The reform of home autonomy services — A necessary pragmatism in the face of demographic urgency

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1. ANALYTICAL SUMMARY

A demographic urgency in the face of a fragile and unequal offer

The Court starts from a quantified observation: 1,493,748 people live at home with a need for assistance with autonomy in 2025, a number that will rise to 1,641,955 by 2030 and then to 1,846,884 in 2035 (p. 9). This provision is based on two historically separate components — nursing care services (SSIAD, ≈ 2,000 managers, mostly public and non-profit) and assistance services (SAAD, ≈ 9,000 managers, predominantly commercial) — managed by different authorities (ARS and departments) according to heterogeneous economic and accounting models (p. 11). The sector suffers from "white zones", a lack of understanding of the real needs of individuals, an unpredictable out-of-pocket expense, and precarious workers (the sector is three times more accident-prone than the national average, p. 12).

A consensual reform on the goal, contested on the method

Originating from Article 44 of the LFSS 2022, the reform aims to merge SSIAD and SAAD into "mixed SAD" covering the same territory within a single legal entity (p. 10-11). Its objectives are consensual, but its technical modalities are almost unanimously rejected by the departments and the ARS (p. 11). By the end of March 2026, only the easiest mergers have been completed (p. 13). The Court therefore recommends pragmatic management based on results — number of people jointly cared for, adverse events, hours of assistance provided — rather than by legal form, to delegate competence to the departments, and to replace administered pricing with national rules governing out-of-pocket expenses (p. 13-15).

2. KEY POINTS OF THE DOCUMENT

1. The demographic wall arrives before the supply. The increase in the number of people losing autonomy at home by 2030 (+148,207) already exceeds the total current places of SSIAD (127,073 places recorded in 2024). The "first steps" are the highest to climb, with the peak expected in 2052 (2,121,796 people) (p. 9).
2. The economic model of SAAD is structurally fragile. Almost exclusively salary costs, regulated rates, low margins, and a poorly concentrated sector: the failure rate of SAAD is double the average of other sectors. The SSIAD, on the other hand, remain financially solid thanks to the global allocation, but the new pricing is already generating revenue declines (p. 11, p. 51-63).
3. The needs of users are poorly understood — and were not collected before the reform. The surveys conducted by the Court with five user and caregiver associations (France Alzheimer, France Parkinson, Lewy Body Association, France DFT, UNAFAM) reveal significant unmet needs and a qualitative inadequacy of services, due to not having directly questioned individuals beforehand (p. 12, p. 36-38).
4. Results-based management is proposed as an alternative to merging. The Court suggests conditioning the authorisation on three concrete indicators — people benefiting from coordinated help and care, adverse events (including refusals and care discontinuations), hours of intervention carried out — by removing the obligation for a single legal entity and territory (p. 13, recommendation 7 p. 17).
5. The tax credit remains the last bastion of the remaining charge. In its current state, it is the only effective guarantor of controlling the remaining costs for vulnerable individuals; its transformation into an immediate advance (legal deadline of 1st September 2027) must absolutely succeed, as the obligation to advance funds generates non-use among modest users (p. 14).

3. ACTION PATHS FOR LOCAL ACTORS

1. Map the "white zones" of its territory by crossing the presence of SSIAD, availability of liberal nurses and authorised aid operators, to identify the accumulation of difficulties (rural, island, mountainous areas) and objectify a local advocacy (p. 25, p. 31-35).
2. Systematise the recording of refusals and discontinuations of care as undesirable events, from 2026: this is the most revealing field indicator of unmet needs and it is among the three proposed management criteria (p. 13, recommendation 2 p. 17).
3. Involve users and caregivers in the training of home care workers, anticipating the announced modification of the specifications (decree no. 2023-608), to anchor good treatment and value lived experience (p. 12, recommendation 3 p. 18).
4. Integrate the service into its local environment (medical-social establishments, direct employment, local housing policies, mobility, integration) rather than reasoning in silos: the Court makes this a requirement of the specifications for SAD (p. 87).
5. Prepare for HAS quality evaluation and self-evaluation as an internal lever, without waiting for the ATC deadline, relying on the mandatory criteria (17 for mixed SAD, 16 for aid SAD) — see additional reference below (p. 90).
6. Anticipate the shift of management to the department and the likely end of administered pricing: secure a readable analytical accounting now to document its costs and defend its rates (p. 65-66, p. 91-93).

Identified unmet needs : people suffering from cognitive or mental disorders, and residents of areas with multiple vulnerabilities, remain the major forgotten in the current offer (p. 12).

4. ADDITIONAL REFERENCES

🔍➕ For more information, see the articles referenced by "Health Practices" on the topic of home care ➡️🔗 https://www.pratiquesensante.com/blog/tag/aide-a-domicile-92

1. CNSA — Toolkit of the Departmental Public Service for Autonomy (SPDA) (generalisation 2025; specifications by order of 28 May 2025). Methodological guides, self-diagnosis, thematic sheets (governance, territorialisation, participation of individuals). Directly linked to the key recommendation of the Court to make the department the pilot. → https://www.cnsa.fr/informations-thematiques/service-public-departemental-de-lautonomie
2. HAS — Practical sheet "Reference and implementation methods for evaluating the quality of home autonomy services" (published on 3 April 2026, adopted in CSMS on 24 March 2026). Regulatory framework, methods (accompanied tracer, targeted tracer, system audit), mandatory criteria specific to SAD, preparation for evaluation. Complements the "quality monitoring" section of the report. → https://www.has-sante.fr/upload/docs/application/pdf/2026-04/dir1/fiche_pratique_-_repere_et_modalites_de_mise_en_oeuvre_pour_levaluation_de_la_qualite_des_services_autonomie_a_domicile_mars.pdf
3. DREES — Studies and Results No. 1341, "Home Aids: an average annual salary of 7,040 euros in 2021…" (June 2025). Highlights wage precariousness and the fragmentation of contracts that the Court's report identifies as a central barrier to attractiveness. → https://drees.solidarites-sante.gouv.fr/publications-communique-de-presse/etudes-et-resultats/250612_ER_aides-a-domicile-revenu-salarial-annuel-moyen

5. FREQUENTLY ASKED QUESTIONS (FAQ)

1. What is a "home autonomy service" (SAD) and how does it differ from SSIAD and SAAD?
   The SAD is the entity resulting from the reform, intended to bring together assistance (ex-SAAD) and nursing care (ex-SSIAD) within the same structure. A "mixed" SAD provides both; a "help" SAD provides only assistance (p. 10-11).
2. Why is the reform stalled when its objectives are widely agreed upon?
   Because its technical modalities require merging three very disparate elements: legal entities (7 different contractual frameworks), territories (incompatible SSIAD and SAAD networks), and economic models. Hence, there is almost unanimous rejection from departments and ARS (p. 10-11).
3. Who will manage home assistance and care tomorrow?
   The Court recommends delegating complete management to the departments, starting in 2027, through a convention with the ARS, within the framework of the departmental public service for autonomy (p. 14, recommendation 6 p. 17).
4. What is the proposed "results-based management"?
   Conditioning the authorisation not on legal merger, but on three results: number of people receiving coordinated assistance and care, number of adverse events, number of hours of assistance provided. If not achieved, the authorisation could be withdrawn and reallocated (p. 12-13, recommendation 7 p. 17).
5. Will the out-of-pocket expenses for users increase?
   The increase in assistance costs is deemed inevitable. The Court proposes abandoning administered pricing in favour of national rules guaranteeing zero or minimal out-of-pocket expenses for low incomes, with progressivity according to contributory capacities (p. 14, recommendation 10 p. 17).
6. What happens to the tax credit for home employment?
   It remains the main guarantor of controlled out-of-pocket expenses. Its "immediate advance" version, expected on 1st September 2027, must come to fruition to eliminate the non-use related to the obligation to advance funds (p. 14).
7. Are people with disabilities treated the same as elderly people?
   Yes: the Court recommends gradually making the versatility the rule (2027-2032), with SSIAD still maintaining a legal distinction between disability / old age that mixed SADs render obsolete — an evolution that has broad consensus (p. 15, recommendation 9 p. 17).

6. REWRITING IN EASY TO READ LANGUAGE

What is this document about?

In France, many elderly people want to stay at home.

People with disabilities do too.

To stay at home, they need help.

They need help to wash, eat, and move around.

Some also need nursing care.

There is a problem.

In the coming years, there will be many more people to help.

By 2030, there will be 148,000 more people.

Today, there are not enough services for all these people.

In some places, there is no one to help. These are called "white zones."

Two types of services exist.

The help services are called SAAD.

The care services are called SSIAD.

A new law wants to combine these two services into one service.

This new service is called the SAD.

This law is difficult to apply.

Everyone agrees with the aim of the law.

But many people find the law too complicated.

Bringing the two services together is expensive and time-consuming.

Many support services have little money. They are at risk of closing.

The people doing this work are poorly paid. They often get injured.

What the Court of Auditors proposes.

The Court is an organisation that oversees public money.

The Court proposes to look at the results, not the form of the service.

A good service helps many people.

A good service prevents serious problems.

The Court proposes that the department manages all the services.

The Court wants poor people to pay little or nothing.

7. CROSS-ANALYSIS — VALUES OF HEALTH PRACTICES

• Literacy : the report notes a lack of readability of the remaining costs and provisions for users, but does not propose suitable understanding tools (p. 14).
• Empowerment : strong point — the Court recommends involving users and caregivers in the training of practitioners and valuing their experience in continuous improvement (p. 12, recommendation 3).
• Participation : co-construction is described implicitly (needs were not gathered before the reform); the Court elevates it as an expected corrective to the specifications (p. 12).
• Community health : the collective dimension appears through the territorial anchoring of the SAD in their local environment and the departmental network (p. 87).
• Ethics : the report emphasises the quality of care and the recording of undesirable events, but does not explicitly address cultural or social biases (p. 12).
• Human rights : equity and financial accessibility are central — ensuring a minimal out-of-pocket expense for low incomes and combating non-utilisation (p. 14).
• Intersectorality : recommended — coordination of health / social / housing / mobility / integration under departmental management contracted with the ARS (p. 14).
• Partnership : formalised through the departmental-ARS agreement and the departmental public service for autonomy (p. 14).
• Combating discrimination : the report highlights territorial inequity and the abandonment of individuals with cognitive or psychological disorders; it also notes that tensions regarding residence permits affect the workers (p. 12, p. 33), without developing a structured anti-discrimination approach.

8. EVALUATION OF THE RELIABILITY OF THE RESOURCE

Scientific relevance: high. Independent institutional source (Court of Auditors) based on contradictions with the administrations. Recent and traceable numerical data (DREES, ACOSS-DSN, INSEE, France Travail, Bank of France). Method combining national instruction, controls from regional chambers, and surveys conducted with five user associations. The demographic data is based on the LIVIA model from DREES (2026).

Operational relevance: indirect. The document is a tool for understanding and advocacy, not a guide for action. Its recommendations are aimed at national and departmental public authorities; their implementation will depend on upcoming legislative decisions (deadlines 2026-2032). The field actor will mainly find a framework for interpreting the ongoing recompositions and objective arguments.

10. STRATEGIC HASHTAGS

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