Organization and Delivery of Long-Term Care in Singapore

Summary

This paper focuses on the Singaporean model of long-term care for older people. With only about 2% of the older population living in institutions, the mainstay of long-term care is community care. The reader is provided an overview of the Singaporean services, including case management, followed by a discussion of the current issues and future challenges. In keeping with the prospect of a rapidly aging population profile, the Singapore government plays a leading role in framing policy and planning for future needs of this sector of the population.     

Expansion of long-term care in the prison system: an aging inmate population poses policy and programmatic questions

Throughout the United States, departments of corrections are experiencing increases in their inmate populations. More specifically, the number of aging inmates is increasing and will continue to grow as younger prisoners who have long sentences with no possibility of parole age in prison. In addition, the number of younger inmates with illnesses such as AIDS has increased. Although long-term care can be required by individuals of any age, the need for such assistance tends to increase with age. Long-term care, therefore, can be seen as an issue confronting prisons with aging inmate populations. Yet, little is known about the nature or extent of the need. This paper focuses on older inmates and includes reasons for the increased need for long-term care in the prison setting. The standard for prison health care, the long-term-care status of older inmates, and examples of long-term-care services and facilities are described. Key questions related to furnishing long-term care to an older incarcerated population are identified. Recommendations are presented for both corrections and long-term-care providers and policymakers as they develop strategies to address this challenge.     

Global Convergence: Aging and Long-Term Care Policy Challenges in the Developing World

Aging around the world poses a global challenge in eldercare. This challenge is particularly felt in low- and middle-income countries (LMICs), where population aging outpaces the development of aged care policies and services. This Perspective highlights the phenomenon of global convergence in several unsettling trends and challenges shared across LMICs. These include the weakening of informal family care systems for the elderly, growing need for formal long-term care of the frail and disabled who can no longer be adequately supported by family members, and mounting pressures for policy responses to tackle these societal challenges. It is argued that policymakers should take a proactive stance. That is, when family care for the elderly falls short and family caregivers are increasingly under strain, the government should step in and step up support to fill in the gap by developing appropriate policies and a continuum of long-term care services that are accessible and affordable for the majority of older people in need. Three general principles are then suggested with regard to long-term care provision, financing, and quality assurance, which transcend national borders and can be used to guide long-term care policymaking across LMICs.     

Relocation to a long-term care facility: working with patients and families before, during, and after

Permanent relocation of a dependent older adult to a long-term care facility can occur for a number of reasons, including the need for postacute care or a higher level of care than can be provided in a less-restrictive environment, and/or the inability of family members or others to care for the individual in a noninstitutional setting. Outcomes of institutional placement may be either negative, such as the older adult experiencing relocation stress syndrome, or positive, such as improved management of chronic illnesses and reversal of functional decline. This article offers a review of the factors that predict when and where older adults will relocate for institutional long-term care, an overview of individual transitions to institutional care, and suggestions for seamless transitions during the preinstitutionalization, transitional, and postinstitutionalization phases of relocation, which are guided by a transactionist approach to stress and coping.     

Elder abuse and neglect

Elder abuse and neglect is a critical health care issue that must be brought to the attention of health care providers and older adults' family members. Adults older than 65 who live at home or in long-term care facilities may be at risk for abuse. Nurses should be aware of the causes, screening questions, symptoms of abuse, and resources in the community. Armed with information and a better understanding about the issue, nurses can minimize the devastating effects of abuse on older adults and their families.     

Foreign Domestic Workers and Home-Based Care for Elders in Singapore

As with other developed nations where rapid population aging has led to increasing health care and social care burdens, Singapore has searched for ways of paying for and providing long-term care for its increasing numbers of elders. The Singapore state, faced with the prospect of one-fifth of the population aged 65 or older by 2030, has reinforced its basic principle of rendering the family the “primary caregiving unit” and home-based care as the highly preferred option for eldercare. Our paper demonstrates why, despite the range of alternative care arrangements available or emerging on Singapore's eldercare landscape, the employment of live-in foreign domestic workers as care workers for the elderly has become one of the more common de facto modes of providing care for the elderly. In this context, we discuss the politics of eldercare in the privatized sphere of homespace and conclude with policy implications relating to the employment of foreign domestic workers as caregivers for the elderly.     

Public policy implications of elderly interstate migration to Oregon, 1985-1990

Several Oregon counties received a noticeable influx of elderly migrants from other states during the 1980s. Oregon policy regarding taxes, land use, and long-term care is examined for possible influence on migration. Models of elderly migration are examined for insight into how public policy influences migration, and previous research regarding the effects of elderly migration on public policy is reviewed. Data regarding disability and financial vulnerability among elderly by migration status are analyzed for possible influence upon public policy. Change in the population aged 65 and older mirrored state and national patterns for 1980 to 1990 and 1990 to 1999. Interstate elderly arriving in attractive counties reported a low prevalence of disability and financial vulnerability, indicating a low risk of demanding public assistance. Interstate elderly arriving in population centers reported a relatively high prevalence of disability but a low prevalence of financial vulnerability. This may suggest that Oregon's long-term care policy influenced elderly migration.     

The changing world of long-term care: a state perspective

Based on data from an eight year longitudinal study of Ohio's long-term care use patterns, this paper describes the changes now being experienced by this industry. Although Ohio has been a state with a heavy reliance on institutional services, the data suggest a change in how long-term care is provided in the state. Over the past eight years, despite an increasing disabled older population, nursing home occupancy rates have fallen from 92.5% to 83.5%. At the same time, in-home service and assisted living use has increased. The paper concludes by describing how such changes are likely to impact the system of the future.     

Older lesbians' experiences with home care: Varying levels of disclosure and discrimination

ABSTRACT

There is considerable evidence that lesbian, gay, bisexual and transgender (LGBT) older adults have experienced barriers to health care access and have profound fears about how they will be treated in the long-term care system, but the specific experiences of older lesbians have received less attention. Most older adults needing long-term services and supports (LTSS) prefer to remain at home, and this is true for lesbians as well. This article reports on a national, qualitative study of the experiences of 20 older lesbians (age 65 and older) with home care workers. The experiences of six informal partner caregivers with home care services are also included. Emergent themes regarding level of disclosure, experiences with homophobia, evaluation of care received, and thoughts about ideal LTSS are described. Most study participants did not disclose their sexual orientation to their home care workers. A significant minority experienced homophobia, but nearly all ultimately found workers who provided good care with which they were comfortable. Their visions of ideal LTSS included greater affordability and particular qualities that were important for home care workers to possess, such as competence, caring and acceptance. Practice and policy implications are outlined including careful recruitment, training and supervision of home care workers to foster lesbian-sensitive care, but also improved wages and work conditions in order to maintain a quality home care workforce.     

Negotiating user preferences, discrimination, and demand for migrant labour in long-term care

The restructuring of long-term care for older people has been marked both by the role of the market and by the role of migrant labor. This article develops the analysis of these processes at the microlevel of the provision of care. It draws on data collected as part of a cross-national comparative study on the employment of migrant care workers in residential care homes and home care services for older people in England and Ireland. The article examines, first, the ways in which divisions of race, ethnicity, and citizenship shape the preferences of service providers/employers and some service users as regards who provides care. Second, it examines how the institutional context of quasi-markets in long-term care shapes the negotiation of demand for migrant labor, the racialized preferences of individual users, alongside the rights of care workers to non-discrimination. It is argued that market-oriented policies for personalization, as well as for cost containment, raise implications for divisions of race, ethnicity, and citizenship in the provision of long-term care. At the same time, those divisions point to the limits of framing care in terms of the preferences of the individual as opposed to the social relations in which care is embedded.     

An exploration of older Hong Kong residents’ willingness to make copayments toward vouchers for community care

Because of its rapidly aging population, Hong Kong faces great challenges in the provision and financing of long-term care (LTC) and needs to explore sustainable funding mechanisms. However, there is a paucity of research on older people’s willingness to pay (WTP) for LTC services in Hong Kong. This study utilizes data collected in Hong Kong in 2011 (N = 536) to investigate older people’s receptivity to this financing mode by assessing their co-payments for a community care service voucher scheme and then testing how potential factors affect respondents’ amount of co-payment. Results show that respondents’ WTP was positively associated with family financial support, financial condition, and positive attitudes toward this novel policy and negatively associated with family caregiving support. Direct and moderating effects of family financial support on WTP were found. The policy-related implications of LTC financing to improve older people’s acceptance of co-payment mechanisms, financial condition, and shared responsibility of care are discussed.     

Senior Centers and Services for the Frail Elderly

This article reviews and synthesizes the research on senior center programming and utilization relating to one important group of elders-the physically and mentally frail. It examines the thesis that senior centers do play an important role in providing programs for this population, especially given the resources available to them, and can be considered as part of the long-term care continuum. The article also identifies a number of barriers that limit how much most centers do in serving significant numbers of frail older persons.     

Senior centers and services for the frail elderly

This article reviews and synthesizes the research on senior center programming and utilization relating to one important group of elders--the physically and mentally frail. It examines the thesis that senior centers do play an important role in providing programs for this population, especially given the resources available to them, and can be considered as part of the long-term care continuum. The article also identifies a number of barriers that limit how much most centers do in serving significant numbers of frail older persons.     

Client Satisfaction with Live-In and Live-Out Home Care Workers in Israel

Abstract

In an era of globalization where the migration of long-term care workers is common, foreign live-in home care workers can compensate for the unavailability of family members and, perhaps, even substitute for institutional care in the provision of long-term care services to disabled older persons.

This study examines differences in home care satisfaction between disabled older persons in Israel with “live-in” home care workers and those with “live-out” workers, and explores some differences in socio-demographic and personal characteristics between these two groups. Face-to-face interviews were held with a random sample of 93 older persons in Beer-Sheva.

Older persons with live-in home care workers were more satisfied with their home care service than those with live-out workers. Those with live-in workers were more severely disabled, tended not to have any children living in close proximity, although an adult child was available as an informal caregiver. Communication difficulties between the elderly persons and their home care workers were found not to affect negatively the satisfaction with the service.     

Public Policy Implications of Elderly Interstate Migration to Oregon, 1985-1990

Abstract

Several Oregon counties received a noticeable influx of elderly migrants from other states during the 1980s. Oregon policy regarding taxes, land use, and long-term care is examined for possible influence on migration. Models of elderly migration are examined for insight into how public policy influences migration, and previous research regarding the effects of elderly migration on public policy is reviewed. Data regarding disability and financial vulnerability among elderly by migration status are analyzed for possible influence upon public policy.

Change in the population aged 65 and older mirrored state and national patterns for 1980 to 1990 and 1990 to 1999. Interstate elderly arriving in attractive counties reported a low prevalence of disability and financial vulnerability, indicating a low risk of demanding public assistance. Interstate elderly arriving in population centers reported a relatively high prevalence of disability but a low prevalence of financial vulnerability. This may suggest that Oregon's long-term care policy influenced elderly migration.     

The impact by race of changing long-term care policy

Long-term care policy has evolved with little attention to racial differences in the need for and use of services. Using 1987 National Medical Expenditure Survey data on nursing home care, formal in-home personal care, and informal-only help, a model was created to show how different races would use each type of care if: (1) a universal home-care benefit was established, (2) existing Medicaid home-care benefits were ended, or (3) the income level for Medicaid eligibility was substantially reduced. Expanded community care benefits would primarily serve severely disabled older whites. Reductions in long-term care benefits or eligibility would disproportionately impede access to long-term care for severely disabled older African-Americans. These differences indicate that race must be taken into account in long-term care policy initiatives.     

The influence of the economic crisis on quality of care for older people: system readiness for innovation in Europe

The aim of this study is to examine the influence of the recent economic crisis on the quality of long-term care for older people in Belgium and the Netherlands. A mixed-method approach was applied, primarily focused on conducting semi-structured qualitative interviews with health professionals working in a management role in organizations providing long-term care for older people. The results show that Dutch organizations seem to be prepared for the influences of the economic crisis on the quality of its care provision primarily in terms of a sound system readiness. At the same time, Belgian organizations seem to be prepared for the influences of the economic crisis on the quality of its care provision primarily in terms of a favorable sociopolitical context. Comparing two countries allows for reciprocal lesson-drawing. The conclusion drawn in this study is that a sustainable long-term care system requires above all stability and structure.     

Commentary: Barriers to a Sustained Restraint-Free Environment

A restraint-free culture is becoming a standard practice in the provision of long-term care services for older people, a standard by which licensure and accreditation agencies evaluate providers. Although most health care providers initiate restraint-elimination processes, many fail to achieve the intended result or sustain the practice because of a variety of barriers. Faltering organizations find themselves faced with monumental changes in administrative and supervisory staff, substantial recruitment and retention crises, and inadequate attention to a culture of continuous learning, teamwork, and leadership skill building. This article informs policy makers about the barriers to achieving and sustaining a restraint-free environment and suggests public policy agendas and processes to improve conditions for the aging population.     

生态养老:养老服务中场所性的健康促进策略

老年人口占总人口比例以及提供健康服务成本的财政需求增加,正日益威胁着全球的稳定性。同时,这样的人口发展趋势也给传统的老年人健康服务供给带来挑战。本文以澳大利亚的案例为背景,论证在养老服务中运用场所性的健康促进能够给老年人创造更大的福利,缩短通常与年龄增长有关的慢性病患病率时间。提倡生态养老意味着无需像以前那样对老年人实行隔离管理,而是将他们视为整个社会生活、工作和娱乐不可缺少的一部分。文章比对了健康促进学校与养老产业等场所性的健康促进的特征,认为涵盖各种养老服务的场所是建立一个新的健康促进场所的最佳选择。场所性的健康促进策略的核心就在于为老年人的生活创造有利的环境。更广义地说,生态养老指导我们将环境与健康联系在一起,减少这一日益庞大的人口群体对环境的影响。因此,在老龄事业中应用场所性的健康促进策略有助于降低待赡养的老年人口对全球稳定性的威胁。     

Distribution and utilization of home- and community-based long-term care services for the elderly in North Carolina

Provision of home- and community-based long-term care is a growing concern at the national, state, and local levels. As more persons grow old, the need for these services is expected to rise. This analysis examines the distribution and utilization of three home- and community-based long-term care programs in North Carolina for each of the state's 100 counties. Maps were generated to examine how counties differed in respect to service utilization among the elderly. Great variability was found in number of elderly utilizing the services across the state as well as the percent of Medicaid- and/or age-eligible persons who utilized the programs. Multivariate modeling for associations to service utilization was only possible for one of the long-term care programs. Results indicated that living alone, being non-white, and having a mobility and self-care limitation were all positively related to utilization. Percent of persons 85 years or older and the ratio of institutionalized long-term care beds were negatively associated with utilization. It was concluded that states must engage in concerted efforts to ensure equity in access to home- and community-based long-term care.