CHAPTER
1 INTRODUCTION
In Hong Kong, the trend of ageing is accelerating when the baby boomers
enter into their old age. In 2001, there were 1,004,300 people who are
60 years or above, constituting 14.9% of the total population
(1) . It is expected to rise to 1,936.000 in 2021(22.9%)and 2,341,100
in 2029 (25.9%) (2). The average
life span in 1999 was 77.2 for male and 82.4 for female and it is expected
to rise to 79.4 for male and 84.6 for female in 2029. The growing number
of old-old is conspicuous. In 2001, there were 292,700 people who are
75 years old or above, accounting for 29.1% (3)
of the aged population . There will be a drastic increase of this age
group to 368,400in 2006 and 427,400 in 2011.
With the increasing longevity, people are more likely to suffer from
different degrees of frailty and thus require different degree of Long-term
care service. In 2001, there are nearly 291,247 people, making up 3%
of population aged 60 or over cannot perform 1 or above ADL functions.
Over 40% of the aged population suffered from more than one chronic
disease (4). This percentage
tends to increase with the growing number of "old-olds" in
the future years.
In 2000, there are over 25% of the people living alone, living with
their old-aged spouses or with other unrelated persons. They are unlikely
to receive adequate care and support from their relatives. As highlighted
in the Deloittee Study (5),
the next general of elderly would prefer to live apart from their children.
It is thus anticipated to have a great need for formal elderly care
and the provision of a well organized comprehensive Long Term Care system
is urgently called for.
In view of this, the Resource Group on Long Term Care System under
The Specialized Committee on Elderly is exploring the future development
of the Long Term Care System in Hong Kong. This resource corner provides
information for the stimulation of thinking on the development of a
Long Term Care System suitable for the local context.
(1) Census and Statistics Homepage(October,2000)
(2) Census and Statistics (2001)
(3) Census and Statistics Homepage(October, 2001)
(4) Special Topics Report No27 (2000)
(5) Deloittee and Touche Consulting Group(1997) The Study of the Needs
of Elderly People in Hong Kong for Residential Care and Community Support
Service,commissioned by the HK Government
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CHAPTER
2 BASIC CONCEPT OF LONG TERM CARE SYSTEM
A) What is Long Term Care?
There are different definitions of the concept "Long
Term Care":
- Kane,1998 (6)
Long-term care is defined as assistance given over a sustained period
of time to people who are experiencing long term inabilities or difficulties
in functioning because of a disability. Long-term care services are
those services needed to compensate for the individual's functional
impairments or those services designed to restore or improve functional
abilities.
- Evashwick,2001 (7)
A wide range of health and health-related support services provided
on an informal or formal basis to people who have functional disabilities
over an extended period of time with the goal of maximizing their
dependence.
In short, "Long-term care" is a client-centered service system
with a spectrum of services organized in an integrated manner. The aim
of Long-term care is to maintain elders in the maximum level of independency
and capacity.
B) Characteristics
of an ideal continuum of Long Term Care (Evashwick,2001):
F) Long
Term Care Service Content
Community care service
| Home
help Service |
A
home helper visits the home to provide nursing care and other assistance |
| Visiting
bath Service |
A
vehicle with portable bath is brought to the home. Bathing assistance
and other care is provided |
| Home
Visit Nursing Service |
A
registered nurse or public health nurse visits the home to provide
nursing assistance |
| Home
Visit Rehabilitation Service |
A
Physiotherapy Therapy or other medical practitioner conducts rehabilitation
therapy at the older person's home |
| Home
Visit Medical advice |
Treatment-based
medical advice by a doctor or dentist who visits the home |
| Day
Care Service |
General
nursing care, social and recreational activities at a Home Service
Centre or other facility
|
| Rehabilitation
Centre Service |
Nursing
care and physical therapy at a medical facility |
| Short-stay
Service(Nursing care) |
Short
term admission to a special nursing home with support and physical
therapy |
| Short-stay
Service (Health care facility) |
Short
term admission to a Health care facility to receive medical treatment
and assistance in daily life (Such as nursing care and physical
therapy) through nursing and health care management |
| Group
Home Service for the Demented |
Nursing
care
for demented elderly living in a group home |
| Rental
or purchase of Health care equipment |
Rental
service provided in Home Support Centre |
| Financial
assistance for home modification |
Financial
support for small scale home repairs, such as installation of hand
rails or removal of steps |
Institutional Service
| Special
Nursing Home |
Provide
service to the older persons who have required continuous nursing
care and those their independent living is difficult |
| Health
Care Facilities |
Provide
service to the older persons who has been stabilized from an illness
and medical and nursing care, especially rehabilitation service
is required |
| Long
Term Care Geriatric Hospital |
Provide
service to the older persons who required ling term medical treatment |
G)
Financing - Long Term Care Insurance
The long term care financing in Japan is
classified as social insurance. It is financed by taxes, private contribution
and co-payment.
All citizens aged 40 or above are required to participate in the Long
Term Care Insurance Scheme. The local municipal government is the insurer.
Insured and Premium
| |
Type
I |
Type
II |
| Insured
|
65or
above |
Between
40 and 64 |
| Premium |
The
amount of the premium depends on the services available in the municipalities
and the income of the elderly.
There are
five premium levels according to the elderly person's income.
The average premium is US$26 a month.
|
For
employees, the amount is dependent on the income. The payment is
shared between the employee and the employer (1:1)
(9)
For the self-employed, the premium is calculated according to their
amount of income and assets. The national government pays the same
amount of contribution as the insured person |
(9) The premium paid by employee is about 0.5%
of the income
Financing of the Long Term Care Insurance
|
50%
Public Funds
25% from National Government
12.5% from Prefectures
12.5% from Municipalities
|
17%
Premium from 65 or above
|
33%
Premium from 40 to 64
|
Beneficiary
*Exchange rate: Yen100:HK$6.5
| Care
Level |
In
Home Service (HK$) |
LTC
facilities (HK$) (10) |
| Support
Required |
4
000 |
--- |
| Care
Level 1 |
10
777 |
13
084 - 23 263 |
| Care
Level 2 |
12
662 |
13
825 - 24 160 |
| Care
Level 3 |
17
387 |
14
547 - 25 057 |
| Care
Level 4 |
19
890 |
15
288 - 25 954 |
| Care
Level 5 |
23
289 |
16
009 - 26 851 |
In the new system, the municipal government is the insurer, while the
older person is the customer of the service operators. The older person
(customer) is entitled to receive long term care service with the insurance
benefits according to their care need. They can shop around different
service operators. Besides, the service providers are no longer a contractor
of the government Instead, they are the supplier of long term care services
to the older persons.
In view of such changes, the service operators are having greater flexibility
in the service provision to meet the service needs of the older persons.
The older persons also have greater voice to negotiate for better service.
Integration between medical and welfare service
There is integration between the welfare and health insurance system
for the older persons. Some services originally under the health insurance
(Visiting nursing, health care facilities) were pooled into the Long
Term Care Insurance in order to render a more comprehensive service.
The applicants can receive both welfare and medical services under the
same LTC system.
Case Management System
With the development of a case management system, the care of older
persons can be better arranged and coordinated. However, since the case
manager may be employee of a service operator of community care service,
there would be conflict of interest in the process of service planning
in favor of the service provider.
Interest of the Low Income Class
In the past, low-income recipients can use the welfare service at no
cost. Under the new insurance system, they are required to pay for the
premium ( on a sliding scale) and also the 10% co-payment, it may strain
the financial situation of the low income family.
Responsibility of care for Older Persons
Prior to the implementation of Long Term Care Insurance, all elderly
welfare services were funded from the taxes under the Welfare Law for
the Elderly (1963). The service was mainly for poor people as the eligibility
of the service was based on the income of the older persons and their
family. Therefore, for the middle-income group, the family bears all
the care responsibility of their seniors. With the implementation of
Long Term Care insurance, the middle-class families can be included.
Both the individual and the society are jointly responsible for the
care of frail elderly.
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CHAPTER 5
LONG TERM CARE SYSTEM FOR OLDER PERSONS IN GERMANY
A)
BACKGROUND
With the implementation of the Exceptional Medical Expenses Act in
1968, the Insurance for exceptional medical expenses is responsible
for the funding of long term or high cost care in various types of institutions.
This long term care insurance policy had favored the institutionalization
of elderly. In 1980, the institutionalization rate was 10%.
Because of the increasing expenditures for long term care, the Dutch
started to develop home care service and aimed at replacing institutional
service by less expensive community services. In 1980, the home nursing
services were incorporated into the insurance system and it was extended
to home help services in 1989.
B Eligibility
of Using Long Term Care Service
Eligibility
Residents of the Netherlands regardless of the nationality and age.
Assessment
The assessment process reviews the applicant's general health, physical
disability, psychological and social functioning, home environment,
availability of formal and informal care and the possibility of continuing
care. There is no uniform tool for the assessment. The assessment
of the level of assistance and the service type according to the professional
judgment.
The Regional Assessment Organization that comprises of policyholder,
consumer organizations, service providers, physicians, insurers and
the local authority appoint a team of assessors to take the assessment.
The assessors may be nurses, social workers, psycho-geriatricians and
social geriatricians. For the recipient who is assessed to require institution
service, a further review by a team of experts is required.
C Service Content and Service Delivery
Home care - include home nursing and home help
Mainly provided by NGO in a defined areas. Only a few for-profit agencies
provide home care in large cities.
Home Nursing :
Nursing care and loan of rehab aids. The service is provided by qualified
nurses with a background in public health.
The maximum service hour is 3 hour/day, but for special cases, such
as terminally ill, it will be extended to a maximum of 8 hours per day.
Home help
Services included housekeeping, personal care and emotional support.
The hours of care depends on the individual's needs.
"Alpha Care"
The Home help service provided by housewives that the client directly
paid to a housewives rather than through a professional service agency.
The maximum service hour is 16 hrs per week.
Institutional Care
Nursing Home - provide diagnosis and assessment, nursing care, rehabilitation
and terminal care.
Residential Home - provide an appropriate environment for people who
cannot live alone and provide assistance in ADLs, activity therapy,
and medications.
Shelter Housing - provide accommodation with a supportive and adapted
environment to those who can live independently.
Both the nursing home and residential home would provide services
for the older person in the community, such as day care centre.
Service Delivery
The applicant would be responsible for the service arrangement after
himself/herself receiving the report from the assessment team. They
can freely to choose the service providers from the market. Once the
service provider received the agreement to provide services, the service
provider would design the care plan according to the guideline of the
assessment result.
D Quality
Assurance
The national government is responsible for the quality assurance. There
is periodic formal inspection of the service providers by the representatives
of health care system. Providers are also expected to have an internal
quality control to monitor the service quality. A consumer council must
be set up in every service unit.
E Financing
The long term care in the Netherlands is funded through compulsory
premium, co-payment and general taxation (relative small percentage)
Insurer and Premium
The insurer is the Ministry of Health, Welfare and Sport, which designated
health insurance companies to implement the Exceptional Medical Expenses
Act.
Premium
For the monthly income between USD 3 831 and USD 20 940.06, the premium
is about 9.6% of the income in 1998. For the monthly income above NFL
47 000, it would be a flat payment. The employer is mainly responsible
for the payment.
Children under 15 or persons aged over 15 with no taxable income are
not required to pay a premium
Beneficiary
The benefit is mainly in-kind. Recipients can use various kinds of home
care service and institutional service. There is no limit in the amount
of service received with home care but in home nursing service, the
maximum service hours is 3 hours/day.
There is a restricted program of "personal Budget" which
is a restricted cash allowance provided to people eligible to receive
home care service. The personal budget is calculated by multiplying
the number of hours of care required by the authorized cost per hours
of the service. The personal budget must be used to purchase service
from formal or informal service providers. The family member may be
complimented by the informal assistance.
Co payment
| Service |
Co payment (US$) |
| Home Nursing |
USD 24.5 to USD61.04 |
| Home Help / Alpha Care |
USD 4.4/hr
Low income: USD 0.98/ week |
| Institutional Care |
USD 980
Low income(Less than USD2 109/month) will be exempted
|
Areas of Concern
Development of Case Management
The case management approach is not yet developed in the Netherlands.
After receiving the assessment result, the recipient is required to
search for an appropriate service provider on their own. The older person
and their carers may not have sufficient information and knowledge to
search for appropriate service provider.
Objectivity of the Assessment tools
There is no uniform set of assessment tools. The assessment of the type
and level of assistance depends on the professional assessment only.
Therefore the standard of the assessment may vary amount different assessors.
Development of Cash Allowance
The Dutch are satisfied with the "Personal budget" as program
that increases the feeling of autonomy and there is improvement in the
service quality as well. In order to prevent the money from being spent
on employment from the illegal market and to ensure the service quality,
it is very important to set regulation on the use of cash allowance
so as to protect the right of older persons.
The Dutch Government has also taken some measures, for example, the
Health Insurance Fund Council would set guidelines on the use of personal
budget and the Association of Personal Budget-holder has been set up
to act as the intermediary between budget holders and service providers.
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CHAPTER
7 SOME THOUGHTS FOR HONG KONG
Some experiences can be learnt from the above three countries for the
future development of Long Term Care System in Hong Kong.
A) ELIGIBILITY OF LONG TERM CARE SERVICE
Eligibility Assessment tools
In these countries, significant efforts have been made to ensure standardization
and objectivity in the eligibility assessment. The eligibility is based
usually based on the level of disability, independent of the reason
of disability. The difficulties in the performance of ADL, IADL, cognitive
functioning and the need for constant supervision (especially for older
person suffered from dementia) are often counted in the eligibility
assessment.
In Hong Kong, a standardized care needs, assessment mechanism has been
implemented since 2000. MDS-HC has been validated as the standardized
assessment tools. Upon several changes, the ADL, cognitive state and
continence state were taken as the only factors to determine the care
level of the applicants, while the mental condition such as the mood
and behavioural problem was only counted as "add on factors"
only. Besides, the nursing care needs are not reflected in the assessment
for service matching. Therefore the assessment is not considered as
be a comprehensive and holistic one.
Calculate the Care Cost according to the level of care
From the experience of overseas countries, the disability level and
the benefit are determined by the care hours required . For example,
in Japan, a detail research has been conducted to calculate the resource
utilization of client with different nursing care needs. There is different
cost for caring of different levels of disability.
In Hong Kong, the assessment tool is mainly for the assessment of care
level but the cost of caring for different level of elderly client cannot
be truly reflected from the assessment
It is argued that for the benefit of the older person and ensuring
the quality, the unit cost of clients in different care and nursing
needs should be clearly calculated.
B) SERVICE CONTENT & SERVICE DELIVERY
Enhance the continuum of service
In order to enhance the continuum of service from acute care to long
term care, it is suggested that the LTC institution in Hong Kong would
provide short stay bed to provide rehabilitation service to the older
persons discharged from acute hospital. It also provides assistance
to the family members to take care of the discharged frail older persons.
In Japan, there is short stay service in various institutions. After
the period of intensive rehabilitation, the older person would return
to the community.
Encourage the community support service
"Community Care" is one of the policy objectives in the spectrum
of long term care service in various countries. There are often a comprehensive
range of community care service covering from housekeeping to home rehabilitation
service.
In Hong Kong, the Enhanced Home & Community Care Services (EHCCS)
provides a comprehensive community care service including social and
medical elements to the older person. However, the provision of EHCCS
is currently restricted to client assessed to be of moderate impairment
level. It is suggested that the eligibility of EHCCS should be based
on the care/nursing need instead of the impairment level only.
Development of Case Management as a Service Delivery Model
In order to ensure a better care planning, service arrangement, coordination
and service monitoring, case management is a desirable service delivery
model. In Hong Kong, the concept of case management has not been widely
adopted. With the increasing choice of services and the autonomy for
the elderly, the concept of case management should be developed.
C) QUALITY
ASSURANCE
There are a number of components of quality assurance such as training
and supervision of formal and informal caregivers, licensing of service
providers, establishment and regulation of quality standards found in
the previous overseas countries.
In Hong Kong, all social service agencies are under the regulation
of SQS and the Government is setting up an accreditation system for
residential service. It is suggested that quality assurance of the community
support service should also be strengthened in order to ensure an overall
quality of the long term care services.
D) FINANCING
-- Responsibility of care for Older Persons
The above three countries have adopted the Long Term Care Insurance
as the financing model of long term care service. Taken the example
from Japan's Long Term Care insurance, individual and the society are
jointly responsible for the care of frail elderly.
With the increasing population of older person and the raising long
term care need, it is time to consider an alternate mode of financing
that can ensure the sustainability and further development of the service
provision. In the long run, it is difficult for the government to bear
the long term care responsibility solely.
Reference
1. Hong Kong Government(2000), Special Topics Report No27 (2000), Government
of the Hong Kong SAR
2. Deloittee and Touche Consulting Group(1997) The Study of the Needs
of
Elderly People in Hong Kong for Residential Care and Community Support
Service, commissioned by the HK Government
3. Kane RL, Kane RA,& Ladd RC(1998), The Heart of Long Term Care
New
York: Oxford Press
4. Evashwick CJ (2001), The Continuum of Long-Term Care, US: Delmar
Thomson Learning
5. World Health Organization 2000, Long Term Care Laws in Five Developed
Countries - A Review, WHO
Web-site
1. Hong Kong Census and Statistic Homepage (October, 2001)
2. http://www.caremanager.net/
Remarks: The Information on the LTC system is mainly
summarized from the Long Term Care Laws in Five Developed Countries
- A Review, WHO and the information gained from the Study Visit on Long
Term Care System for Older person in Japan in July, 2002.
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SYMPOSIUM ON LONG TERM CARE
SYSTEM FOR THE OLDER PERSON
In Hong Kong, the trend of ageing is accelerating when the baby boomers
enter into their old age. With the increasing longevity, people are
more likely to suffer from different degrees of frailty and thus require
different degree of Long-term care service.
In view of this, we have started the discussion on the development
of a Long Term Care System for the older persons in Hong Kong. In July
2002, we have visited Japan to study their Long Term Care System and
their Long Term Care Insurance. In this symposium, we will share our
initial thinking on Long Term Care system and the insights gained from
Japan. Besides, academics and practitioners from elderly services would
share their views as well.
Thus, our Council had organized a "Symposium on Long Term Care
System for Older Person" on October 4, 2002. The presentation paper
can be download as below:
AM Session:
- Infrastructure of Long Term Care System
Ms Anita Wong, Convenor of Resource Group on Long Term Care System
- Eligibility & Assessment of LTC needs
in Japan
Mrs. Lee Leung Man Ying, Home Manager Wo Ping C&A Home, Haven
of Hope Christian Service
- Service Content and Service Delivery Model
in Japan (1)
(2)
(3)
Ms Tsang Fook Yee, Deputy Executive Director, The Hong Kong Society
for the Aged
Ms Wong Kin Yee, Assistant Supervisor, Fong Shu Chuen Care and Attention
Home Tung Wah Group of Hospitals
- Quality Measurement in LTC Services in Japan
Mrs. Lillian Li, Assistant Principal Social Services Secretary (Elderly
Service)
Po Leung Kuk
PM Session
Quality Measurement in Elderly Services in Hong
Kong
- Ms Leung Ka Chun
Officer (Elderly) The Hong Kong Council of Social Service
- Ms Regina Ting
Chief Manager, Hong Kong Sheng Kung Hui Nursing Home
SKH Diocesan Welfare Council
- Ms Jennis Ho
Chief Officer (Research Dev"t & Performance)
The Salvation Army
Long Term Care Financing in Japan
- Ms Wan Ka Pik, Service Coordinator
Chuk Yuen Canon Martin & Wong Tai Sin Multi-service Centre for
the Elderly
Hong Kong Sheng Kung Hui Welfare Council
Long Term Care Financing in UK
- Prof. Alfred Chan, Director
Asia-Pacific Institute of Aging Studies (APIAS), Lingnan University
Considerations of LTC Financing in HK
- Mr. Choi Shing Kiu, Convenor
Resource Group on Financing of Subvented Elderly Services
HKCSS
