Transcript Caregiver`s Perception of Long Term Healthcare Services and
A Longitudinal Study of Caregivers’ Perception of Long-Term-Care Services and Services Use in Singapore
Chang Liu
Assistant Professor Program in Health Services & Systems Research Email: [email protected]
April 17, 2014 1
• Lower fertility • Increased longevity • Later marriage • Higher rate of non-marriage and divorce
Demographic Challenges
Source: World Population Prospects: The 2010 Revision, http://esa.un.org/unpd/wpp/index.htm
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Demographic Challenges
• The number and proportion of highly disabled elderlies are rising.
50 000 45 000 40 000 35 000 30 000 25 000 20 000 15 000 10 000 5 000 0 2010 2015 2020 Source: Ansah JP, Matchar DB, Love SR, et al. 2013.
Year 5-7 ADL limitations 1-2 ADL limitations 3-4 ADL limitations
2025 2030 3
Demographic Challenges
• • The number and proportion of highly disabled elderlies are rising.
Family are getting smaller 7 6 5 4 3 2 1 2011 2014 2017 2020
Year
Age 60 Age 70 Source: Ansah JP, Matchar DB, Love SR, et al. 2013.
2023 Age 80
1-2 ADL limitations
2026 2029 4
Demographic Challenges
• • • The number and proportion of highly disabled elderlies are rising.
Family are getting smaller More caregivers will have significant depression attributable to caregiving 12000 10000 8000 6000 4000
Individuals with depression attributable to caregiving 1-2 ADL limitations
2000
Individuals with depression irrespective of caregiving
0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030
Source:
Malhotra C, Malhotra R, Østbye T,,et al. 2012.
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How much can the system handle?
Temporary beds in air-conditioned tent @ Changi General
Source:
Straits Times.
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A framework for addressing the challenges
Self-care Enhanced Family Service integration Transitional care
Agency for Integrated Care (AIC)
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Long-Term Care Services Use
• Governmental investments on formal Long-term Care Services (LTCS) – Provide higher subsidy in 2012 – Invest S$ 500 million on eldercare facilities from 2013-16 – Add 3000+ NH beds by 2016 1 – Planned to increase NH beds by 70% by 2020 – from 9,000 today to 15,600 1 • LTCS utilization is low compared to Western societies 2 – AIC: take-up rate for some community services is less than 50% • Should we promote take-up LTCS given that: – Limited information and awareness of the services – LTCS can be cost-effective for the society 3 Source: 1. William Haseltine, Affordable Excellence: the Singapore Healthcare Story, 2013.
2. Koh GC-H, et al, 2012; Wee, Liu et al. 2014. 3. Khiaocharoen et al, 2012; Saka et al, 2009; Yuan et al, 2014 8
Main Research Questions
• What are the factors associated with the take-up of formal LTCS?
And whether they differ across different LTCS?
• Are there some sub-groups of population with extremely low utilization rates (outliners)?
• What are the potential ways to improve take-up of LTCS? Can we increase the take-up rate by impacting the caregiver’s perception on services?
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Previous Studies
• The Andersen Model of Health Care Utilization 1 Does not consider caregiver (CG) characteristics, which are important in the Asian context.
– – – Care recipients (CR) for LTCS have higher dependent level CG and CR are more likely to live together Social norm • Does not account for their awareness and perception about the services 2 • With limited empirical studies in Asia: Hong Kong (2009), Japan (2011) 3
Source
: 1. RM Andersen.
J Health Social Behavior
1995; 36:1-10.
2. Ching AT et al, 2010; Gneezy U, et al, 2011; Crawford GS, et al, 2005.
3. Lou et al, 2011; Murayama et al, 2011. 10
AIC LTC Referral Study: Survey and Data
•
A Longitudinal study
– – Dyads of care recipients and their caregivers Three waves over a 12 month period • Gathered information on both CR and CG: demographic, health status, financial resources, living arrangement, knowledge and awareness, etc.
• Two measures of LTCS utilization: 1) whether took-up the referral 2) current LTC services use (a choice of nursing home, center-based services, home-based services, family and friends, maid). • CG’s perception/rating of formal and informal LTCS: quality, convenience, social connectedness, and affordability (score range from 1-5).
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AIC LTC Referral Study: Survey and Data
• Stratified sampling by:
1) 2)
Service types - Day Rehabilitation, Dementia Day Care, Home Medical, Home Nursing, Home Therapy, and Nursing Home Socio-economic characteristics – Seven Mosaic Singapore groups* • Response rate : 43% • First wave analytic sample: 1586 dyads 553 care recipients, 1027 proxies and 1502 caregivers Note: Mosaic Singapore is a geo-demographic consumer segmentation system, developed based on more than 20 years of segmentation development expertise. It classifies all Singapore households and neighborhoods into 7 groupings that share similar demographic and socio economic characteristics. It paints a rich picture of Singapore consumers in terms of their socio-demographics, lifestyles, culture and behaviors.
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CR Baseline Characteristics
Any Community Center-Based Home-Based P-Value Variable (%) LTC Services (n=1,416) Age: <=64 65-74 >=75 22.4
24.9
52.8
Female Married Education: None Primary Secondary+ Household Income: 55.9
50.5
41.7
30.1
28.3
LTC Services (n=792) 23.2
26.5
50.3
55.9
53.3
37.2
31.7
31.1
LTC Services (n=624) 21.3
22.8
55.9
55.9
47.0
47.3
28.0
24.7
0.096
0.999
0.020
0.001
500-1999 2000+ Don’t know/refuse Comorbidity: 0-1 2-4 5+ ADL Score: Low Medium High 27.4
15.1
18.6
18.8
50.1
31.1
38.1
31.8
30.2
35.0
31.6
15.7
17.8
17.7
52.2
30.2
48.7
37.5
13.8
43.8
22.1
14.4
19.7
20.2
47.6
32.2
24.5
24.5
51.0
0.000
0.000
0.000
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Take-up of Referred LTC Services
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Approaches
• • • • • Dependent variables: 1) whether took-up the referral 2) current LTC services use (a choice of nursing home, center-based services, home-based services, family and friends, maid). Independent variables: CG’s perception score on quality, convenience, social connectedness, and affordability (score range from 1-5).
Covariates: CR’s age, sex, housing, education, comorbidity, ADL, iADL, income, Medisave status, and CG’s age, sex, housing, health, # of family members in the household, decision, and whether or not they have a maid.
Statistical methods:
1) Logistic Regression 2) Conditional Logistic Regression
Two waves data
: repeated cross-sectional and longitudinal analysis 15
Perception Scores and Take-up Referred LTCS
Odds Ratio of Referred LTC Service Utilization [95% CI] Any LTC Services Center-Based Services Home-Based Services Wave 1 + Wave 2 Quality Score Convenience Score Social Connectedness Score Affordability Score N=1,795
1.27** [1.08, 1.48] 1.24** [1.09, 1.41] 1.07
[0.94, 1.21] 1.34*** [1.20, 1.49]
N=875
1.34* [1.06, 1.70] 1.31* [1.08, 1.60] 1.21
[0.99, 1.48] 1.40*** [1.18, 1.66]
N=650
1.18
[0.89, 1.15] 1.22
[0.96, 1.54] 0.92
[0.75, 1.13] 1.42*** [1.19, 1.69] Adjusted for care recipients’ age, sex, housing, education, comorbidity, ADL, iADL, income, Medisave status, and care givers’ age, sex, housing, health, # of family members in the household, decision, and whether or not they have a maid. *p<.05 **p<0.01 ***p<0.001
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Perception Scores and Take-up Referred LTCS
Odds Ratio of Referred LTC Service Utilization [95% CI] Any LTC Services Center-Based Services Home-Based Services Wave 1 on Wave 2 Quality Score Convenience Score Social Connectedness Score Affordability Score N=782
1.19
[0.94, 1.51] 0.98
[0.80, 1.20] 1.11
[0.90, 1.37] 1.21* [1.03, 1.42]
N=406
1.12
[0.77, 1.63] 1.25
[0.91, 1.73] 1.22
[0.89, 1.67] 1.34* [1.04, 1.74]
N=264
1.32
[0.81, 2.15] 0.70
[0.44, 1.10] 1.50
[0.97, 2.32] 1.05
[0.77, 1.42] Adjusted for care recipients’ age, sex, housing, education, comorbidity, ADL, iADL, income, Medisave status, and care givers’ age, sex, housing, health, # of family members in the household, decision, and whether or not they have a maid. *p<.05 **p<0.01 ***p<0.001
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Perception Scores and Current Service Utilization
Odds Ratio of Current LTC Service Utilization [95% CI] Model 1 Model 2 Wave 1 + Wave 2 N=5,996 N=3,180 Quality Score
1.18* [1.03, 1.34] 1.14
[0.93, 1.39]
Convenience Score
1.17* [1.04, 1.32] 1.19
[0.99, 1.43]
Social Connectedness Score
1.07
[0.96, 1.20] 0.96
[0.82, 1.13]
Affordability Score
1.29*** [1.18, 1.42] 1.39*** [1.21, 1.61] In these conditional logistic models, each patient becomes 5 observations, each stands for one type of current LTC services: community-based, home-based, nursing home, family and friends, and maid. In model 1 we only adjusted for whether referred service type; in model 2, we, in addition, adjusted for care recipients’ ADL and iADL. *p<.05 **p<0.01 ***p<0.001
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Top Reasons for Withdrawal/Rejection of Referred Service
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Household Income and Affordability
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Next Steps
• Examine effect of use/non-use on subsequent health status, other service use and quality of life • System modeling the demand of formal LTCS for lower income, moderate to high ADL population • Design a randomized controlled trial (RCT) to improve the uptake of and adherence to outpatient rehabilitation service among stroke patients 21
Collaborators
• •
Agency for Integrated Care (AIC)
Wee Shiou Liang Wayne Chong •
Changi Hospital
Goh Soon Noi • • • • •
Duke-NUS
Kirsten Eom Angelique Chan Amudha Aravindhan Tian Yuan David Matchar 22
“Health economics (health services and systems research) can be intellectually stimulating, socially useful, and personally rewarding.” - Victor R. Fuchs
Thank You!
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A Longitudinal Study of Caregivers’ Perception of Long-Term-Care Services and Services Use in Singapore
Chang Liu
Assistant Professor Program in Health Services & Systems Research Email: [email protected]
April 17, 2014 24
Referred vs. Current Services
Referred Services
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% None Maid Family and Friends Nursing Home Home-Based Services Community-Based Services Community-Based Services 163 86 72 2 1 426 Home-Based Services 113 73 48 9 337 3 Nursing Home 9 0 7 152 1 0 25