the impact of long-term care policy on caregiving hours and labor force participation in singapore...
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The Impact of Long-Term Care Policy on Caregiving Hours and Labor Force Participation in SingaporeDavid Matchar, John Ansah, Sean Love, Young Do, Kelvin Foo, Rahul Malhotra, Angelique Chan, Robert EberleinDepartment: Health Services and Systems Research ProgramIFA’s 11th Global Conference on Ageing | Prague, Czech Republic | 31 May 2012
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Singapore
• Population: 5,183,700– Citizens: 3,257,000
• 77% Chinese, 14% Malay, 8% Indian• GDP Per Capita: $59,900 USD (5th)• Median age: 40.1 years• Total fertility rate: 1.20• Life expectancy at birth: 83.75• Public health expenditure: 4% GDP• Unemployment: 2%
CIA World Factbook 2012, SingStat 2012
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Background
• By 2030, the proportion of elderly Singaporeans (≥65 years) is expected to reach 19%
• The prevalence of disability (≥1 ADL limitation) among older Singaporeans is 10.8%
• Demand for long-term care (LTC) is expected to increase
• Meanwhile, the resident workforce is expected to contract
Asher et al 2008, Ducanes et al 2008, Koh 2007
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LTC Services in Singapore
Formal LTC Options
Institutionalized Residential Care
Community HospitalsNursing Homes
Chronic Sick FacilitiesRespite Care
Hospice Inpatient Care
Community-Based Services
Center-Based Services
Day RehabilitationDementia Day Care Psychiatric Day Care
Hospice Day Care
Home-Based Services
Medical/Nursing ServicesHome Help
Hospice CareHome Therapy
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Who Are the Providers of LTC in Singapore?
Family
• Main provider of care for the elderly
• Sometimes assisted by foreign domestic workers (FDWs)
Voluntary Welfare Organizations
(VWOs)
• Partially-subsidized nursing homes and community care services
Private Sector
• Full fee hospitals and nursing homes
State
• Finances intermediate and LTC
• Provides subsidies for VWOs
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LTC Policy
• “Ageing in place”– Limited access to nursing homes– Maintain frail elderly at home
• Promote home and community-based services• Grants for eligible households w/ frail elderly to employ FDW• Potential consequences?– Increased burden (care hours) on families and caregivers
• Caregiver depression• Increased caregiver healthcare utilization• Reduced caregiver labor force participation
Ministry of Community Development, Youth and Sports 2008/2009, 2012, Khalik 2012
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Research Question
Given the growing population of ADL-limited elderly, what is the projected impact of LTC policy on caregiving hours and labor force participation in Singapore?
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Methods
1. Developed a preliminary System Dynamics (SD) model of LTC in Singapore– SD is a methodology for modeling dynamic problems– Admits many variables, causal factors, incorporates feedback
loops, policy levers
2. Presented model to LTC stakeholders for critique and for help identifying policy levers
3. Formulated and parameterized model to simulate observed system behavior
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Constructing the LTC Model
1. Generate projection of ADL-limited elderly population– Look at number of people becoming 65, use prevalence of
ADL-limitations, and mortality data
2. Simulate use of community and institutional services– Incorporate referral and uptake rates, number of elderly living
at home with and without services, use of nursing homes, etc.
3. Add capacity constraints, model inputs, policy levers
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Inputs Value Source
Proportion of families with FDW helping with eldercare
0.3 Author estimate using SSIC data
Proportion of elderly Singaporeans with institutional care needs
0.03 Singapore Ministry of Health
Primary caregiver hours for elderly residing in a nursing home
0 Author estimate
Attractiveness of HCBS (proportion of referrals accepted by elders and their families)
0.2 Estimated with help of stakeholders
Current nursing home beds (2012) 9,900 Singapore Ministry of Health
Proposed nursing home capacity needs
Year: Beds: Inter-Ministerial Committee on Health-care for the Elderly: 1999 (Report)2020 14,900
2030 22,400
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Inputs: Average Total Care Hours for People with ADL Limitations
Source: Singapore Survey on Informal Caregiving
1-2 ADL Limitations 3-4 ADL Limitations 5-6 ADL Limitations0
20
40
60
80
100
120
85
97
109
Hou
rs/W
eek
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Results: Projected Number of ADL-Limited Elderly Needing Human Assistance
20102011
20122013
20142015
20162017
20182019
20202021
20222023
20242025
20262027
20282029
20300
10,000
20,000
30,000
40,000
50,000
60,000
70,000
Total5-6 ADL Limitations1-2 ADL Limitations3-4 ADL Limitations
Year
Pers
on
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Policy Levers
1. Attractiveness of home and community-based services (HCBS)
2. Fraction of families with a foreign domestic worker (FDW)
3. Nursing home capacity
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Results: Average Primary Caregiver Hours by ADL Limitations of Care Recipients
1-2 ADL Limitations 3-4 ADL Limitations 5-6 ADL Limitations0
10
20
30
40
50
60
70
43
55
65
36
46
5351
No Policy or Capacity Changes Double Proportion of Families with FDWDouble Attractiveness of HCBS
Hou
rs/W
eek
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Results: Projected Number of Primary Caregivers
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 203010,000
20,000
30,000
40,000
50,000
60,000
No Policy or Capacity Changes Planned Nursing Home Bed Capacity
Year
Pers
on
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Results: Primary Caregivers Likely to Drop Out of the Labor Force
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 20303,000
5,000
7,000
9,000
11,000
13,000
No Policy or Capacity Changes Double Attractiveness of HCBSPlanned Nursing Home Bed Capacity Double Proportion of Families with a FDW
Year
Pers
on
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Results: Percentage of Primary Caregivers Likely to Drop Out of the Labor Force by 2030
Policy: Percentage:No policy or capacity changes 38%Double attractiveness of HCBS 37%Double proportion of families with a FDW 33%Planned nursing home bed capacity 28%
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Conclusions
• By 2030, elderly requiring human assistance will nearly triple• The number of caregivers likely to drop out of the labor force is
expected to rise– All considered policies would reduce caregiver burden and help keep
caregivers employed– Second to expanding nursing home capacity, increasing the proportion
of families with a FDW has the greatest impact• Additional challenges may include:
– Financial hardship for caregivers as result of withdrawing from labor force
– Caregiver depression– Increased caregiver healthcare utilization
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Appendix I: Projecting the size of the ADL-limited elderly population
Population 65+becoming 65 deaths
Population 65+ withADL limitation(s)ADL incidence
deaths from ADLpop
population 65+ withno ADL limitation
incidence rate
mortality rate
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Appendix II: LTC Model
Elderly at Home without Services
Elderly at Homewith Servicesincidence ADL to HCBS
deaths
deaths fromHCBS
Elderly in NursingHome
admission tonursing home
admission to nursinghome HCBS
deaths nursinghome
nursing home capacity
gap
available nursinghome beds
demand fornursing home
capacity HCBSHCBS gap
available HCBScapacity
demand for HCBSmortality rate
mortality rate HCBS
mortality ratenursing home
uptake ratereferral rate
Family EldercareHours
net change
indicated familyeldercare hours
effect of carehourson demand
total care hours homewithout services
total care hours homewith services
carehours nursinghome
fraction of familieswith FDW
fraction care hours byFDW
attractiveness of home and community-based services
(HCBS)
effect of carehoursdemand on HCBS uptake
rate
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Appendix III: Limitations
• Some inputs were based on survey data from an older population
• The use of mean values to represent the population may under or over-estimate certain values
• The outcome values are only as reliable as the Singapore population projections
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Appendix IV: Total Work Hours Lost to Caregiving of Those Who Stay Employed
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 203050,000
70,000
90,000
110,000
130,000
150,000
170,000
190,000
210,000
No Policy or Capacity Changes Double Attractiveness of HCBSPlanned Nursing Home Bed Capacity Double Proportion of Families with a FDW
Year
Hou
rs/W
eek