Organization and delivery of long-term care in Singapore: present issues and future challenges

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.     

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.     

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.     

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.     

Resource Effects on Access to Long-Term Care for Frail Older People

Abstract

Access to long-term care depends primarily on personal resources, including family members and income, and on external resources, including Medicaid and Medicare. This study investigates how resources affect frail older individuals' access to long-term care, with a focus on Black and White widows. Data from the 1989 National Long-Term Care Survey is used, in conjunction with state-level Medicaid and Medicare reimbursement rates for nursing home and home health care, to estimate the likelihood of five types of care arrangements. Results show that children are a primary resource for unmarried individuals in maintaining access to informal care. Income effects are nonlinear in relation to nursing home care: increasing incomes below the mean income are associated with decreasing probabilities of nursing home care, while increasing incomes above the mean are associated with increasing probabilities of nursing home care. Income and Medicaid effects are interrelated, with nonlinearities associated with income having the potential to adversely affect some older persons' ability to access nursing home care.     

Homes of Choice

Abstract

State policymakers increasingly recognize that housing is not only an important shelter resource for older persons, but also a key element of community-based care. Over the last two decades, significant state and local activity has led to an increase in service-enriched housing for older persons. Service-enriched housing refers to living arrangements that include health and/or social services in an accessible, supportive environment. Emerging forces are leading to increased pressure for the expansion of service-enriched housing. These forces include: a growing and diverse population of older renters; older adults' preferences to age in place; the increasing frailty of subsidized housing residents; the development of assisted living (AL); the enactment of Medicaid waivers; and implementation of the Olmstead decision. Although studies have not included cost-analysis, available research demonstrates that service-enriched housing promotes resident satisfaction, successfully provides services to frail populations, and supports aging in place.

Given both limited resources and research, this article addresses how states can adequately respond to and capitalize on these forces in order to best meet the long-term needs of older adults.     

An International Review of the Long-Term Care Workforce

Abstract

The developed world's population is aging, due to trends of increased life expectancies and decreased fertility rates. These trends are predicted to increase demand on long-term care services. At the same time, the long-term care workforce is in shortage in most of the developed world. Moreover, such shortages are expected to increase due to parallel socio-demographic factors. The increase in demand for long-term care, coupled with shortage in supply of care workers, has promoted some attention from policymakers. The current paper provides an international review of institutional arrangements for long-term care in different developed countries and in particular explores different strategies used or proposed to resolve the shortage in the long-term care workforce.     

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.     

Affordable Clustered Housing-Care: A Category of Long-Term Care Options for the Elderly Poor

ABSTRACT

What we label as affordable clustered housing-care options are making it increasingly possible for poor and frail older Americans to age in place comfortably and securely in residential-like settings combining both affordable shelter and long-term care. The hallmark of these housing arrangements is their sizable population clusters of low-income frail persons in need of supportive services. Despite their greater availability and the compelling factors underlying their growth, the diversity of their supportive services and operations cloud their identity resulting in uncertainty as to whether they have a common mission. In response to the need for a more careful delineation of this aging in place option, this paper describes the distinguishing features of these hybrid settings and constructs a typology of their representative exemplars or prototypes.     

Long-Term Care Preferences Among Older Adults: A Moving Target?

ABSTRACT

This study investigates long-term care preferences across three hypothetical scenarios and over one year of time among a sample of disabled older women receiving informal care (n?=?420). Unpaid or paid help in one's home was preferred, given scenarios of instrumental activities of daily living (IADL) and activities of daily living (ADL) needs; nursing home care was most preferred for dementia care. While aggregate preferences for long-term care were relatively stable, there was considerable fluctuation in individuals' preferences over time, with just 52.5%, 44.4%, and 44.6% of participants retaining their initial first choice across IADL, ADL, and dementia scenarios, respectively. Implications of study findings are discussed.     

Lessons on social and health disparities from older lesbians with alcoholism and the role of interventions to promote culturally competent services

ABSTRACT

Older adults who are lesbian, gay, bisexual, or transgender (LGBT) face greater health risks and possibly more costly care because of their reluctance to seek out health and long-term care services because of limited cultural sensitivity of service providers. This is particularly evident in older lesbians who face substantial risk of health problems associated with alcoholism and are less likely to be open with health care providers because of stigma combined with feelings of alienation, stress, and depression. An estimated 4.4 million older adults are predicted to have problems with alcohol by 2020, and the rates of alcohol-related hospitalizations are similar to those for heart attacks, creating exorbitant medical costs. More culturally competent health and long-term care may reduce health care costs by effectively addressing the dynamics of alcoholism, aging, and lesbian culture. Training initiatives such as those developed by the National Resource Center on LGBT Aging have begun to address the need of a more culturally competent aging services network. This article provides exemplars from empirical data on older lesbians with alcoholism to highlight some of the health, economic, and social disparities experienced in the aging LGBT community. Current interventions in the form of cultural competence training for service providers are presented as a potential step toward addressing health disparities among LGBT older adults.     

The Savings Approach to Financing Long-Term Care in Singapore

Summary

Singapore is grappling with provision of services for the current generation of older people at the same time as building the foundation for the coming generations of elderly. In this article, I analyze four sets of factors that are shaping long-term care policy and financing in ways that are almost unique to Singapore. First, current developments can only be understood in the context of the Central Provident Fund (CPF) that was established by the Government of Singapore in the 1950s to ensure that the working population saved for retirement; the Medisave and related schemes for financing health care were subsequently developed alongside the CPF. Most recently, the existing funding arrangements have been extended to some long-term care services, and options for further extensions are under consideration. Second, the government's philosophy of maintaining the primacy of family support for the elderly has been expressed through a number of initiatives that provide financial and other incentives to families, combined with an emphasis on community care. The third factor is the relationship between government and the voluntary welfare organizations that are the major providers of institutional and community services. Finally, a series of government-sponsored reviews and advisory councils have provided for widespread consultation on policy options. These developments are directed to achieving a multi-pillar approach in which intergenerational transfers through taxation will be limited, and the role of individual savings and insurance will be increased.     

The Physical Housing Environment and Subjective Well-Being Among Older People Using Long-Term Care Services in Japan

Abstract

For older people using long-term care services, the conditions of their life-space may be critical. The relationships between the physical housing environment and aspects of health were examined among older people in Japan (aged 65+ years, N?=?1,928) by multivariable logistic regression analysis, adjusting for sociodemographic characteristics. Lack of safety, low access to emergency assistance, low or high indoor temperature, poor sanitary conditions, and state of home disrepair were significantly associated with negative aspects of health among people with low activities of daily living (ADL) independence. Home care service providers and policymakers need to consider the importance of appropriate environmental conditions for the most vulnerable groups.     

Long-Term Care Insurance in Japan

Abstract

Among all the industrialized countries, Japan has the fastest rate of population aging and the highest life expectancy at birth. It is projected that the proportion of elderly people will reach 35.7% in 2050. In this demographic environment, Japan launched a social insurance program for long-term care for the elderly in 2000. What were the forces that led Japan to establish a long-term care program for elderly people? What are the provisions for financing, benefits, and service delivery? What aspects of policymaking in developing such a program are unique to Japan? This article presents answers to these questions.     

Assessing Capacity in the Setting of Self-Neglect: Development of a Novel Screening Tool for Decision-Making Capacity

ABSTRACT

Compared with older adults with disabilities and those who autonomously choose to live in squalor, self-neglect syndrome arises from a predicate state of vulnerability in frail older adults. This state of vulnerability is characteristically associated with a decline in decision-making capacity regarding the ability to care for and protect oneself. We developed the COMP Screen to evaluate vulnerable older adults to identify potential gaps in decision-making capacity using a screening tool. A total of 182 older adults were evaluated and consistent declines in cognitive ability and decision-making processes were present in this population. However, there were no significant differences between elders referred for self-neglect and matched older adults. These findings suggest that declines in decision-making processes are not uncommon in vulnerable older adults but traditional conceptualizations of decision-making capacity may be inadequate for differentiating the capacity for self-care and protection in elders who self-neglect.     

Sense of Need for Financial Support and Respite Services among Informal Caregivers of Older Americans

ABSTRACT

Financial support and respite services are two of the most frequently reported types of help that caregivers of older adults need. Using an expanded health behavioral model, this study examined the effects of predisposing, enabling, and needs factors on caregivers' sense of need for these two types help. Data were drawn from the 1999 National Long-Term Care Survey and included 1,058 caregiving dyads in the community. The results indicated that caregiver-related factors more than care recipient–related factors affected caregivers' sense of need to seek both types of help. The findings direct to two important implications for long-term care policy for and practice with older adults: improvement of service for caregivers and service delivery systems.     

Changing Needs and Changing Service Delivery for Long-Term Care in Hong Kong

Summary

Both the need for and delivery of long-term care in Hong Kong are shaped by the interaction of the traditional and modern. Rapid social change is affecting traditional family structures and roles in care of the elderly, resulting in increased demand for formal care, which to date has been provided mainly by way of residential care. This growth of demand will escalate with rapid population aging in coming decades. In response to this burgeoning demand, current planning is seeking to reshape the established service system and tackle problems in service delivery in ways that will address the bias towards residential care and improve quality of care.     

Weighing the Success of a National Alzheimer's Disease Service Demonstration

Summary

As the need for long-term care services within the United States has grown dramatically, Congress has consistently deflected the primary responsibility for such care to state governments, local organizations, and, ultimately, the family. This paper examines the impact of the Alzheimer's Disease Demonstration Grants to States (ADDGS) program, a small federally funded initiative within the context of this trend. Although the demonstration can be deemed a huge success relative to the goals of creating new services for an underserved target population, questions are raised about the merits of the program relative to the exploding need for an effective network of long-term care services.     

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.