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.     

Future of Long-Term Care Financing for the Elderly in Korea

ABSTRACT

With rapid aging, change in family structure, and the increase in the labor participation of women, the demand for long-term care has been increasing in Korea. Inappropriate utilization of medical care by the elderly in health care institutions, such as social admissions, also puts a financial burden on the health insurance system. The widening gap between the need for long-term care and the capacity of welfare programs to fulfill that need, along with a rather new national pension scheme and the limited economic capacity of the elderly, calls for a new public financing mechanism to provide protection for a broader range of old people from the costs of long-term care. Many important decisions are yet to be made, although Korea is likely to introduce social insurance for long-term care rather than tax-based financing, following the tradition of social health insurance. Whether it should cover only the elderly long-term care or all types of long-term care including disability of all age groups will have a critical impact on social solidarity and the financial sustainability of the new long-term care insurance. Generosity of benefits or the level of out-of-pocket payment, the role of cash benefits, and the relation with health insurance scheme all should be taken into account in the design of a new financing scheme. Lack of care personnel and facilities is also a barrier to the implementation of public long-term care financing in Korea, and the implementation strategy needs to be carved out carefully.     

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.     

Pflegebedürftigkeit im Lebensverlauf

The paper investigates levels of functional health in old age as an outcome determined by support from family members and the individual’s financial assets. It addresses the question to what extent these risk factors for functional health also apply to the risk of long-term care (LTC) as defined by German Law SGB XI and may thus be transferable. Three hypotheses are presented, relating the individual’s economic resources and social integration to functional health limitations and to the onset of LTC. Results are stratified by levels of care, taking into account changes in levels of care over time as well as the location of care (at home or in a nursing home). The analysis is based the German Socio-Economic Panel (SOEP). For males it was shown that presence of close relative or spouse reduces the utilization of care (according to the LTC- definition by German Law (SGB XI). For males, long-term care was mostly provided by the spouse. The need of care depends not only on functional health status but also on the type of (family-)network. Substitution could not be found in the lower income groups. The utilization of LTC even increases for less affluent males living with a spouse due to financial incentives provided by LTC insurance. Substitutability of care services may thus vary by income group.     

A Generic Model of Long Term Care for Social Work Education

Abstract

With the “graying” of America and the increasing life expectancy for the developmentally disabled, there is an increasing demand for long-term care (LTC). As in the past, provision of this care will depend heavily on families. Professional social work can expect an increased role in facilitating the balance of LTC resources. As this role evolves, social work educators may develop anticipatory responses by incorporating a generic but comprehensive framework of LTC in social work curricula. Such a framework is presented in this paper. It is neither age- nor etiology-specific; it is appropriate for use with the developmentally disabled, the frail elderly, or any other population in need of LTC.     

Reimagining Nursing Homes: The Art of the Possible

Long-term care (LTC) needs to be reconceptualized. The current efforts to reinvent the nursing home perpetuate a flawed model of care. The heritage of the nursing home as the dominant model for LTC needs to be reexamined. The basic LTC building blocks—housing, services, and medical care—can be combined in various ways to meet consumers' needs and preferences. We need innovative solutions that can offer reasonable service while recognizing the value of acceptable risk taking. Modest personal care should not come at the price of surrendering one's autonomy.     

Social Security Reform Ideas in Japan

Abstract

Japan has a complex social security system. This article discusses the demographic and economic situation in Japan as background for understanding the setting in which the social security system functions. Japan has a three-pillar system for retirement income. The first pillar is the social security pension plan; the second pillar is the voluntary occupational pension plan; and the third pillar is personal savings, including the personal pension plan. The most important part of the retirement income system is the social security pension plan, which paid benefits accounting for 64% of the total income of elderly households in 1998. The five Employees' Pension Plans are established on a compulsory social insurance basis. Most large Japanese employers have a mandatory retirement age. Over 90% of all employees, including public sector ones, must retire from their career jobs at age 60.     

Factors Related to the Institutionalization of Older Aged Individuals Using Home- and Community-Based Care Services: Data From the South Korea Long-Term Care Insurance Program, 2008–2013

South Korea introduced a public long-term care insurance (LTCI) program in response to its rapidly aging population. This study analyzed the association between living arrangement and caregiver type with institutionalization in LTCI grade 1 (very severe limitations), 2 (severe limitations), and 3 (moderate limitations) beneficiaries using data from the LTCI cohort, 2008 to 2013. The dependent variable was alteration status from home to institutional care within 1 year of receiving home service. Independent variables were living arrangement and primary caregiver type. The analysis was conducted using the generalized estimating equation model. Higher likelihoods of institutionalization were found in individuals living with a non-family member compared to individuals living with their spouses. Individuals without a caregiver or with a paid caregiver were also more likely to experience institutionalization than individuals with a spouse primary caregiver. Our findings underscore the importance of monitoring identified vulnerable groups of individuals to attain LTCI sustainability and enhance elderly quality of life.     

Nearby Nature and Long-Term Care Facility Residents

Abstract

As the population in North America continues to age, long-term care facilities for housing the elderly are likely to become even more important. Because one of the primary foci of these facilities is on sustaining and enhancing quality of life while eventually helping patients and families cope with the dying process, both the physical and social environments are critical to the facilities' success and the users' well-being. Healing, or restorative gardens and other designed green spaces have been suggested by many academics and practitioners as important components of these environments, yet there has been relatively little systematic research on the use and benefits of nature in this context. Do elderly residents of long-term care facilities benefit from access to outdoor areas? What are the design characteristics that are most important for this unique population?

Forty elderly residents of three different urban long-term care facilities were interviewed about the importance of outdoor green spaces and views within the facility, their use of the facility's outdoor spaces, benefits they derive from those spaces, and barriers to using the spaces. Facilities differed both in terms of the amount of nature in their outdoor spaces and in the design of, scale of, and access to those spaces. Results show that overall residents place a high value on access to green spaces and derive a number of benefits from these spaces, yet they spend relatively little time in these settings. Barriers to greater use of outdoor spaces included physical limitations, lack of staff assistance, and design issues. Implications for the value of nature spaces in long-term care facilities are discussed, along with specific design recommendations.     

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.     

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.     

Willingness to Use Formal Long-Term Care Services by Korean Elders and Their Primary Caregivers

This study examined predictors of older adults' and primary caregivers' willingness to use formal long-term care (LTC) services to understand possible use patterns of mandatory public LTC insurance programs in Korea. It focused on views regarding who (adult children or the government) should bear the responsibility for older adults' care. Logistic regression models were estimated using data from 1,168 older Korean adults aged 65 or older and their primary caregivers from a national survey. The results showed that older adults' and their caregivers' views on care responsibility were a dominant predictor of their willingness to use both formal home care services and nursing home care services. Both older adults and their family caregivers' willingness to use LTC services should be considered when predicting demand for LTC services. Efforts should promote the perspective that formal LTC services are an acceptable social norm.     

Who Plays Bingo in Later Life? The Sedentary Lifestyles of ‘Little Old Ladies’

Abstract Bingo is a popular past time with less than 20% of seniors, but the prevailing stereotype of bingo players describes elderly women with nothing better to do, smoking heavily while gambling away their limited income day after day. Little research has actually explored the lifestyles of seniors who frequent the bingo halls or identified social factors explaining who plays and why. Purpose The purpose of this study was to clarify the social context and lifestyle characteristics of seniors who regularly invest money on bingo. Design and Methods A 30-min telephone survey was conducted randomly with quotas for gender and urban/rural location with 400 Albertans aged 65+. Next, a strategic sample of 44 bingo players was added to the population sample to strengthen the dependent variable for regression analyses. Multiple regression analyses were used to define key characteristics of bingo players among 10 social or contextual factors and 5 lifestyle variables. Results Being female, more elderly, living in rental accommodation, receiving federal income supplements and reporting more health problems were significant predictors of more money typically spent on bingo (18% variance explained), and these findings lend support to the “little old lady” stereotype. However, sedentary living, rather than smoking, was the only significant and predictive lifestyle pattern, suggesting that the lifestyle vices projected about bingo players are not entirely accurate. Conclusions Elderly women of marginal means do dominate the game of bingo in terms of money spent, but their gaming lifestyle apparently has less to do with habits of smoking, eating poorly, drinking alcohol, or having excessive leisure time, and more to do with sedentary recreation that is socially delimited by their gender, age, income and health.     

Caregiving and Care Receiving Among Older Lesbian,Gay, and Bisexual Adults

Abstract

A survey research design was used to examine caregiving, care receiving, and the willingness to provide caregiving among lesbian, gay, and bisexual (LGB) older adults recruited from community groups. More than one-third reported receiving care from people other than healthcare providers in the last five years; more than two thirds provided care to other LGB adults. Those who had given care were more likely than non-caregivers to give care in the future. The gender and sexual orientation of recipients of future help affected participants' willingness to provide care, as did their education level and style of coping. Participants willing to provide care to older LGB adults perceived such experiences to be less burdensome and more personally rewarding than those who were un-willing to provide care.     

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.     

Where Are the Children? Extent and Determinants of Preschoolers' Child Care Time

According to the 1988 National Health Interview Child Health Supplement, half of all children under age six attended nonparental child care on a regular basis. Close to a quarter of all children spent 40 or more hours per week in care. Average time in care was 30.5 hours for children in care. Statistical tests indicate that (a) the predictors of whether parents use any child care differ from the predictors of the number of hours care is used, and (b) estimates for children under three years of age differ from estimates for children from three to five years of age. The probability of attending care is related to a child's age, mother's education, race, family type, number and age of siblings, type of adults living in the household, income, poverty status, and region and size of the community in which a family resides. For children from three to five years of age, hours in care are associated with child's age, mother's education, race, family type, siblings, income, poverty status, and region. For children under three years of age, relatively few factors (mother's education, race, siblings, and region) predict the number of hours spent in child care.     

The continuum of dependent family care: a theoretical explanation and model

ABSTRACT

Caring for dependents with disabilities and how this type of care differs from the care of typically developing dependents has largely remained unaddressed in the work–family literature, partly because of a lack of theoretical development on the concept of dependent family care. Studies examining dependent family care often apply a life course perspective, missing key disability factors influencing dependent family care demands and need for resources. This article develops a theoretical framework of dependent family care that accounts for both typical care, which follows the life course trajectory, and exceptional care, which follows a disability trajectory. We position dependent family care as based on a continuum, achieved by adapting life course theory, family adjustment to chronic illness, ecological systems theory, stigma theory and the social model of disability into a model. We explain how dependent family care occurs and what contributes to whether one is engaging in typical or exceptional care. We draw broad constructs representing predictors of different types of dependent family care. We provide specific examples to illustrate how one might test theoretical propositions, an agenda for further research and discuss implications for family–work–community research and practice.     

Valuing and Integrating Informal Care as a Core Component of Long-Term Care for Older People: A Comparison of Recent Developments in Italy and Spain

The international long-term care (LTC) debate has recently been focusing on how to strengthen home care provision. In this regard, a major role has been played by informal care and how to best integrate it in a holistic care approach. Italy and Spain, usually labeled as “familialist” or “family-based” care models, have been promoting national reforms or actions to support the integration of “informal” actors into the overall LTC system. Through a comparative review of recent trends observed in the two care regimes, this article aims at contributing to improve our cross-national understanding of how LTC is changing across Europe, identifying the basic approaches adopted in Italy and Spain and highlighting both their strengths and drawbacks.     

Targeting Services to Those Most at Risk

Abstract

The budget crises facing many state Medicaid programs have increased interest in the goal of linking services and housing as a way to provide more options to people with disabilities at less cost than institutional care. This article examines some of the premises underlying this interest, especially with respect to linking supportive services and federally subsidized housing for older persons. The first section provides a brief history of the activity in this area. The second section examines the risk factors associated with nursing home admission and how those factors match the characteristics of renters receiving subsidies. The third section focuses specifically on the likelihood that subsidized renters will also become eligible for Medicaid. The fourth section explores the capacity of housing programs to meet the challenges associated with service delivery. Finally, the conclusion examines the implications for public policy decision-makers interested in linking services and housing in order to address the long-term care (LTC) needs of older persons with modest incomes.     

Chapter 3 Residential Care Facilities for the Elderly

Abstract

Residential Care Facilities for the Elderly (RCFEs), known as board and care homes, are licensed in California and many other states for non-medical care in the community. RCFEs are examined here to provide illustrative issues in the definition of types of long-term residential care. The research examines physical functioning, social supports, and course of residential placement for 109 RCFE residents (mean age 84 years). A significant portion of the residents had personal assistance needs not usually provided at the RCFE level (75% assistance with medication, 52% used walking aids, 29% assistance in bathing). Additionally, a third of the residents had restricted social supports and social activity. Residents report declines in functioning and support as reasons for moving to residential care. Length of residence in the facility (range less than a year to 15 years) was not related to physical functioning or social activity. These findings do not support “aging in place,” within the facility, as the rationale for increased need for assistance in residential care. Implications include the need to maintain the social model of residential care ample for the majority of residents while assuring the availability of a higher need for assistance of a significant portion of the residential care population.