is more precise than assuming that formal service use alone tells us whether a person is adequately supported; WHO itself notes that current coverage measures do not establish whether the amount or quality of care received is adequate relative to need.
This distinction matters both for individual care plans and for governance. Systematic information about unmet need can show whether local gaps are concentrated in professional home care, rehabilitation, caregiver respite, transportation, assistive products, cognitive supervision, community day care or residential services.
A transparent assessment framework is therefore not merely a clinical tool. It can also support more equitable planning, financing and resource allocation.
The global LTC agenda makes needs assessment increasingly important
WHO has increasingly positioned long-term care as a core component of healthy ageing and universal health coverage. Its 2021 framework identifies governance, sustainable financing, information and monitoring, workforce, service delivery, and innovation and research as important components of an integrated LTC system.
The 2024 Long-term care for older people: package for universal health coverage provides a set of interventions that countries can consider, prioritize and contextualize within health and social-care systems rather than prescribing one universal service model.
The issue is especially current in 2026. On 18 May, WHO opened public consultation on the draft Global Standards for Long-Term Care, describing them as the first global framework of standards to guide planning, delivery, monitoring and improvement of LTC for older people. The consultation runs until 30 October 2026, after which WHO will revise the standards before finalization and official publication. They should therefore not yet be presented as finalized WHO standards.
Needs assessment sits near the beginning of this quality chain. It is difficult to determine whether support is adequate, equitable or person-centred if the system has never established what support the person actually requires.
Viet Nam can build a practical framework without importing one foreign dependency scale
Countries use different assessment instruments, eligibility rules, dependency categories and financing arrangements. WHO’s current LTC indicator likewise notes variation in functional assessment methods and eligibility thresholds across countries. There is therefore little reason for Viet Nam to copy one foreign dependency scale wholesale.
The national instruments reviewed for this article already establish important foundations: care should respond to older people’s autonomy and needs; multiple forms of care should be developed; intrinsic capacity, personal-care and social-support needs can be assessed; commune-level health stations have an assessment role; and care planning should become more individualized.
What the 2025–2026 older-person care instruments reviewed here do not yet set out is one standardized dependency-level classification used across the full hospital-to-home-to-community-to-long-term-care continuum to translate assessed need consistently into care intensity or LTC service eligibility.
That statement should not be read to mean that Viet Nam has no functional classifications or eligibility criteria in other health, disability or social-protection programs. The narrower point is that the newer national older-person care framework reviewed here has not created one cross-setting LTC dependency system.
This is best treated as an implementation question rather than a criticism of the reforms. A reasonable next step would be to test a minimum common needs-assessment dataset before designing a complex national scoring system. Such a dataset could bring together function, cognitive supervision needs, clinical and rehabilitation needs, environment, caregiver capacity, social support, personal goals and current unmet need.
Pilots could link selected hospitals and rehabilitation services with commune health stations, community day-care points and participating older-person care providers. The practical test would be whether different teams can understand and communicate the same person’s needs consistently enough to support safe decisions as care moves across settings.
Measure whether assessment actually leads to better care
A needs-assessment framework should ultimately be judged by what happens after the assessment, not by how many forms are completed.
Organizations could examine whether older people with greater or changing needs receive a documented multidimensional assessment; whether care plans address identified personal-care and social needs; whether caregiver capacity is considered; whether rehabilitation or assistive products are offered when they could reduce dependency; whether reassessment follows major change; whether relevant information reaches the next care setting; and how frequently important needs remain unmet.
They could also examine whether people with similar underlying needs receive substantially different support because of geography or family circumstances, and whether some people move toward more restrictive care when appropriate support could allow them to remain safely in a less restrictive setting.
These are illustrative quality measures, not a proposed national indicator set for Viet Nam. The safeguard is simple: assessment should not reward organizations for producing dependency categories. Its purpose is to improve the match between the older person and the support they actually receive.
The central question is not simply “How dependent is this person?”
For an older person, the questions that matter are more practical. What can I still do independently? Where do I need help? Could treatment, rehabilitation, assistive products or environmental changes allow me to do more for myself? Is my current home safe? Is the person supporting me able to continue? What matters most to me if I need more help?
Viet Nam’s Population Law, Decree 168, Decision 1976 and the newer implementation framework under Circular 34 now provide an important foundation for answering these questions more systematically. Together, they move policy and implementation toward diversified care, community participation, assessment of individual needs and more personalized care planning.
The next challenge is to connect those components into an assessment approach that is consistent enough to guide care without reducing an older person to a score.
For health, community and long-term-care organizations, the most useful question is therefore not simply “How dependent is this person?” It is:
“What support does this person need to live as safely, independently and meaningfully as possible, what support is already available and being received, what remains unmet, and how should the plan change as their circumstances change?”
When a care system can answer that question consistently, needs assessment becomes more than an administrative exercise. It becomes part of the infrastructure for safe, equitable, person-centred and integrated long-term care.
References
World Health Organization. Achieving universal health coverage for older people. World Health Organization.
World Health Organization. Integrated care for older people (ICOPE): guidance for person-centred assessment and pathways in primary care. 2nd ed. Geneva: World Health Organization; 2025.
World Health Organization. Framework for countries to achieve an integrated continuum of long-term care. Geneva: World Health Organization; 2021.
World Health Organization. Long-term care for older people: package for universal health coverage. Geneva: World Health Organization; 2024.
World Health Organization. Percentage of older people in need of long-term care services receiving long-term care at a facility or at home in the community over the past year. Global Health Observatory indicator metadata.
World Health Organization Centre for Health Development. Long-term care financing: determining the long-term care services covered in the benefits package. Kobe: World Health Organization; 2024.
World Health Organization Centre for Health Development. Gender inequities in long-term care. Kobe: World Health Organization; 2025.
World Health Organization. Call for public consultation on Global Standards for Long-Term Care. 18 May 2026.
National Assembly of Viet Nam. Law on Population No. 113/2025/QH15. 10 December 2025; effective 1 July 2026.
Government of Viet Nam. Decree No. 168/2026/NĐ-CP detailing a number of articles and measures for implementation of the Law on Population. 15 May 2026; effective 1 July 2026.
Ministry of Health of Viet Nam. Decision No. 1976/QĐ-BYT issuing professional guidance on care for older people at home and in the community. 1 July 2026.
Ministry of Health of Viet Nam. Circular No. 34/2026/TT-BYT guiding selected implementation contents of the National Target Program on Health, Population and Development 2026–2035, Phase I: 2026–2030. 8 September 2026.