Institutional care for elders in rural China

The long-term care (LTC) literature has been generally associated with industrialized countries. However, LTC needs are increasing in the developing world at a rate that far exceeds than experienced by industrialized countries. Using China as a case study, the purpose of this report is to provide an example of an emerging institutional care system for rural elders in a rapidly developing country. It covers two major domains of the system: service delivery and financing. The report presents several main issues involved in the development of institutional care for elders and discusses relevant policy implications.     

The Program of All-Inclusive Care for the Elderly (PACE): an innovative long-term care model in the United States

This article examines the long-term care service system in the United States, its problems, and an improved long-term care model. Problematic quality of care in institutional settings and fragmentation of service coordination in community-based settings are two major issues in the traditional long-term care system. The Program of All-Inclusive Care for the Elderly (PACE) has been emerging since the 1970s to address these issues, particularly because most frail elders prefer community-based to institutional care. The Balanced Budget Act of 1997 made PACE a permanent provider type under Medicare and granted states the option of paying a capitation rate for PACE services under Medicaid. The PACE model is a managed long-term care system that provides frail elders alternatives to nursing home life. The PACE program's primary goals are to maximize each frail elderly participant's autonomy and continued community residence, and to provide quality care at a lower cost than Medicare, Medicaid, and private-pay participants, who pay in the traditional fee-for-service system. In exchange for Medicare and Medicaid fixed monthly payments for each participating frail elder, PACE service systems provide a continuum of long-term care services, including hospital and nursing home care, and bear full financial risk. Integration of acute and long-term care services in the PACE model allows care of frail elders with multiple problems by a single service organization that can provide a full range of services. PACE's range of services and organizational features are discussed.     

Demographic Comparisons of Aging in Five Selected Countries

The worldwide aging of the population is having a major impact upon society. The United Nations General Assembly has declared 1999 to be the International Year of Older Persons to increase the awareness of aging worldwide. They identified five principles for older persons: independence, participation, care, self-fulfillment, and dignity. The numbers of elderly are growing around the world with many elderly living considerably longer than in past times. Developed countries are struggling with the high cost of maintaining support programs, and developing countries face dissolution of traditional care systems without institutional replacements. Women around the globe typically live longer than men, often without the economic resources to maintain independence. As nations adapt to their aging populations, a partnership among policy makers, family members, and older persons themselves is needed to offer alternatives to meet the needs of elders.     

The Program of All-Inclusive Care for the Elderly (PACE)

Summary

This article examines the long-term care service system in the United States, its problems, and an improved long-term care model. Problematic quality of care in institutional settings and fragmentation of service coordination in community-based settings are two major issues in the traditional long-term care system. The Program of All-Inclusive Care for the Elderly (PACE) has been emerging since the 1970s to address these issues, particularly because most frail elders prefer community-based to institutional care. The Balanced Budget Act of 1997 made PACE a permanent provider type under Medicare and granted states the option of paying a capitation rate for PACE services under Medicaid. The PACE model is a managed long-term care system that provides frail elders alternatives to nursing home life. The PACE program's primary goals are to maximize each frail elderly participant's autonomy and continued community residence, and to provide quality care at a lower cost than Medicare, Medicaid, and private-pay participants, who pay in the traditional fee-for-service system. In exchange for Medicare and Medicaid fixed monthly payments for each participating frail elder, PACE service systems provide a continuum of long-term care services, including hospital and nursing home care, and bear full financial risk. Integration of acute and long-term care services in the PACE model allows care of frail elders with multiple problems by a single service organization that can provide a full range of services. PACE's range of services and organizational features are discussed.     

Recent developments in institutional elder care in China: changing concepts and attitudes

This study examines recent developments in institutional care for Chinese elders and attitudinal changes toward institutional care in Tianjin, China. Based on studies in 12 elder home sites and survey interviews with 265 older residents, this study compares institutional differences between government and non-government-owned elder homes, and examines elders' evaluations of elder homes' quality and their level of willingness to stay in elder homes. Findings suggest that government-owned elder homes still enjoy institutional and bureaucratic privileges in funding, staffing, and insurance. Elders' overall evaluation of elder home quality was high. Elders' former living arrangement and financial ability were related to their willingness to stay in the elder home. The unfair competition between governmental and non-governmental elder homes is likely to hinder the development of elder home industry in the free-market system and foster a growing gap between the rich and poor elders in their capability and decisions in elder home care. As adult children become increasingly unavailable due to the one-child policy and geographic mobility, institutional care for aging parents is likely to become one of the major options for parent care.     

The limits of multiculturalism in elder care services

Over the past decade, policymakers and practitioners in the field of aging have been increasingly challenged to develop appropriate health and social services for elders from diverse ethnic communities. This has largely resulted from concerns regarding the significant barriers to care faced by disenfranchised elders. However, advances in the articulation of multicultural practice and policy dealing with ethnic communities have focused almost exclusively on developing competency skills based on individual communication and understanding between formal service providers and clients rather than on exposing and altering institutional structures and power relations marked by racism. Indeed, antiracist agendas are rarely articulated in gerontological settings. This article reports on some of the central findings of a qualitative institutional ethnographic study on health care access among ethnic elderly women. It addresses the question of how multicultural programs and policies operate in elder care services and how they are experienced by ethnic elderly female clients and their service providers.     

Migrant Care Workers or Migrants Working in Long-Term Care? A Review of Australian Experience

Discussion of the role of migrant care workers in long-term care (LTC) that has gained increasing attention in the United States and other developed countries in recent years is of particular relevance to Australia, where 24% of the total population is overseas-born, two-thirds of them coming from countries where English is not the primary language. Issues of interest arise regarding meeting LTC workforce demands in general and responding to the particular cultural and linguistic needs of postwar immigrants who are now reaching old age in increasing numbers. This review begins with an account of the overseas-born components of the aged care workforce and then examines this representation with reference to the four factors identified as shaping international flows of care workers in the comparative study carried out for the AARP Public Policy Institute in 2005: migration policies, LTC financing arrangements, worker recruitment and training, and credentialing. The ways in which these factors play out in Australia mean that while overseas-born workers are overrepresented in the LTC workforce, migrant care workers are not identifiable as a marginalized group experiencing disadvantage in employment conditions, nor do they offer a solution to workforce shortages. The Australian experience is different from those of other countries in many respects, but it does show that the experience of migrant care workers is not unique to LTC and points to the need to extend the search for solutions to workforce shortages and improving conditions of all care workers well beyond LTC systems to wider policy settings.     

Recruiting immigrants for long-term care nursing positions

Recent immigrants and workers in foreign countries are two groups frequently identified as potential sources of new workers for nursing positions in long-term care (LTC). Recruiting workers directly from other countries, either permanently or temporarily, is difficult because of restrictive visa classifications; is unlikely to impact significantly the worker shortage; and may have risks that outweigh the potential rewards. On the other hand, with targeted recruitment and retention efforts, the nation's rapidly growing immigrant population (the so-called "New Americans") can become an even more important source of labor for frontline LTC workers. To be successful employees in LTC, however, New Americans will have to overcome a variety of cultural and language barriers. Equally important, the institutions and agencies that comprise the LTC system must exhibit a higher level of sensitivity to cultural differences. Efforts to recruit, train, and retain New Americans for positions in LTC present win-win opportunities and should be expanded.     

Comparing Long-Term Care Recipients in Urban and Rural Municipalities in Japan and Sweden

Japan and Sweden both have national systems of long-term care (LTC) and face similar challenges. This study compared various indicators of disability in LTC recipients in nine large urban, midsize urban, and rural municipalities in both countries. The aim was to establish whether urban-rural differences exist and whether they follow similar patterns in Japan and Sweden. It was found that LTC recipients in large urban municipalities in both countries were on average significantly less disabled than those from the other types of municipalities, regardless of the indicator for disability. Fewer persons in large urban municipalities live in extended families, which may increase the propensity to apply for LTC. The number of older people living alone in Japan is increasing, which means that the formal LTC system will come under increased pressure.     

Long-term care and the private insurance market

Increased life expectancy and the aging of the baby boom generation will bring rapid growth in the number of people at risk of needing long-term care (LTC). This Issue Brief provides an overview of the current LTC financing and delivery system in the United States, focusing on private-sector initiatives to meet the United States' LTC needs. It discusses private-sector plan design--particularly employment-based plan design--providing an in-depth look at the dramatic changes taking place in the private-sector LTC market since its inception in the early and mid 1980s. Aside from informal care provided in the community, the current system of financing LTC depends largely on the Medicaid program and individual financing. Issues confronting this system include spiraling costs associated with LTC services that may threaten beneficiaries' access to care. Other issues include the potential depletion of personal assets and a bias toward institutionalization (which may not always provide the most cost-effective or desired type of care available). Many leaders regard private long-term care insurance (LTCI) as a way to increase access to financing and as a potential alternative to Medicaid and out-of-pocket financing. By the end of 1993, a total of 3.4 million private-sector LTCI policies had been sold, up from approximately 815,000 in 1987. While the majority of these plans were sold to individuals or through group associations, employment-based plans accounted for a significant proportion of this growth. Premiums for LTCI vary substantially based on age and plan design. Insurers generally attempt to set premiums such that they will remain level over the insured's lifetime. However, because little LTC claims insurance experience yet exists, the actuarial basis for developing premiums and statutory reserves is limited. Several bills over the last three Congresses have been introduced to address the issue of LTC. However, due to cost implications and lack of consensus regarding the optimum overall structure required to finance and deliver care, broad legislation to expand coverage--particularly public coverage--is not likely in the near term.     

CARING ABOUT POVERTY

Entry to institutional care is being used as an ineffective and expensive response to child and family poverty in a number of countries. In this paper, the practice of using institutional care for children in poverty is examined, drawing on case studies from three countries–the Republic of Moldova, Bulgaria, and Sri Lanka. Research findings reveal that poverty is a major underlying cause of children being received into institutional care and that such reception into care is a costly, inappropriate, and often harmful response to adverse economic circumstances. We suggest that alternatives to care may be funded from resources currently committed to institutions by developing a policy of gatekeeping. However, alternative strategies must be responsive to local conditions, and all such strategies need to be developed in consultation with children, their families, and communities.     

Long-term care benefits granted to the elderly in Andalusia

ABSTRACT

Using data from the Individual Care Programmes (PIAs) of the whole population of dependent elderly receiving LTC benefits as of 31 December 2014 in the most populated region of Spain, Andalusia, we compare the factors associated with the different types of LTC benefits granted. The study includes 110,966 dependent elderly aged 65 years and over. The percentage of those receiving care at their homes was very high (80%). In contrast to the main aim established in the Dependency Act, financial benefits for care at home were the most common type of benefit (47%) followed by home-based support (33%). Overall, all the determinants examined (age, gender, income, degree of dependency and type of municipality) were found to influence all types of LTC benefits with two exceptions: age in the case of long-term residential care and gender in the case of day and night centres. Our analysis suggests that income level is a key factor for being cared for at an institution but the direction of the relationship is different for private and public institutions. This fact, together with the variations in the access to institutional care depending on where the person lives, points out that a greater effort is necessary to guarantee an adequate supply. Social workers could help to improve the current LTC system if more resources are available when they participate in the design of PIAs.     

Workforce Issues in Residential Care Facilities in Rural China

This study examined contemporary frontline workforce issues related to residential care for elders in rural China. Residential facilities in rural China are in transition from exclusively providing shelter to childless elders to providing long-term care for frail elders. These facilities are also under pressure to improve the quality of services that they provide. The study is based on in-depth interviews with administrators and field observations of facilities. The study focused on the following issues related to the workforce: recruitment and retention, training, work environment, workforce organization, regulations, compensation, and career ladders. The implications of resident characteristics for demands on the work force were examined. The study found that lack of skilled personnel is one of the major reasons that the overwhelming majority of facilities deny admission to frail and demented elders. Improving workers’ skill is critical if these facilities are to meet the increasing demand for institutional long-term care needs.     

Long-Term Care Policy: Singapore’s Experience

Singapore, like many developed countries, is facing the challenge of a rapidly aging population and the increasing need to provide long-term care (LTC) services for elderly in the community. The Singapore government’s philosophy on care for the elderly is that the family should be the first line of support, and it has relied on voluntary welfare organizations (VWOs) or charities for the bulk of LTC service provision. For LTC financing, it has emphasized the principles of co-payment and targeting of state support to the low-income population through means-tested government subsidies. It has also instituted ElderShield, a national severe disability insurance scheme. This paper discusses some of the challenges facing LTC policy in Singapore, particularly the presence of perverse financial incentives for hospitalization, the pitfalls of over-reliance on VWOs, and the challenges facing informal family caregivers. It discusses the role of private LTC insurance in LTC financing, bearing in mind demand- and supply-side failures that have plagued the private LTC insurance market. It suggests the need for more standardized needs assessment and portable LTC benefits, with reference to the Japanese Long-Term Care Insurance program, and also discusses the need to provide more support to informal family caregivers.     

Willingness and availability: Explaining new attitudes toward institutional elder care among Chinese elderly parents and their adult children

This paper studies the attitudes of Chinese elderly parents and their family members toward institutional elder care. Based on a sample survey of 265 elderly residents in 67 elder home institutions and 114 family members, this study finds that elders and family members generally had high evaluations of institutions' quality in terms of facility, medical, and direct care conditions. Elders who reported improved health and emotional well-being after entering institutions gave higher ratings to those institutions' quality. Among adult children, those who had more siblings tended to rate institutions higher than those who had fewer siblings. Factors that influenced elders' willingness to stay in an institution included marital status and financial ability. Widowed elders were more willing to stay in institutions compared with married counterparts. Elders who rated service charge very high preferred to stay at home due to the high cost of institutional care. In the family relatives' sample, gender was found to be related to willingness to place elderly parents in an institution; female children were less willing to place elderly parents in the institution.     

Voluntary long-term care insurance: best practices for increasing employee participation

This is the second of two Issue Briefs (April and May 2000) on long-term care (LTC) insurance. The previous Issue Brief addressed the problem of increasing sponsorship, while this report addresses the issue of increasing employee participation. Participation rates in group LTC insurance plans tend to be low. A potential watershed event for the development of the employment-based group LTC market is the proposed LTC program for federal employees and retirees (a program that would have to be enacted by Congress). The perception of a successful offering to federal employees could provide an enormous boost to the group LTC insurance market. Employee communication and education are seen as critical to the success of LTC enrollments. The importance of support shown by an employer for a new LTC plan offering cannot be overstated. Unlike 401(k) plan participation trends, LTC participation rates are highest among large companies. Insurers tend to view the 40-60 age range as the primary target for group LTC insurance, and employee salary as the best predictor of LTC insurance enrollment. Higher educational levels also are associated with higher levels of LTC participation. Perceived need for LTC insurance is perhaps the biggest barrier to the purchase of LTC insurance by employees due to competing financial priorities and the fact that LTC issues are generally off the "radar screens" of younger employees. Plans with skilled nursing home and home care benefits experience higher participation rates than plans lacking these benefits. The availability of lower-cost and long duration benefit options can be an important factor in determining participation. Most sponsors have chosen to offer noncontributory (i.e., fully employee-paid) LTC plans. Employer reluctance to make contributions may be caused by HIPAA's prohibition on the inclusion of LTC insurance in cafeteria plans. One of the major advantages of group LTC plans is the availability of guaranteed issue (i.e., issuing coverage without requiring evidence of insurability) for employees, which is not available in the individual LTC market. It is easy for enrollment to be derailed by the presence of any of a number of harmful conditions, such as employer-sponsors who distance themselves from the offer, ineffective communications, or difficult enrollment processes. Achieving consistently strong levels of participation in LTC plans will require employer-sponsors and their insurance carriers to form strong partnerships, with worker participation as their primary stated goal.     

Engaging Experts: Expanding Participation and Enhancing Research in Chinese Eldercare Institutions

Due to the myriad factors straining China’s traditional family-based eldercare system, today unprecedented numbers of older adults are turning to institutions for caregiving needs. As researchers and policy makers organize conferences, analyze trends, and allocate resources, the subjective experiences of elders themselves are often forgotten or ignored. While providers recognize that institutionalized elders are at an increased risk for mental health issues, most cite personnel and resource shortages as insurmountable barriers to provision. Using examples from ethnographic research in Chinese eldercare institutions, this article examines the link between participation and mental health for contemporary Chinese elders and makes a case for expanding the role of elders in research in order to improve both the experience and understanding of institutional eldercare.     

Strengthening home and community-based care through Medicaid waivers

States are increasingly using the Medicaid 1915c waiver program to provide community-based long-term care (LTC). We examined state predictors of waiver utilization and expenditures for waivers serving both older and working-age individuals. State level data for the period 1992 to 2001 were used to estimate random effects panel models. States with increased community-based care (e.g., home health agencies) and decreased nursing home bed capacity were positively associated with state per capita rates of use, expenditures, and the share of Medicaid LTC dollars supporting 1915c waivers. States appeared to substitute Medicare for Medicaid services for individuals eligible for both. State per capita income was positively related to each measure. State policies that facilitate decreased institutional and increased community- based capacity appear essential to state efforts to expand access to community-based services. Federal policies that address state resource issues may also spur growth in community-based LTC, which, in most states, continues to be limited.