Formal Long-term Care Research Articles

Level of Resident Care Need and Staffing by Size of Nursing Home under the Public Long-term Care Insurance in South Korea

Purpose: Formal long-term care in nursing homes became a popular means of caring for frail elders in South Korea. This universal long-term care (LTC) insurance for elders was introduced in 2008. The aim of this study was to provide information on the extent of and variations in residents’ care needs and nursing staffing characteristics across nursing homes. Methods: This was a population-based secondary analysis of a large national survey study involving 1,472 older residents in 92 nursing homes in South Korea in 2013. Characteristics of residents and nursing homes were collected by functional assessment and an examination of administrator surveys for nursing home size was done using descriptive analysis. Results: Small and small-medium nursing homes were more likely to provide care to non-Medical-aid beneficiaries and older people with lower care need level. These smaller homes also better met the minimum nursing staffing standard. However, they were less likely to hire registered nurses (RNs), as it is not yet a staffing requirement for nursing homes in Korea. Conclusion: South Korea has a policy agenda to increase nursing staffing level, especially by adding RNs, and decrease variations in staffing levels by nursing home size. Further evidence on care-need level, proper resource allocation, and policies designed to strengthen the LTC workforce is essential to advance the LTC system in Korea.

Health Insurance and Long-Term Care Services for the Disabled Elderly in China: Based on CHARLS Data.

PurposeThis paper aimed to explore the relationship between the different factors, especially health insurance, and the availability of long-term care (LTC) services, among the disabled elderly.MethodsBased on the data of China Health and Retirement Longitudinal Study (CHARLS), the logistic regression model was utilized to evaluate the influence of the different factors, especially health insurance, on the availability of long-term care services.ResultsOur findings show some interesting results. Firstly, the findings suggest that informal long-term care (LTC) services for elderly persons with disabilities heavily depend on a family member from different health insurance groups. About 80.733% of the disabled elderly depend on a family member as their primary caregivers. Secondly, other influence factors such as income and area of residence were also significantly related to the availability of long-term rental services. Thirdly, Health insurance is a very important factor influencing the availability of Long-term care services both in urban and rural areas (p<0.001) but Income is the most interesting variable.ConclusionBased on our results, the growth and integration of formal long-term care (LTC) services should be facilitated. Firstly, policymakers can encourage formal long-term care (LTC) services from a variety of sources to work together to increase overall supply capability. Secondly, the long-term living security needs of people who do not have health insurance should be regulated through subsidies according to the economic status.

Urban\u2013Rural Disparities in Informal Care Intensity of Adult Daughters and Daughters-in-Law for Elderly Parents from 1993\u20132015: Evidence from a National Study in China

The Chinese population is ageing and the burden of caregiving for elderly on society is getting heavier. With formal long-term care system underdeveloped, informal care provided by family members remains the predominant form of care provision in China. Urban and rural caregivers may face different situations in their informal caring roles due to China’s strict household registration system (hukou). There are few studies focusing on rural–urban disparities in elderly care from the perspective of female caregivers. We used hukou status rather than living location to distinguish urban and rural, and the informal care was divided into low-intensity and high-intensity in our study. We used repeated cross-sectional data from the China Health and Nutrition Survey (CHNS). Multinomial logistic regressions and Oaxaca–Blinder decomposition techniques were used to explore the urban–rural disparities. We found that respondents with urban hukou were around 30% more likely to provide informal care than those with rural hukou, and the relative risk ratios value for both low (RRR = 1.29) and high (RRR = 1.30) intensity care were significantly at 5% level. The results of the Oaxaca–Blinder decomposition showed that the mean difference of informal care time between urban and rural was 3.11. Among them, education attainment can explain 25.10% of the total difference between urban and rural and was the largest contributor to the overall gap. Long-term care system in China should be established and improved, and policies should focus more on the most vulnerable groups such as rural hukou holders and the less-educated.

The plight of migrant care workers in Japan: A qualitative study of their stressors on caregiving

ObjectiveThis study explored the phenomenological experiences of migrant care workers working in the formal long-term care setting in Japan and identified their stressors on caregiving. MethodsWe collected data using in-depth interviews among Filipino (n = 21), Indonesian (n = 6), and Vietnamese (n = 4) migrant care workers. We conducted the interviews in either their native language or in Japanese. All interviews were audiotaped and transcribed verbatim. We analyzed the transcripts using thematic analysis. We used qualitative data analysis software NVivo 10Ⓡ to code and manage the data. ResultsSix key themes emerged that were related to stressors on caregiving. These include (1) coworker relationship, (2) language barrier, (3) work-life balance, (4) health concerns, (5) physical environment, and (6) patient relationship. Migrant care workers struggled with Kanji (Chinese characters) and verbal communication. Most of them shared having fatigue and chronic back pain. A few also mentioned about anxiety and depression. The low salary and heavy workload have made caregiving jobs unattractive to them. Workplace discrimination, patients’ attitude, and a hostile work environment were part of their stressors at work. DiscussionThis study is the first step in highlighting the current issues being faced by migrant care workers in Japan. The stressors were the identified psychosocial issues of migrant care workers. The Japanese government is suggested to amend their care work policy and provide psychosocial support explicitly tailored for migrant care workers.

The kids are alright - labour market effects of unexpected parental hospitalisations in the Netherlands

Unexpected negative health shocks of a parent may reduce adult children's labour supply via informal caregiving and stress-induced mental health problems. We link administrative data on labour market outcomes, hospitalisations and family relations for the full Dutch working age population for the years 1999-2008 to evaluate the effect of an unexpected parental hospitalisation on the probability of employment and on conditional earnings. Using an event study difference-in-differences model combined with coarsened exact matching and individual fixed effects, we find no effect of an unexpected parental hospitalisation on either employment or earnings for Dutch men and women, and neither for the full population nor for the subpopulations most likely to become caregivers. These findings suggest that the extensive public coverage of formal long-term care in the Netherlands combined with widespread acceptance of part-time work provides sufficient opportunities to deal with adverse health events of family members without having to compromise one's labour supply.

INTEREST GROUP SESSION—ASSISTED LIVING: DEMENTIA IN ASSISTED LIVING: STATE VARIABILITY IN REGULATIONS, OVERSIGHT, AND RESIDENT OUTCOMES

Approximately one million individuals, an estimated 40% with a diagnosis of Alzheimer’s disease-related dementias (ADRD), reside in assisted living (AL); yet, little is known about their experience or the quality of care provided in AL. Unlike other forms of long-term care (LTC), the licensing, operating, and enforcement requirements for AL falls to the states, which vary dramatically in their regulatory approaches. The overall objective of this symposium is to examine states’ AL regulatory environments and understand if and how the health outcomes of AL residents with ADRD are impacted by states’ regulatory decisions. Presenters will highlight the state variability in the regulation, oversight, resident composition, and outcomes of AL residents with ADRD. The first presentation will describe states’ different regulatory requirements for staffing and admission/discharge criteria as it relates to residents with ADRD and how those have changed over the last decade. The second presentation will report results from a national survey of state agents regarding their oversight and enforcement activities in AL. The third presentation will characterize differences in the resident composition and healthcare utilization among residents with ADRD across states. The fourth presenter will report on the effect of residing in an AL licensed to provide specialized dementia care versus a standard-licensed AL on ADRD residents’ outcomes. The discussant will contextualize findings as they relate to the current state of the AL industry. Results will ultimately inform policy-makers, organizational leaders, and clinicians as they seek the most effective ways to ensure optimal outcomes vulnerable residents with ADRD.

LGBT OLDER ADULTS IN RURAL SOUTHERN APPALACHIA: PERCEPTIONS OF CURRENT AND FUTURE FORMAL SERVICE NEEDS

Older sexual and gender minority adults in rural communities face challenges in accessing formal health, mental health, and long-term care services (Butler, 2017; Koch & Knutson, 2016; Stein et al., 2010). Formal service providers in rural Southern Appalachia are more likely to have conservative values that are closely linked to their religious beliefs (Keefe, 2005). Some may be opposed to gender non-conformity and same-sex relationships or marriage, making it wise for LGBT older adults in rural contexts to carefully select formal service providers and settings (Willging et al., 2006). Barriers to accessing formal services for LGBT older adults residing in rural contexts include few LGBT-inclusive service providers and facilities, transportation, cost, and health insurance (Butler, 2017). When faced with the prospect of long-term care, older LGBT adults are more likely to conceal their sexual or gender identity due to fears of being mistreated (Brotman et al., 2003). This session will present results of a qualitative study examining experiences, concerns, and recommendations regarding formal services among 11 LGBT older adults residing in rural southern Appalachia. Several of the participants described experiencing discrimination from local service providers. A number of participants were fearful about the perceived lack of LGBT-inclusive services in the area and expressed that they would consider leaving the area if their own or their partner’s health declined. Many participants expressed the need for local provider education about the needs of LGBT older adults. The presenters will discuss the implications for research and for health, social, and long-term care services.

DEPRESSION, FUNCTIONAL DISABILITY, AND ACCESSING HEALTH CARE AMONG OLDER MEN AND WOMEN IN GHANA AND SOUTH AFRICA

Objectives. To inform a preventive approach to mild depression among older Ghanaians and South Africans, this study will investigate the association and possible variabilities between mild depression, functional disability, accessing health care, sociodemographic, and socioeconomic factors across genders in both countries. Methods. Cross-sectional wave 1 (2007-2010) data from WHO’s Study on Global Ageing and Adult Health (SAGE) are used, and a sample of 3871 for Ghana and 3076 for South Africa are analyzed. Binary multiple logistic regression is used to identify the association between mild depression, functional disability status, socioeconomic and sociodemographic factors, and health status. Results. The proportion of mild depression (MD) is 3.78% and 8.15% for older Ghanaian men and women, and 2.29% and 11.91% for South African older men and women, respectively. At 95% CI, increased severity (mild and high levels) of functional disability are associated with increased odds of MD in Ghanaian and South African older men and women. Apart from South African older men, older people in the study who do not receive healthcare when needed have increased odds of MD. Sociodemographic and socioeconomic factors are also associated with MD. Discussion. An untreated, persistent MD may lead to worse conditions with fatal outcomes. Since, mental health care is lacking in both countries, this study recommends policies directed towards support for formal and informal long-term care, and healthcare access to reduce the risks of depression. Thus, this study’s findings may provide relevant information for managing depression among older Ghanaians and South Africans.

TECHNOLOGY-BASED INTERVENTIONS TO IMPROVE CAREGIVER WELL-BEING

Informal or unpaid care is the most common form of long-term care. Despite clear benefits for the care recipient, caregiving can have unintended physical and emotional consequences for caregivers. Traditional caregiver interventions are limited in scope, as they often focus on the emotional consequences of caregiving; however, the physiological effects of caregiving are equally deleterious to caregiver health. Exercise improves physical health, yet the demands of caregiving can limit participation in physical activity. Traditional gym-based interventions may not be feasible for many caregivers. Advances in technology present an opportunity to address these limitations, specifically in the areas of accessibility and acceptability. The Combined Online Assistance for Caregiver Health (COACH) program combines evidence-based skills training with physical exercise in a tablet-based intervention. Preliminary evidence for the physical and psychological benefits are promising; however, differential attrition rates are informative as to the acceptability of technology-based interventions among some caregivers.

THAT’S MY CREATOR’S REALM: UNDERSTANDING AFRICAN AMERICAN ASSISTED LIVING RESIDENTS’ END-OF-LIFE PREFERENCES

Assisted living, one of the fastest growing formal long-term care options for older adults in the U.S., increasingly is a site for end-of-life care.. Most residents are non-Hispanic and white, yet African Americans reside in these settings and relatively little is known about their end-of-life preferences. In this paper, we present an analysis of data collected as part of a larger five-year mixed-methods NIA-funded study (R01AG047048) examining end of life in assisted living. We analyze longitudinal qualitative data collected over two years in a large (>90 beds) care community catering to African American older adults. Drawing on 850 hours of participant observation, in-depth interviews with 25 residents, and record review data, we seek to: (a) understand residents’ end-of-life preferences; and b) identify how and why preferences vary. Guided by principles of grounded theory, our analysis shows that most preferred a death where “you go to sleep and never wake up.” Yet, residents varied in their preferences for the timing and location of death, nature of end-of-life care, and use of advanced directives. Age, health, health literacy, perceived quality of life, and not wanting to be a burden all influenced preferences. For most, religious beliefs were a key factor shaping these preferences. Perceiving that end of life, including how, when, where one dies, and the nature of suffering and care, ultimately is their “creator’s realm,” led to the near universal conclusion: “I got no control over it.” We discuss implications of these findings for improving end-of-life care for African American residents.

Optimal long-term care policy in an intergenerational exchange setting

We examine the optimality of public long-term care policy, incorporating an exchange game between elderly parents and adult children and transfer-seeking competition among siblings, instead of children's altruism. Results reveal that when children compete to obtain more valuable bequests from parents in exchange for elderly care, public long-term care policy is optimal if government can provide long-term care more efficiently than children can, thereby reducing parental bequests, possibly to zero. This is likely to be the case when children's wages are high. Formal long-term care might not be necessary if parents can receive adequate informal care in exchange for bequests to children with low wages.

Mass evacuation and increases in long-term care benefits: Lessons from the Fukushima nuclear disaster.

BackgroundThough mass evacuation may increase the need for long-term care (LTC) services, how the need for LTC services increases and how the public LTC system affects it is not well understood. We evaluated changes in public LTC benefits for the people living in the mandatory evacuation areas established after the 2011 Fukushima nuclear disaster and examined the roles of the universal LTC insurance system in Japan.MethodsIn order to evaluate the effect of the mandatory evacuation on LTC benefits, we examined the trends of LTC benefits in the Fukushima evacuation group and the nationwide non-evacuation group. We first decomposed per-elderly-individual benefits at the municipality level into the LTC certification rate and per-certified-individual benefits, and then implemented difference-in-differences analysis using these variables as outcomes.ResultsPer-elderly-individual benefits significantly increased from 2012 onward in the evacuation group, and this was explained by an increase in the certification rate rather than in per-certified-individual benefits. Increases in per-elderly-individual benefits and the certification rate in the post-disaster period were observed in all but the highest care level, and the corresponding outcomes for the highest care level decreased immediately after the disaster. We also found that the increase in the certification rate had been mostly realized by an increase in the number of certified individuals.ConclusionsThe increase in LTC benefits can be associated with the impact of the increase in the number of people newly certified to receive LTC benefits after the mandatory evacuation. In order to cope with the increase in utilization of long-term care and associated costs after disasters in aging societies, both formal long-term care services and social support for informal care for evacuees should be considered important.

Impact of increased long-term care insurance payments on employment and wages in formal long-term care

This paper examines the effect of raising Long-term care insurance (LTCI) payments on employment and wages of workers in the long-term care (LTC) industry. Specifically, I use the change in the regional premium in 2012 as an exogenous shock to the insurance fee schedule: the change in the unit price of LTCI service ranges from a decrease of 2.8% to an increase of 4.2%. I find no increase in the number of employees in the establishments, registered under the LTCI scheme, in municipalities where the regional premium increased. The earnings and working hours of LTC workers did not increase, either.

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

ABSTRACTAging 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.

Impact of Increased Long-Term Care Insurance Payments on Employment and Wages in Formal Long-Term Care

This paper examines the effect of raising Long-term Care Insurance (LTCI) payments on employment and wages of workers in the long-term care (LTC) industry. Specifically, I use the change in the regional premium in 2012 as an exogenous shock to the insurance fee schedule: the change in the unit price of LTCI service ranges from a decrease of 2.8% to an increase of 4.2%. I find no increase in the number of employees in the establishments, registered under the LTCI scheme, in municipalities where the regional premium increased. The earnings and working hours of LTC workers did not increase, either.

The Relationship with Previous Use of Community-Based Services and Informal Caregiver Support and Elderly and Informal Caregivers’ Views of Living Arrangement: Analysis of Official Statistics from 2004 to 2014

Background and Objectives: Views on living arrangement from elderly and informal caregivers are crucial to “ageing in place”. They might be related to the experience in the use of elderly care services, which remains inconclusive in previous literature. This study aimed to explore the association of previous experience in formal and informal long-term care services with views of both elderly and their informal caregivers on living arrangement. Research Design and Methods: This study adopted a cross-sectional design. Assessment records of Minimum Data Set-Home Care for community-dwelling elderly who were eligible for subsidized long-term care services in Hong Kong from 2004 to 2014 were made available. Multivariate logistic regression was applied to examine associations between both views on elder’s living arrangement from the elderly, caregivers and their previous informal caregiver support, and experience in formal care services. Results: 82,306 dyads of elderly and informal caregivers were included in the analysis. The elderly with previous use of home and community-based services (OR = 0.84, 95% CI 0.80 - 0.88) and informal caregivers (OR = 0.78, 95% CI 0.76 - 0.81) believed that the elderly should live away from home. Temporal trends of fewer elderly and caregivers supporting the idea of living away from home were also observed. Discussion and Implications: The results highlighted the importance of informal caregiver’s support and previous utilization of formal home and community-based services. It was concluded that resources and information of community-based care have a significant association with views on living at home also proper support services and training of care for the elderly should be made available to informal caregivers to reduce their burden.

Will Fewer Children Boost Demand for Formal Caregiving?

Today, 25 percent of all caregivers of elderly are adult children. However, while the parents of the Baby Boom generation had three children per household on average, the Boomers themselves only have two. This project uses the Health and Retirement Study to assess how the number of children a person has affects the demand for formal long-term care, i.e. Long-term services and supports (LTSS), using ordinary linear regression, a Cox proportional hazard model, and an instrumental variable approach. Results suggest that the lower fertility of the Baby Boom generation is likely to lead to greater demand for LTSS in the coming decades. For example, the instrumental variable estimates indicate that having one fewer child increases the probability of having spent a night in a nursing home in the last two years from 10.7 percent to 12.4 percent among those with two or more Activities of Daily Living limitations.

Estimation of duration of formal long-term care among frail elderly people in Japanese communities using national long-term care insurance claims records

Objective The aim of this nationwide study was to estimate the duration of formal long-term care, provided by Japanese long-term care insurance (LTCI) services, among frail Japanese elderly people living in the community.Methods The study subjects were 2,188,397 (men: 579,422, women: 1,124,022, age≥65 years) beneficiaries who used LTCI services for community living in June 2013. The duration of LTCI services for community living per diem per capita was estimated by converting the benefit amount to duration of care using the code for service in claims bills according to gender and care levels, which are a nationally certified classification of individual needs for long-term care (care level 1: lowest need, care level 5: highest need). Subsequently, LTCI services for community living were categorized into respite services and community services. Community services were further subcategorized into home visiting services and daycare services.Results The overall average duration of formal care per diem per capita for men and women were 97.4 and 112.7 minutes for care level 1, 118.3 and 149.1 for care level 2, 186.9 and 246.4 for care level 3, 215.2 and 273.2 for care level 4, and 213.1 and 261.4 for care level 5, respectively. Length of respite services increased gradually with care level, whereas duration of community services peaked at care level 3 and decreased at care levels 4 and 5. With regard to the community service subcategories, duration of home visiting services increased with care level, but duration of daycare services peaked at care level 3.Conclusion Although the care levels in the LCTI system are designed to assess the need for formal care in terms of duration of care, our results suggest that the use of formal LTCI services for community living is not vertically equitable. Services that efficiently increase duration of formal care for those with higher needs for care may improve the equity and sustainability of formal long-term care services for community living.

Preparing for population ageing: Estimating the cost of formal aged care in China

Abstract China, in common with many other countries in Asia, will confront rapidly increasing demand for formal Long-term Care (LTC) over coming decades. This paper uses a unique regional monthly database on utilization of comprehensive care in Qingdao, China, to estimate transition probabilities and compute duration of care, using Markov chain simulations. Duration of care estimates are then combined with price per unit of care to calculate the total cost of care for the disabled elderly. Results show that the transition probabilities from institutional care to home care are ten times higher than those in the opposite direction; the average support duration in the plan is about 53 months, including both home and institutional care, when admitted at the age of 60, and 44 months if admitted at the age of 85, with costs ranging from RMB 40–120,000 per recipient. The cost analysis suggests that this provision model is an affordable comprehensive care model for elderly Chinese.

The estimated cost of dementia in Japan, the most aged society in the world.

ObjectiveDementia has become a global critical issue. It is estimated that the global cost of dementia was 818 billion USD in 2015. The situation in Japan, which is the most aged country in the world, should be critical. However, the societal cost of dementia in Japan has not yet been estimated. This study was designed to estimate cost of dementia from societal perspective.DesignWe estimated the cost from societal perspective with prevalence based approach.Setting, participants and measuresMain data sources for the parameters to estimate the costs are the National Data Base, a nationwide representative individual-level database for healthcare utilization, the Survey of Long-Term Care Benefit Expenditures, a nationwide survey based on individual-level secondary data for formal long-term care utilization, and the results of an informal care time survey for informal care cost. We conducted the analyses with ‘probabilistic modeling’ using the parameters obtained to estimate the costs of dementia. We also projected future costs.ResultsThe societal costs of dementia in Japan in 2014 were estimated at JPY 14.5 trillion (se 66.0 billion). Of these, the costs for healthcare, long-term care, and informal care are JPY 1.91 trillion (se 4.91 billion), JPY 6.44 trillion (se 63.2 billion), and JPY 6.16 trillion (se 12.5 billion) respectively. The cost per person with dementia appeared to be JPY5.95 million (se 27 thousand). The total costs would reach JPY 24.3 trillion by 2060, which is 1.6 times higher than that in 2014.ConclusionsThe societal cost of dementia in Japan appeared to be considerable. Interventions to mitigate this impact should be considered.