Demographic Challenges

1. 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: chang.liu@duke-nus.edu.sg April 17, 2014

2. 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

3. Demographic Challenges 1-2 ADL limitations • Source: Ansah JP, Matchar DB, Love SR, et al. 2013. The number and proportionof highly disabled elderlies are rising.

4. Demographic Challenges 1-2 ADL limitations • Source: Ansah JP, Matchar DB, Love SR, et al. 2013. The number and proportionof highly disabled elderlies are rising. Family are getting smaller

5. Demographic Challenges Individuals with depression attributable to caregiving 1-2 ADL limitations Individuals with depression irrespective of caregiving The number and proportionof highly disabled elderlies are rising. Family are getting smaller More caregivers will have significant depression attributable to caregiving • Source: Malhotra C, Malhotra R, ØstbyeT,,et al. 2012.

6. How much can the system handle? Temporary beds in air-conditioned tent @ Changi General • Source: Straits Times.

7. A framework for addressing the challenges Specialty Outpatient Clinic General Practitioner Acute Hospital Polyclinic Community services Self-care Enhanced Community services Family Medical Clinic Specialty Outpatient Clinic General Practitioner Acute Hospital Community services Polyclinic Agency for Integrated Care (AIC) Service integration Transitional care

8. Long-Term Care Services Use 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 • 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

9. 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?

10. 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 awarenessand 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.

11. 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: • whether took-up the referral • 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).

12. AIC LTC Referral Study: Survey and Data • Stratified sampling by: • 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.

13. CR Baseline Characteristics

14. Take-up of Referred LTC Services

15. Approaches • Dependent variables: • whether took-up the referral • 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: • Logistic Regression • Conditional Logistic Regression • Two waves data: repeated cross-sectional and longitudinal analysis

16. Perception Scores and Take-up Referred LTCS

17. Perception Scores and Take-up Referred LTCS

18. Perception Scores and Current Service Utilization

19. Top Reasons for Withdrawal/Rejection of Referred Service

20. Household Income and Affordability

21. 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

22. Collaborators Agency for Integrated Care (AIC) Wee ShiouLiang Wayne Chong ChangiHospital Goh Soon Noi Duke-NUS Kirsten Eom Angelique Chan Amudha Aravindhan Tian Yuan David Matchar

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

24. 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: chang.liu@duke-nus.edu.sg April 17, 2014

25. Referred vs. Current Services