Organization and delivery of long-term care in Taiwan

Taiwan reached the World Health Organization (WHO) benchmark of 7% aged 65 and over for defining an aging population only as recently as 1993. With this proportion projected to double to 14% by 2020, Taiwan faces a rapid increase in need for long-term care. This article presents an account of the current service delivery system, which is divided between health and social affairs administrations, with a substantial role also taken by the Veteran Administration, and growing provision of facilities that operate outside the government-registered system. While a basic level of both institutional and community care services has developed, they are not organized into an integrated service system. Problems arising from the divisions and overlaps in responsibility are identified in relation to competition for resources, differences in regulation and eligibility, funding arrangements and misallocation of resources, and divergent views about the philosophical basis of long-term care. Other aspects of services fall under each jurisdiction, but there is also some overlap. A case study of Taiwan's second largest city, Kaohsiung City, reports the outcomes of these divisions as a thin spread of a range of services rather than a coordinated service network. Several planning exercises have been undertaken in recent years to address these problems, and although at an early stage of implementation, the outcomes of these plans are seen as shaping the future directions of long-term care in Taiwan.     

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.     

Vertical Axes on the Long-Term Care Continuum

Abstract

As the continuum of long-term care has expanded, public funding has not accompanied new care options. I detail access, provider profits and resources, and care quality in two types of residential care that fall in the center of the continuum, assisted living and board and care. These two options provide examples of how limited public funding leads to vertical axes, which represent access to services, the resources providers draw on to give care, and the quality of long-term care services, at each service point on the long-term care continuum.     

Exploring Policy and Financing Options for Long-Term Care in Taiwan

Summary

Policy and financing arrangements for long-term care are important themes in each country and/or region, and Taiwan, with its unique historic and politico-economic background, can be regarded as a bridge between well-developed and under-developed countries. Policy formulation about long-term care in Taiwan involves several agencies in the government, including Ministry of Health, Interior Affairs, Education, Insurance Bureau, and Economic Council, and formulation of policy objectives has progressed considerably in the last five years. Financing arrangements are less well-developed because the National Health Insurance Program began only in 1995, and most long-term care is not yet covered. As demand for long-term care exceeds supply, and this gap will grow in future, current resource allocation measures are concerned to facilitate the expansion of community care rather than allowing institutional care to absorb more resources. Developing future financing options is now a central task for policymaking, and government must continue to take a leading role in consolidating financing and integrating the service systems.     

Long-Term Care Policy and Financing as a Public or Private Matter in the United States

Summary

Effective approaches to assure adequate resources, infrastructure, and broad societal support to address chronic care needs are volatile and potentially unpopular issues that can result in many losers (those getting far less than they want) and few winners (those who gain access to scarce societal resources for care). In the United States, debates on long-term care involve a complex set of issues and services that link health, social services (welfare), and economic policies that often pit public and private sector interests and values against one another. Yet long-term care policies fill a necessary function in society to clarify roles, expectations, and functions of public, non-profit, for profit, individual, and family sectors of a society. By assessing and developing policy proposals that include all long-term care system dimensions, a society can arrive at systematic, fair, and rational decisions. Limiting decisions to system financing aspects alone is likely to result in unforeseen or unintended effects in a long-term care system that stopgap “fixes” cannot resolve. Three underlying policy challenges are presented: the need for policymakers to consider whether the public sector is the first or last source of payment for long-term care; whether government is seen primarily as a risk or cost manager; and the extent to which choice is afforded to elders and family caregivers with regard to the types, settings, and amount of long-term care desired to complement family care.     

A comprehensive health service evaluation and monitoring framework

ObjectiveTo develop a framework for evaluating and monitoring a primary health care service, integrating hospital and community services.MethodA targeted literature review of primary health service evaluation frameworks was performed to inform the development of the framework specifically for remote communities. Key principles underlying primary health care evaluation were determined and sentinel indicators developed to operationalise the evaluation framework. This framework was then validated with key stakeholders.ResultsThe framework includes Donabedian's three seminal domains of structure, process and outcomes to determine health service performance. These in turn are dependent on sustainability, quality of patient care and the determinants of health to provide a comprehensive health service evaluation framework. The principles underpinning primary health service evaluation were pertinent to health services in remote contexts. Sentinel indicators were developed to fit the demographic characteristics and health needs of the population. Consultation with key stakeholders confirmed that the evaluation framework was applicable.ConclusionData collected routinely by health services can be used to operationalise the proposed health service evaluation framework. Use of an evaluation framework which links policy and health service performance to health outcomes will assist health services to improve performance as part of a continuous quality improvement cycle.     

Distribution and Utilization of Home- and Community-Based Long-Term Care Services for the Elderly in North Carolina

ABSTRACT

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.     

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.     

Voluntary work in the Norwegian long-term care sector: complementing or substituting formal services?

ABSTRACT

Across Europe, governments call for increased involvement of volunteers to shoulder some of the welfare burden. Nevertheless, there is little research into what kind of work and how much volunteers currently contribute in the long-term care services and whether this has the potential to substitute formal services. Drawing on findings from a survey of employees in Norwegian nursing homes and home care districts, we examine the nature and volume of voluntary, unpaid work in the long-term care services in Norway. Our data suggest that volunteers to a very limited degree carry out work that has traditionally been considered the formal system’s domain: personal care and practical help. Nearly all the voluntary, unpaid contributions in our data takes place within cultural, social and other activities aimed at promoting mental stimulation and well-being, indicating a classic specialisation of tasks between volunteers and professionals. However, there has been an expansion of the formal care system to include activities aimed at promoting well-being in recent decades. This may indicate that there is a certain level of task sharing between voluntary and formal care. Thus, social workers need to consider voluntary service provision when assessing the needs of clients.     

Community Care in Taiwan

SUMMARY

This article explores the policy definitions and the funder roles of central and local governments in community care in Taiwan. The notion of community care has been adopted in Taiwan following the model of Hong Kong but the main question of the article is whether this has resulted in actual service provisions at the community level, forming an alternative to institutional care. The data has been collected from several sources: policy documents, official statistics, surveys, general reports, funding provision reports, and empirical studies. The results show that neither central nor local authorities are seriously involved in caring for elderly people or persons with disabilities in Taiwan's communities. In Taiwan, community care for these groups of people still means, in practice, informal care provided by female family members without any support from public policies.     

An Aging Workforce in an Increasingly Global World

Summary

The aim of this article is to demonstrate the diversity in delivery of long-term care at the provincial level, within a national legislative framework that provides universal health insurance and public administration. Not all provinces have legislated provision of long-term care, but mandates for provincial long-term care programs typically address the needs of those with chronic health needs and maintain them in the community for as long as possible. Eligibility is based on common criteria of residency, health need, facility, assessment, and consent. The three common components of the service delivery system are institutional care, community-based services, and home-based services; the kinds of services within each component and the mix among them vary from province to province. There are also five common features in provincial service delivery systems: single point of entry, assessment, client classification, case management, and single administration. Throughout the article, examples from different provinces show the varying ways in which these aspects of service delivery have been addressed, and recent innovations have furthered this diversity. A detailed account of quality management systems also shows that while all provinces have adopted a common set of principles, they use a range of methods to pursue quality of care and to promote good practice.     

Coordinating Health,Extended Care,and Community Support Services

Abstract

Under pressure to maximize the cost-effectiveness of programs, efforts to improve coordination have become increasingly central to the development of the broader health and welfare service delivery system in Australia in the past few years. This article reviews recent experience in two related fields: (1) the coordination of different community care services for older people and people with disabilities, funded by the Home and Community Care program; and (2) the attempt to enhance links between community and residential care services, hospitals, and other health care providers. Why coordination has emerged as such an important issue in the field of community care and, increasingly, across the entire system of what the Australian government now terms health and family services is discussed. A number of measures that have been introduced or are proposed to improve a coordination of services are briefly reviewed. These range from individualistic approaches based on information and referral, through schemes involving gatekeeping, case management and brokerage of services, to models involving the reconfiguration of organizational structures, linkages, and finances. These measures are not mutually exclusive and are increasingly likely to be applied in more complex mixed models of service coordination. It is argued that coordination at the level of direct-service provision is difficult if government policies that direct services lack coordination.     

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.     

Aged Care Service Delivery in Japan

Summary

The implementation of Japan's Long-Term Care Insurance Scheme in early 2000 presaged many changes in service delivery and much debate among service providers, different levels of government, academic analysts, and major media interests. The first part of this paper gives an account of the major changes in the organization of service delivery that have increased opportunities for private sector providers, including large corporations, and restructured contractual relationships between municipalities and providers in all sectors. New arrangements for client assessment, classification, care management, and extended service types are then outlined. An assessment is then made of the likelihood that the expected outcomes of the scheme will be realized, with the concerns of welfare professionals that the public welfare system is under threat juxtaposed with bureaucratic goals of liberalizing the provision of long-term care.     

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.     

Recent Developments in Aged Care Policy in Australia

Summary

A series of major reforms implemented through the mid 1980s sought to contain residential care and expand community care in Australia's long-term care system. While this goal has been maintained, a number of new policy initiatives followed the change of federal government in 1996. This article presents a systematic account of current policy objectives, implementation measures, and outcomes in three major policy areas: changing the balance between residential and community care, targeting in community care, and support for family caregivers. This analysis shows that while there have been shifts in emphasis from time to time, concerted policy efforts over the last 20 years have contained the growth of expenditure on long-term care and realized significant change in the service system.     

From State Care to Independence

Abstract

Historically, insufficient resources and assistance have been provided to young people leaving state care. Care leavers have been found to experience significant health, social and educational deficits including homelessness, disproportionate involvement in juvenile crime and prostitution, poor social supports, and early parenthood. The U.S. and Australia share a roughly common political language and system and have often exchanged ideas, agendas, and policies for government. This paper finds that whilst there are some minor differences in the respective legislative frameworks and responses, the similarities are far greater. Both countries have failed to provide the range of in-care, transitional, and post-care supports and services required to ensure improved outcomes for care leavers.     

Australian Approaches to Resident Classification and Quality Assurance in Residential Care

Summary

This paper begins with an account of the structure of Australia's residential long-term care program, which was divided into two distinct levels of hostel and nursing home care until 1997. In response to changed policy objectives, a number of measures were then taken to create an integrated residential care system. The main measures were the development of a single scale for classification of resident care need and associated funding to replace two previous separate scales, and the implementation of a new quality assurance system, which included new standards for buildings as well as revised standards for care. I give accounts of these measures and the extent to which they have achieved their intended outcomes before proposing some further developments that could see closer links among pre-admission assessment, resident classification, and quality assurance.     

A Comparison of Foster Care Outcomes Across Four Child Welfare Agencies

ABSTRACT

A post-discharge outcomes interview for alumni of foster care was designed by four peer foster care agencies. Across all four agencies, 222 alumni were interviewed six months after being discharged from foster care services. Outcome domains, based on common measurement practices in child welfare and on social validation studies, include type of living environment (e.g., restrictiveness), placement stability, homelessness, school performance, employment, self-sufficiency, aggression, criminal behavior, substance use, relationships, community involvement, protection from harm, satisfaction, and impact of services. Results of the outcomes were compared to nationally sampled studies of children not in care. Generally, alumni reported positive outcomes across the various domains. The type of foster care, length of care, and age of alumni influenced the results. Implications for expanding this study to establish national benchmarks for outcomes, service use, and cost in foster care conclude the article.