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A Longitudinal Study of Caregivers’ Perception of Long-Term-Care Services and Services Use in Singapore Chang LiuAssistant ProfessorProgram in Health Services & Systems Research  Email: chang.liu@duke-nus.edu.sg

April 17, 2014

Demographic Challenges

• Lower fertility

• Increased longevity

• Later marriage

• Higher rate of non-marriage and divorce

Source: World Population Prospects: The 2010 Revision, http://esa.un.org/unpd/wpp/index.htm 2

Demographic Challenges

• The number and proportion of highly disabled elderlies are rising.

20102012

20142016

20182020

20222024

20262028

20300

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

Year

Pe

rso

ns 5-7 ADL limitations

3-4 ADL limitations

Source: Ansah JP, Matchar DB, Love SR, et al. 2013.

1-2 ADL limitations

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Demographic Challenges

• The number and proportion of highly disabled elderlies are rising.

• Family are getting smaller

1-2 ADL limitations

20112012

20132014

20152016

20172018

20192020

20212022

20232024

20252026

20272028

20292030

1

2

3

4

5

6

7

Age 60 Age 70 Age 80

Year

Child

ren

Source: Ansah JP, Matchar DB, Love SR, et al. 2013. 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

Source: Malhotra C, Malhotra R, Østbye T,,et al. 2012.

1-2 ADL limitations

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 20300

2000

4000

6000

8000

10000

12000

Individuals with depression attributable to caregiving

Individuals with depression irrespective of caregiving

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Source: Straits Times.

Temporary beds in air-conditioned tent @ Changi General

How much can the system handle?

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PolyclinicSpecialtyOutpatientClinic

Acute Hospital

Community services

General Practitioner

Service integration

Transitionalcare

Community services

General Practitioner

PolyclinicSpecialtyOutpatientClinic

Acute Hospital

EnhancedCommunity services

Self-care

Family Medical Clinic

A framework for addressing the challenges

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 20161

– Planned to increase NH beds by 70% by 2020 – from 9,000 today to 15,600 1

• LTCS utilization is low compared to Western societies2

– 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 society3

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

• 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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Main Research Questions

Previous Studies

The Andersen Model of Health Care Utilization1

• 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 services2

• 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.

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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 referral2) 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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• Stratified sampling by:1) Service types - Day Rehabilitation, Dementia Day Care, Home Medical,

Home Nursing, Home Therapy, and Nursing Home2) 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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AIC LTC Referral Study: Survey and Data

CR Baseline Characteristics

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Variable (%)

Any Community LTC Services

(n=1,416)

Center-Based LTC Services

(n=792)

Home-Based LTC Services

(n=624)P-Value

Age: <=64 22.4 23.2 21.3 0.096

65-74 24.9 26.5 22.8>=75 52.8 50.3 55.9

Female 55.9 55.9 55.9 0.999 Married 50.5 53.3 47.0 0.020

Education: None 41.7 37.2 47.3 0.001 Primary 30.1 31.7 28.0

Secondary+ 28.3 31.1 24.7Household Income: <500

38.8 35.0 43.8 0.000500-1999 27.4 31.6 22.12000+ 15.1 15.7 14.4

Don’t know/refuse 18.6 17.8 19.7Comorbidity:

0-1 18.8 17.7 20.2 0.0002-4 50.1 52.2 47.65+ 31.1 30.2 32.2

ADL Score: Low 38.1 48.7 24.5 0.000Medium 31.8 37.5 24.5

High 30.2 13.8 51.0

Take-up of Referred LTC Services

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• Dependent variables: 1) whether took-up the referral2) 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

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Approaches

Odds Ratio of Referred LTC Service Utilization [95% CI]

Any LTC Services Center-Based Services Home-Based Services

Wave 1 + Wave 2 N=1,795 N=875 N=650

Quality Score 1.27**[1.08, 1.48]

1.34*[1.06, 1.70]

1.18[0.89, 1.15]

Convenience Score 1.24**[1.09, 1.41]

1.31*[1.08, 1.60]

1.22[0.96, 1.54]

Social Connectedness Score 1.07[0.94, 1.21]

1.21[0.99, 1.48]

0.92[0.75, 1.13]

Affordability Score 1.34***[1.20, 1.49]

1.40***[1.18, 1.66]

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

Perception Scores and Take-up Referred LTCS

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Odds Ratio of Referred LTC Service Utilization [95% CI]

Any LTC Services Center-Based Services Home-Based Services

Wave 1 on Wave 2 N=782 N=406 N=264

Quality Score 1.19[0.94, 1.51]

1.12[0.77, 1.63]

1.32[0.81, 2.15]

Convenience Score 0.98[0.80, 1.20]

1.25[0.91, 1.73]

0.70[0.44, 1.10]

Social Connectedness Score 1.11[0.90, 1.37]

1.22[0.89, 1.67]

1.50[0.97, 2.32]

Affordability Score 1.21*[1.03, 1.42]

1.34*[1.04, 1.74]

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

Perception Scores and Take-up Referred LTCS

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Perception Scores and Current Service Utilization

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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

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

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CollaboratorsAgency 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

Thank You!

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“Health economics (health services and systems research) can be intellectually stimulating, socially useful, and personally rewarding.” - Victor R. Fuchs

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A Longitudinal Study of Caregivers’ Perception of Long-Term-Care Services and Services Use in Singapore Chang LiuAssistant ProfessorProgram in Health Services & Systems Research  Email: chang.liu@duke-nus.edu.sg

April 17, 2014

Referred vs. Current Services

Community-Based Services Home-Based Services Nursing Home

Community-Based Services 426 3 0

Home-Based Services 1 337 1

Nursing Home 2 9 152

Family and Friends 72 48 7

Maid 86 73 0

None 163 113 9

5%

15%

25%

35%

45%

55%

65%

75%

85%

95%

Referred Services

Cu

rren

t P

rim

ary

LT

C S

ervi

ce

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