Emerging Services for Community-Based Long-Term Care in Urban China

Abstract

China's rapid economic reforms, coupled with the changes in age composition of the demographic structure, have greatly affected the traditional family support system. In response to these changes, efforts to develop new models of community-based long-term care (CBLTC) for elders in China have received growing attention. This paper provides a systematic analysis of the current status of emerging CBLTC systems in Shanghai, China. It covers several domains of the system: service delivery, workforce, financing, and quality of care management. Several main issues involved in the development of the emerging system are addressed, and relevant policy implications are presented in the paper.     

The family caregiving career: implications for community-based long-term care practice and policy

Informal (i.e., unpaid) long-term care for disabled older adults is often chronic, but it is only recently that research has considered the longitudinal implications of family caregiving. In particular, investigators have conceptualized caregiving as a "career," and within the caregiving career, a number of diverse trajectories and transitions can occur. Following a summary of these findings, this paper considers how longitudinal caregiving research can influence and potentially address key policy and practice concerns, especially in the delivery and support of community-based long-term care (CBLTC) services. It is suggested that with the refinement of the informal long-term care literature, existing policy and practice to support caregiving families can be similarly advanced.     

Predictors for resolution of antisocial behavior among foster care youth receiving community-based services

Youth in the foster care system are more likely to be diagnosed with mental illness than those in the general population. Within this system, youth with antisocial behavior (e.g., aggressive, oppositional) are overrepresented. The challenges youth with antisocial behavior present to foster care systems make understanding the factors that predict remission in this population important for improving placement stability. Using Optimal Data Analysis (ODA), this study examines potential moderating effects of various individual, social, and strength variables on clinically significant decreases antisocial behavior in a sample of foster care youth over time. Results revealed positive improvements in youths' wellbeing to be the optimal predictor of resolution, followed by positive changes in family functioning and positive changes in adjustment to trauma (i.e., symptoms of PTSD). These results indicate that clinically significant decreases over time in antisocial behavior were associated with concurrent improvement in individual and environmental variables. Implications for service providers working with this population are discussed.     

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.     

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.     

HEALTH CARE REFORM IN THE UNITED STATES: IMPLICATIONS FOR TRAINING AND PRACTICE IN MARRIAGE AND FAMILY THERAPY

Americans are spending 12-14% of their income on health care, and costs are rising about 11-12% per year. These increases are fueled by many social problems and are not limited strictly to health matters. Many alternatives have been examined to limit the rapidly increasing costs. The long-term results of these efforts are likely to be a reduction in health care benefits for many and the continued development of a two-tier system of health care. This article addresses the place of mental health care in general and marriage and family therapy in particular in the emerging system. Suggestions for training and practice for the new health care system are given.     

Inclusion of caregiver supports and services in home- and community-based service programs: recent reports from state units on aging

Caregivers have an important role in assisting frail and/or disabled individuals to maintain their independence in the community. Support to assist caregivers in this often stressful and demanding role is critical to sustaining the caregivers' health and ability to provide care. This paper reviews federal policy changes since 2000 that have expanded and enhanced services for informal caregivers. Next, data collected from State Units on Aging and other state agencies are presented to describe the extent to which caregiver services are included in home- and community-based programs under three funding streams (Medicaid waivers, Centers for Medicare and Medicaid Services-funded programs, and state-funded programs). Program characteristics, such as eligibility and consumer-directed options, are included. Finally, the accomplishments and initiatives reported by state respondents related to supporting informal caregivers are also explained. Results indicate that services for informal caregivers are receiving greater attention and are frequently offered under home- and community-based service programs by the states that participated in this study.     

Mobile crisis services for children and families: Advancing a community-based model in Connecticut

The purpose of this paper is to describe a best practice model of care for children's mobile crisis services in Connecticut: Emergency Mobile Psychiatric Services (EMPS). EMPS responds to homes, schools, emergency departments and other community locations to provide children and their families with mobile crisis stabilization, assessment and brief intervention, and referral and linkage to ongoing care. The system is comprised of a statewide network of contracted providers, a statewide Call Center to manage and triage incoming referrals, and a Performance Improvement Center to provide data analysis, reporting, quality improvement, and standardized training. Data collected since 2009 demonstrate high service utilization, consistently high mobility rates, and rapid response times as well as statistically significant improvements in child outcomes. The paper discusses the role of mobile crisis services within a comprehensive continuum of behavioral health care for children and families.     

The changing landscape of public service delivery systems for disabled people in China: a Shanghai case study

This article will consider the current development of an emerging contract culture for the delivery of social services and its impact on disabled people in China. The discussion is based on an original qualitative study in Shanghai. The past 30 years have seen dramatic changes in China, which in parts have led to improvements in the lives of disabled people. The China Disabled Persons’ Federation (CDPF) became a key player in delivering these changes with the government. However, the CDPF is being criticized by disabled people for being too bureaucratic and not being effective enough in its delivery of services. One of its responses is to work with newly emerging not-for-profit organizations (NPOs) of and for disabled people. The CDPF has now begun to contract the delivery of some services to such NPOs. It is hoped that this may improve their effectiveness but the development of a contract culture in the delivery of services for disabled people may also be seen to pose a threat.     

Understanding emerging disabilities

This research seeks to understand social and environmental characteristics that distinguish emerging from traditional disability populations. We qualitatively analysed how emerging disabilities are understood by persons with disabilities, and used these themes with a public use data source to analyse differences between emerging and traditional disabilities. Our findings first illustrate the difficulty in diagnosing and categorizing emerging disabilities. This is true for both persons who have these conditions and medical personnel who are expected to interpret them. Compared with persons with traditional disabilities, persons with emerging disabilities had less education, greater difficulties with activities of daily living, lower income, less private insurance, more frequent medical care and were less likely to work. The picture emerges of that of an underclass within society. There is an ongoing need for a referral and support system with greater recognition and acceptance of all disabilities, especially within independent living centers and among employers.     

Home and community-based care: recent accomplishments and new challenges

This article traces the development of home and community-based care to its current place in the worlds of health and social policy. An argument is developed to the effect that such services have by now gained both heightened policy legitimacy and organizational capacity. Building on these contentions, the article goes on to suggest that such services should continue to gain a more prominent place within long-term care policy, and that long-term care issue deserve a more central place within social insurance policy more generally. The article concludes by suggesting that demonstrations of policy efficacy such as those that are taking place in home and community services might help to at least modestly offset the frontal assault which is currently taking place across the range of American social policy.     

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.     

‘Nothing about us without us’: the emerging disability movement and advocacy in China

The disability movement and disabled persons’ self-help organizations (DPOs) are emerging in China, some of which succeeded in promoting policy and social changes with special strategies. Based on an original survey and interview, this article explains the development and survival strategies of China’s DPOs, and especially interprets some successful cases of social advocacy and policy advocacy in the emerging disability movement. It is hoped that scholars will pay more attention to the advocacy and public engagement of the disability community in non-western settings in the future.     

Home is where the help is: community-based care in Denmark.

Policy regarding long-term care has been an issue of rising national concern. In this paper we examine the transition of Danish long-term care policy with special attention to Skaevinge, the first community in Denmark to integrate institutional and community-based services for the elderly. Recent studies on the variation between costs and services in Danish communities and the results of U.S. studies on community-based care suggest that successful implementation of integrated institutional and community-based long-term care is feasible in the United States. Lessons from Denmark highlight conditions that will facilitate success in this endeavor.     

NO ROOM FOR ABUSE

In Canada, media reports on health care tend to focus on the high costs of the health care system; reporting privileges the economic aspects of this social service. In the Canadian system, long-term care or chronic care is a type of service that is situated within the health care system. Long-term care institutions typically house older individuals who have lost a significant amount of autonomy and require constant care. Until recently, the services dispensed within these institutions were unseen by the media, and thus the public did not reflect much on these services. The publication of the Report of the Royal Commission on the Future on Health Care in Canada in 2002 has fostered a growing public awareness of the vulnerability of older individuals and those with chronic illnesses, and their relationship with their care-givers. Although it may be the case that the typical care for such persons in these situations is now emerging from a zone of invisibility, it is uncertain that the media coverage accurately portrays the realities of institutionalized care-giving. This essay examines the care practices in long-term care institutions in order to understand the processes at work in an environment in which care is commodified. The ‘area’ in which this caring labour is located is an area where constant moral compromise can create a climate where abuse can become endemic. This paper considers these environments and the potential for abuse in them in relation to the concept of ‘grey zone’, first formulated by Primo Levi and later adapted by Giorgio Agamben and Claudia Card, as well as in relation to the related concept ‘bare life’, also formulated by Agamben. The author argues that the ‘greyness’ produced by care practices that are bound to a cost-effective and task-oriented framework create an environment that is not conducive to proper moral behaviour.     

A comparative study of health delivery systems of India and China

The medical systems which most of the developing countries have, are ad hoc adoptions inherited from their colonial masters and have met with little success in making health planning as part of their national planning. Very few countries have been able to overcome the resistance of the medical profession and the bureaucratic inertia which is a major obstacle in the transformation of this system to a broad based social service and integrating it with the process of socio-economic development planning. The adoption of this system by developing countries is a typical example of technological misfit. A cheap and labour intensive model for developing countries shall be a proper solution for the development of a health care delivery system for the masses. A solution to this problem is a mix or hybrid of the traditional and modern medicines which very recently have been exploited both in India and China. How far India and China have been successful and what is needed to be done is the subject matter of this paper.     

Reforming the health care delivery system

The health care delivery system is evolving rapidly. There have been changes in the way health care is financed, the types of treatments available, the sites of care, and the physician patient relationship. These changes have resulted primarily from reactions to health care cost inflation. Health care reform is likely to accelerate some of these changes. The threat/promise of health care reform has already accelerated the consolidation of the health care services market. Health care reform is likely to reduce the number of insurers, increase the number of Americans in managed health care plans, increase the number of physicians in group practice, change provider income, and in general make the health care delivery system more concentrated and vertically integrated.     

Managed care and the rationalization of mental health services

Managed care represents a response to the wider institutional demand for technical rationality and efficiency, and it may be in conflict with professionally generated logics of mental health care which emphasize the delivery of quality care, as well as providing services to all who need care. The organizational and policy conundrum is to balance conflicting institutional demands for efficiency (cost savings) and effectiveness (access and quality). This paper examines managed care in one public sector mental health care system that has attempted to incorporate the principles of managed care into a community based system of care and to overcome the potential contradictions between demands for efficiency and professional logics of care. Both qualitative and quantitative data are used to examine changes in organizational structure and service offerings; providers' experience of managed care, and the effect of managed care on working conditions and work experiences, and changes in the goals of the organization as measured by the specification of client outcomes. I find that, while increased performance accountability and outcome assessment (in keeping with demands for efficiency) have the potential to improve mental health care services, in fact, providers report that the primary effect of managed care has been an emphasis on cost containment, and there has been a corresponding de-emphasis on the provision of community based services for clients with long term care needs. However, there is potential for professional logics to be maintained by larger institutional forces demanding quality care.