ConsultancyStudyonCommunityCareServicesfortheElderly

FinalReport

Submittedby

SauPoCenteronAgeing and

DepartmentofSocialWork&SocialAdministrationTheUniversityofHongKong

June2011

GlossaryAbbreviationcode DescriptionC&A CareandAttentionHomesC&SD CensusandStatisticsDepartment CACP CommunityAgedCarePackagesCCHSA CanadianCouncilonHealthServicesAccreditationCCS CommunityCareServicesCMS CentresforMedicare&MedicaidServicesCMS ContractManagementSystemCSSA ComprehensiveSocialSecurityAllowanceCWL CentralWaitingListDE/DCU DayCareCentre/UnitfortheElderlyDECC DistrictElderlyCommunityCentreDH DomesticHelperDofH DepartmentofHealthEBPS EnhancedBoughtPlaceSchemeEC ElderlyCommissionEHC ElderlyHealthCentresEHCCS EnhancedHomeandCommunityCareServices ELCSSHK EvangelicalLutheranChurchSocialServicesofHongKongEN EnrolledNurseERB EmployeeRetrainingBoardFDH ForeignDomesticHelpersFMAP FederalMedicalAssistancePercentageFY FinancialYearHA HospitalAuthorityHACC HomeandCommunityCareHC HomeCareHCA HomeCareAllianceHCA HomeCareAssistantsHCW HomeCareWorkersHD HousingDepartmentHKSARG HongKongSpecialAdministrativeRegionGovernmentHPS HealthProtectionSchemeHW HealthWorkersIDSP IntegratedDischargeSupportProgrammeforElderlyPatientsIHC/IHCS IntegratedHomeCareServices IHC/IHCS(FC) IntegratedHomeCareServices(FrailCases)IHC/IHCS(OC) IntegratedHomeCareService(OrdinaryCases)IHCST IntegratedHomeCareServicesTeamISP IndividualServicePlanLDH LocalDomesticHelpersLTC LongTermCare

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LTCI LongTermCareInsurance LWB LabourandWelfareBureauM/E ExmultiserviceCentreMDSHCassessment MinimumDataSetforHomeCareAssessmentMFP MoneyFollowsthePersonNEC NeighbourhoodElderlyCentreNGO NongovernmentalOrganizationNH NursingHomeNHS NationalHealthService NOFA NetOperationalFloorAreaOECD OrganisationforEconomicCooperationandDevelopmentOGCIO OfficeoftheGovernmentChiefInformationOfficerOT OccupationalTherapistPACE ProgrammeforAllInclusiveCarefortheElderlyPCW PersonalCareWorkerPEVS PreprimaryEducationVoucherSchemePGB PersonalBudgetsPSG PlanningStandardandGuidelinePT PhysiotherapistQF QualificationsFrameworkRC ResidentialCare RCHE ResidentialCareHomefortheElderlyRCS ResidentialCareServicesRUG ResourceUtilizationGroupsSCNAMES StandardizedCareNeedAssessmentMechanismforElderly

ServicesSE SocialCentreforElderlySE SocialEnterpriseSPMS ServicePerformanceMonitoringSystemSSI SupplementalSecurityIncomeSUS SkillsUpgradingSchemeSWD SocialWelfareDepartmentUK UnitedKingdomUS UnitedStateUSA UnitedStateofAmericaVHT VisitingHealthTeamVTC VocationalTrainingCouncil

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TableofContent1 CHAPTERONE:EXECUTIVESUMMARY..p.62 CHAPTERTWO:BACKGROUNDOFSTUDY.p.13

2.1 Introduction2.2 ObjectiveoftheStudy2.3 ReviewofExistingCCS

2.3.1 Historyofdevelopment2.3.2 Scopeofservices2.3.3 ElderlyCentres2.3.4 FinancingofCCS2.3.5 SelffinancingandprivateCCS

2.4 Issuesandchallenges2.4.1 Imbalancebetweenhomecareandresidentialcarehighinstitutionalizationrates 2.4.2 Overrelianceonpubliclyfundedprovisionsimbalancebetweenpublicandprivate

LTCservices 2.5 Methodology

2.5.1 Literaturereview2.5.2 Interviews

2.5.2.1 Questionnairesurvey 2.5.2.2 Informantinterviews

2.6 Secondaryanalysisofexistingdata3 CHAPTERTHREE:INTERNATIONALEXPERIENCESINCCSPROVISIONp.31

3.1 Introduction3.2 HighlightsofCommunityCareServicesintheInternationalScene3.3 Policytoolsforpromotingageinginplaceagainstinstitutionalization3.4 ProvisionofCCSinothercountries/regions

3.4.1 FinancingModelofServiceProvision3.4.2 Formsofgovernmentsubsidizedservice 3.4.3 Issuesrelatedtotheimplementationofavoucherscheme3.4.4 Theregulationonvoucherusers3.4.5 QualityassuranceofCCSproviders3.4.6 Careneedsassessmentandservicescope3.4.7 Casemanagement3.4.8 ManpowerissuesinLTCprovision

3.5 Implications/lessonsforHongKong3.5.1 MeritsofCCS 3.5.2 Financingandbeneficiaryofprovision3.5.3 Servicedeliverysystem

4 CHAPTERFOUR:ANALYSISOFCURRENTPROBLEMSOFCCSp.524.1 ExistingproblemsofthecurrentdeliverymodeofCCSandsuggestedimprovements

4.1.1 Servicehours4.1.2 Scopeofservices4.1.3 Servicesforfamilycarers4.1.4 ReasonsofnotusingCCS

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4.1.5 Servicedeliverymode,servicebiddingandresources4.1.6 Spaceprovisionforelderlycareunits4.1.7 Manpowershortageofformalcareworkers4.1.8 Ancillaryservicestransportationforusersandoperators

4.2 MeanstestandCCSvoucher5 CHAPTERFIVE:CONCLUSIONANDRECOMMENDATIONS..p.74

5.1 Valuesandprinciples5.2 Recommendations

5.2.1 Improvingtheexistingmodeofserviceprovisionandincreasingtheservicevolume5.2.1.1 Improvingservicehours,scopeofservices,andspaceforoperators5.2.1.2 Increasingthesupportserviceforfamilycarer5.2.1.3 Providingmoretransitionalcareandrespite5.2.1.4 Finetuningtheexistingmodeandserviceperformancemonitoringsystem5.2.1.5 Realigningtheserviceboundaries5.2.1.6 RCHEservingasCCSbase5.2.1.7 Promotingsynergybetweencentrebasedandhomebasedservices5.2.1.8 PromotinginterfacebetweenLTCandnonLTCservices5.2.1.9 PromotinginterfacebetweenhospitalandhealthcareandCCS5.2.1.10 IntroducingcasemanagementinCCSdeliveryandbetterutilizationof

clinicalassessmenttooldata5.2.2 Modifyingthefinancingmodelofprovision:IntroducingCCSvoucherbasedon

affordabilityandsharedresponsibilityandequitableallocationofresources5.2.2.1 Adoptingmeanstestandslidingscaleofsubsidyintheallocationofsubsidized

CCS 5.2.2.2 Voucherofvariableamount5.2.2.3 CCSVoucherasincentivetochooseCCSfordualoptionapplicants 5.2.2.4 Implementingmonitoringmechanismsonvoucherusers

5.2.3 CreatinganenvironmentforfurtherdevelopmentofCCS 5.2.3.1 PromotingthedevelopmentofnonsubsidizedCCSwithqualityassurance

mechanism 5.2.3.2 StrengtheningHumanResourceplanninginLongTermCare5.2.3.3 PromotingpublicawarenessofCCS

6 CHAPTERCHAPTERSIX::OtherPertinentIssues.p.97

6.1 :Fosteringelderlyfriendlyinfrastructure6.2 :Improvingservicesforolderpeoplesufferingfromdementia

: 7 Appendix..p.101

8 References...p.102

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CHAPTERONE

EXECUTIVESUMMARY1. Thisstudyoncommunitycareservices(CCS)isconductedbasedontherecommendationsof

theElderlyCommissions(EC)studyin2009onresidentialcareservices(RCS)forelders,witha view to further encouraging elders to age in place and thus avoiding premature orunnecessary institutionalization.OnbehalfofEC,theLabourandWelfareBureau(LWB)hascommissionedtheUniversityofHongKongsresearchteamtoconducttheconsultancystudy.

ObjectiveoftheStudy2. In linewiththeGovernmentspolicyofsupportingageing inplaceasthecore, institutional

care as backup, the objective of the Study is to examineways to a) strengthen CCS forelders through amore flexible approach and diversemode of service delivery, and b) toencouragesocialenterprises(SE)andtheprivatemarkettodeveloprelatedservices,withaview to facilitatingelders toageathomeas faraspracticable,andavoidingprematureorunnecessaryinstitutionalization.

Methodologyofthestudy3. The research team has adopted multiple methods in collecting both quantitative and

qualitativedataandintheanalysis,includinga)reviewofrelevantlocalandoverseasstudies;b)questionnairesurveywith2,490elderlypeopleandcarersand162employeesofoperators.The sampling frame includes a wide variety of respondents with different backgroundsgroupedunderelevensamplingcategories;c)50keyinformantsinterviewswithgovernmentofficials,operators/stakeholdersofCCS;andd)secondaryanalysisofexistingdataprovidedbySocialWelfareDepartmentandCensus&StatisticsDepartment.

ExistingCCSprovision 4. Currently, theGovernmentsprovisionof subsidizedCCS as Long TermCare (LTC) services

include the three aspects of Enhanced Home and Community Care Services (EHCCS),IntegratedHomeCareServices(IHCS)(FrailCase)andDayCareCentres(DEs)andDayCareUnits (DCUs). As of February 2011, therewere 24 EHCCS teams, 60 IHCS teams and 59DEs/DCUinthe18districtsinHongKong.

IssuesandchallengesinHongKongsLTCprovision

Imbalancebetweenhomecareandresidentialcarehighinstitutionalizationrates 5. There iscurrentlyan imbalancebetweenRCSandCCS in termsofvolumeandgovernment

expenditure on the two types of services (24746 subsidized RCS vs. 7 089 CCS places;HK$2549millionvs.HK$381million in20102011financialyear(asestimatedbasedonthefiguresfromHead170,theBudgetofyear201112).

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OverrelianceonpubliclyfundedprovisionsimbalancebetweenpublicandprivateLTCservices 6. Hong Kongs LTC provision is largely a publicly funded taxbasedmodel provided by the

Government. Furthermore,withoutmeanstests, there isno effectivemechanism allowingtheGovernmenttotargetsubsidizedservicesatelderswhoaremostinneed.

Lessonslearnedfromoverseasexperience7. International experiences have revealed that effective CCS can reduce or delay

institutionalization, improve thephysical functions of elderly serviceusers and reduce thedeclineincognitivestatus.

8. ApublicmodelofCCSprovision iseitherfinancedbypublicrevenuewhichwould implya

high tax regime (e.g.Nordic countries),orbya social insurance system (e.g.GermanyandJapan).Therecanbeprivate insurancemodel (e.g.USA) inwhichpeoplepurchasehealthand/orLTCinsurancethatcoversserviceexpenses.Governmentsindifferentcountrieswouldalso support the public in accessing LTC services, either through providersubsidy orusersubsidy.Endusersarealsoencouragedtosharetheexpensesbycopayment.

9. OverseasexperiencesrevealthatCCSwouldrequireaviablesystemofclinicalassessmenttoascertainthelevelofcareandscopeofservicestobeprovided.Theadoptionofacasemixsystembasedonclinicalassessment,furthersupportedbycasemanagementmodel,wouldhelp toenhancecostefficiencyandserviceeffectivenessandaddress thediversity inolderpeoplesneeds.

ValuesandprinciplesinLTCprovisioninHongKong 10. InthedevelopmentofLTCinHongKongthereshouldbetheadoptionofthefollowingvalues

andprinciples:firstly,theservicesshouldbeelderlyfriendly;secondly,ageing inplace;thirdly,sharedresponsibilityofcareamongthe individual,thefamily,thecommunity,themarket,andtheGovernment;andfourthly,equitableallocationofresources,inwhichtheallocationofpublicsubsidizedservicesshouldbeprioritizedtothosewithmostgenuineneed.

RECOMMENDATIONSArea1:ImprovingtheserviceprovisionofsubsidizedCCSandincreasingtheservicevolume1a)Improvingservicehours,scopeofservices,andspaceforoperators11. The service hours of various types of CCSmay be extended beyond office hours and to

weekend and public holidays to better accommodate service recipients needs and familycaregivers.

12. Additionalservicescouldbeprovided,suchasadhocescortserviceformedicalappointment,

massage at users home, home visitwith rehabilitation service, cognitive training service,traditionalChinesemedicine treatment;andmore space includingkitchenandoffice spacecouldbeprovidedfortheoperators.

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1b)Increasingsupportservicesforfamilycarers13. Knowledgeoncommunityresources,elderlycaringskillsandtechniques,andelderlydiseases

and symptoms could be conveyed to family caregivers through talks and training coursesoffered at convenient time forworking carers and supplementedwith eldersitter service,massmediaandinternet.

1c)Providingmoretransitionalcareandrespite14. The success of Integrated Discharge Support Program for Elderly Patients (IDSP) best

illustrates the merit of transitional care. Some NGOs have developed selffinancingtransitionalcareservicesthatadoptarevolvingdoorconcept inwhicholderpersonsmaychoose to change the services according to the health condition. Itwould be desirable tofurtherimprovethecurrentprovisionofresidentialrespiteplaces.

1d)Finetuningtheexistingfundingmodeandserviceperformancemonitoringsystem15. Theremaybethedesignationofshorttermcasestoservethoseacutefrailelderdischarged

fromthehospitalorthosewhoonlyneedservicefora3monthperiod.

16. There is a need to strike a good balance in ensuring service continuity and stabilitywithrationalallocationofresourcesbyreviewingthemechanismofbiddingforservice.

1e)Realigningtheserviceboundaries17. Amore communitybasedmodel of service boundary alignment can be adopted so that

smallerteamscouldbedeployedattheestateorstreetblockorTertiaryPlanningUnit levelsoastoreducethetravelingtimeofboththeelderlyandserviceoperators.

1f)ResidentialCareHomesfortheElderly(RCHEs)servingasCCSbase18. Thewide geographical spread of the 777 RCHEs that are already equippedwith kitchen,

dininghallandspacecanbeaverypenetrativenetworkofbasefortheprovisionofCCS.PilotprojectswiththoseprivateRCHEthathaveparticipatedintheEnhancedBoughtPlaceScheme(EBPS)couldbelaunchedtoincreasethesupplyofselffinancingCCS.

1g)Promotingsynergybetweencentrebased(DE)andhomebased(EHCCS/IHCCS)services19. Therecouldbereallocationandthusreshufflingofserviceproviders,orrealignmentofservice

boundaries,amongstthevariousserviceproviders,sothatvariousservicescouldbeprovidedbythesameagencytoavoidinteragencyreferral.SuchreshufflingmaystartwithdistrictsinwhichoneagencyprovidestwoorallthethreetypesofCCS.

20. The scope of service and function of day care centresmay be expanded to be a base for

multiservicesprovisionthatmayofferacontinuumofcareservices,rangingfromdaycaretohomecare,andevenrespiteresidentialcare.

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1h)PromotinginterfacebetweenLTCandnonLTCservicesreviewofIHCS(OrdinaryCase)(OC)service21. ItmaybedesirabletoreviewthepossibilityofreintegratingtheIHCS(OC)elderlycases into

theLTCsystembymergingtheIHCS(OC)teamintotheexistingEHCCS.Onepossiblestrategyisto target thoseapplicantsassessedby theStandardisedCareNeedAssessmentMechanismforElderlyServices (SCNAMES)ashavingmildfrailty level.ProvidingnecessarysupportiveservicesviatheIHC(OC)servicescouldhelpreducetherateofphysicaldeterioration,andthuspostponetheirdemandforhigherlevelofLTCservices.

22. The211elderlycentres(asofFebruary2011)i.e.DistrictElderlyCommunityCentres(DECC),

NeighbourhoodElderlyCentresandSocialCentresfortheElderly,areactuallyanothertypeof community support service, and can serve as the frontdesk to identify and referrelevantolderpeoplewhoareonthevergeofneedingCCS.

1i)PromotinginterfacebetweenhospitalandhealthcareandCCS

23. TheIDSPhasachieveditsgoalsofprovidingseamlessfollowupserviceforpatientsdischarged

fromhospitals,buttherecouldbe further improvementsofthe IDSP.TherecouldbebettersynergyandcoordinationbetweenDepartmentofHealthandSWDintheprovisionofCCSforcommunitylivingolderpeople, inwhich the18EHCmay serveas themechanismofearlyidentificationofLTCneedsandthusmakereferralstotheSWDfortheallocationofCCS.

1j) Introducing casemanagement inCCSdeliveryandbetterutilizationof clinicalassessmenttooldata24. Theexperiencegatheredfromoverseascountriesintheadoptionofcasemanagementmay

shed light on the development of the casemanagement approach in the provision of LTCservices in future. That said, these countries have a different financing system in LTCservices,mainlyaprivateinsurancesystemorselfcontributionmodel. Hence,thecasemanager system adopted in other countriesmay not be entirely applicable inHong Kong. Successful implementation of case management in Hong Kong depends on: firstly, theavailability of a large number of competent casemanagers in the frontline, secondly, theeffective coordination between the casemanager and the various operators; thirdly, theavailability of effective clinical assessment of care needs. Thus, there would bemerit inreviewingtheSCNAMEStoidentifyitspotentialstrengthsincontributingtolongtermserviceandresourceplanning.

Area2:IntroducingCCSvoucherbasedonaffordabilityandsharedresponsibilityandequitableallocationofresources2a)meanstestandslidingscaleofsubsidy

25. Different categories of survey respondents support the principle of equitable allocation of

public resourcesand thusamore targetedprovisionof subsidizedCCS services.Amajoritywasinsupportofadministeringmeanstest.

26. Therecanbeaslidingscaleofvaryingdegreesofprovisionorfeechargedtothesubsidizedservices,sothatthoseofbetterfinancialconditionwouldberequiredtopayhigherfee.The

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principles of copayment and affordability may help to address to the varying needs ofdifferentsectorsoftheolderpopulation.

2b)voucherofvariableamount27. There could be merit in exploring the CCS voucher scheme that is administered with a

meanstest with varying amounts of value in accordance with the applicants frailty andfinancialconditions.

2c)CCSVoucherasincentivetochooseCCSfordualoptionapplicants

28. TheprovisionofaCCSvoucher,coupledwiththeanticipatedexpandedvolumeofprovisionbytheNGOswithaselffinancingmodeandtheprivateoperators,mayserveasanincentivetoencourageelderlyapplicantsforsubsidizedLTCservicestooptforCCSunderthedualoptionsystem.

2d)Implementingmonitoringmechanismsonvoucherusers29. Thesuccessofavouchersystemrequiresaneffectivemechanismofmonitoringandscrutiny

tobeput inplace. Ontheotherhand, itwouldbebettertoavoiddisbursingcashsoastoensureproperusageofthesubsidyontargetedconsumption.

30. ThesuccessofaCCSvouchersystemalsodependson theavailabilityofasufficiently largenumberofserviceprovidersandamplesupplyofstaff,theinstitutionofaclinicalassessmentsystem thatoperates independently from theCCSproviders and the stipulation ofqualityassurancemechanisms.

Area3:CreatinganenvironmentforfurtherdevelopmentofCCS3a)PromotingthedevelopmentofnonsubsidizedCCSwithqualityassurancemechanism 3ai)Providingsupporttooperators31. InordertoexpandthevolumeofCCSprovisioninthecommunity,theGovernmentmayneed

todevisestrategiestopromotethedevelopmentofselffinancingCCSsuchastheprovisionofpremise,financialsupport,andthe like.Thereshouldbethesettingupofqualityassurancemechanismstoensureservicequality.

3aii)QualityassuranceofnonsubsidizedCCSoperators 32. SettingupalicensingorstatutoryregulationregimeforCCSprovidersmaynotbepracticable

in the short run, as it is practically difficult to define the licensing requirement for CCSprovidersbecausetherangeofservicescovered istoowide,fromsimplehousecleaning,tonursingcare. Thatsaid,ifaCCSvoucherwastointroduce,inthelongrun,thereshouldbeaseparatemonitoringmechanism toensure their servicequality. It is imperative toestablishserviceperformance standard, independentparty audit, and transparent complaint systemfordevelopingaviableprivatesectorofserviceprovision.

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3b)StrengtheninghumanresourcesinLTC3bi)strengtheningrecruitmentandretentionofformalcarers/paidstaff33. There should be strategies to promote the recruitment ofmore formal carers, including

nurses,occupational therapists (OT)andphysiotherapists (PT).Local training institutesmayincreasethestudentintakeorlaunchblisterprogrammestoincreasetheoverallsupplyofnursesandOT/PT.

34. TheGovernmentshouldcontinueitseffortstoprovidemoretrainingforhealthcareworkers

andpersonalcareworkersundervariouschannelstoincreasetheirsupply.Ontheotherhand,extendingtheEducationBureausQualificationsFramework(QF)tocoverelderlycareserviceindustrywouldhelpfacilitatefurthertraininginservicepersonnelandattractmorepeopletojointhesector.

35. There isalsoneed todevise strategies to retainexisting staff,which relate toemploymentcondition,promotionprospects,salaryandworkingcondition,worksatisfactionandthelike.

3bii)EnhancingthecaringskillsofDomesticHelpers 36. Effortsshouldbemade topromoteawarenessamongst theemployersofDomesticHelpers

(DH) to encourage theirDH to attend trainingon taking careof frailelderly. Furthermore,perhapsHongKongmayconsider stipulating requirement forDH toundertake trainingandobtainalicensefortheirpractice.

3biii)Mobilizingneighboursinprovidingsupport37. Informal caregivers such as neighbours could be an additional human resource. The

mobilizationofneighbourstoserveas informalcaregiversmayalsopromote localeconomy,especially in some old urban areas and old PRH estateswith high concentration of olderpeopleandlowincomehouseholds,byimprovingtheirfinancialcondition.Itmaybeapoolofhuman resources thatcanbe tappedbySEand theprivatemarket indeveloping theirCCSbusiness.

3c): PromotingpublicawarenessofCCS38. Thereisneedtoimprovepromotingpubliceducationinchangingpeoplesconceptioninthe

application of subsidized RCS that subsidized CCS (in kind or in voucher) can be a viablealternativeofsubsidizedRCS.Thereisalsoneedforincreasingpublicity,publiceducationandprovision of readily available information to the public, the older people and their familymembers.

OTHERPERTINENTISSUESIssue1: Fosteringelderlyfriendlyinfrastructure39. The sustained development of a viable system of CCS in the community actually requires

other policy measures in fostering an elderly friendly environment, that includes the

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availability of premises for the provision of CCS, barrierfree community environment,accessible transportation to enable elderly peoples accessibility and thus communityengagement;andasustainableLTCfinancingsystem.

Issue2:Improvingservicesforolderpeoplesufferingfromdementia40. Itmight be desirable to extend the provision of the dementia supplements to other CCS

services,sothattheserviceoperatorscouldhavemoreresourcestoservethehomeboundelderlypeople suffering fromdementia. Itwouldbedesirable to explore if theDECCs canserveasfrontdesk,toearlyidentifyolderpeoplesufferingfromdementia.

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CHAPTERTWO

BACKGROUNDOFSTUDY

Introduction41. Following up on the recommendations of the study on residential care services (RCS) for

elders,theElderlyCommission(EC)hasdecidedtoconductamoreindepthstudyonpossibleenhancementofcommunitycareservices(CCS),withaviewtofurtherencouragingelderstoageinplaceandthusavoidingprematureorunnecessaryinstitutionalization.OnbehalfofEC,the Labour andWelfare Bureau (LWB) has commissioned the University of Hong Kongsresearch team to conducta consultancy studyonCommunityCareServices for theElderly(theStudy).

42. HongKong isalreadyhavinganageingpopulation:thenumberofpeople inthepopulation

aged65andabovewas925900in2010,thatconstituted13.1%oftheterritorys7.1millionpeople; while those aged over 60 comprised as much as 18.6% (Census and StatisticsDepartment (C&SD)), theHongKongSpecialAdministrativeRegionGovernment ((HKSARG),2011).TheCADENZAs2008studyon the internationalcomparisonofwellbeingofseniorsrevealedthatHongKongseniorsgenerallyliveahealthyandactivelife.Notwithstandingthis,there can still be considerable extent of natural physiological deterioration of the humanbody,whichresultsinamoreprofoundmorbidityamongtheelderlypopulation,especiallyinthecontextofincreasedlongevity.

43. Fromthe2009RCSStudy,itwasfoundthatHongKonghasarelativelyhigherrate(6.8%)ofinstitutionalizationofolderpeople(aged65andabove),butatthesametimetherehasstillbeensubstantialdemandforsubsidizedRCSservices,asrevealedfromthelongwaitingtime.Apparently,therehasbeenatendencyforolderpeople(ortheirfamilymembers)tooptforRCS instead of CCS. It could be attributable to the inadequacy of subsidized CCS and theunavailabilityofprivateCCS inthecommunity;thatmadetheolderpeopleandtheirfamilycaregiverstohavenoalternativesbuttochooseRCS. Infact,the2009Studyrevealedthattherewasactuallyapreferenceamongstolderpeople to remain living in theirownhome,insteadofinaninstitution.

44. Ontheotherhand,thoughthere isasubstantialprivatesectorprovisionofresidentialcarehomes fortheelderly (RCHE),constitutingsome70%ofthetotalsupplyofbeds,therehasbeenpublicconcernonthediversityofservicequalityinsuchprivateRCHEs.Yet,duetothefactthatasubstantialportionoftheprivateRCHEusersarerecipientsoftheGovernmentsComprehensiveSocialSecurityAssistance (CSSA), theGovernment isactuallyprovidingRCSdirectly throughprovisionofsubvention toNGOsasoperatorsand indirectly throughCSSApaymentstousers.Inviewofthepossible increaseddemandfromanagingpopulation,thehighly subsidized nature of long term care (LTC) services, and the fact that there is nomeanstestmechanism in thecurrentallocationofsubsidizedLTCservices, it isanticipatedthatitcouldincursubstantialfiscalpressureontheGovernmentinthelongrun.

45. The 2009 Study investigated the desirability and feasibility of introducing ameanstestedvoucherschemeintheprovisionofsubsidizedLTCservice.Surveyresultsrevealedthattherecouldbeacceptanceamongst the currentbeneficiariesand thegeneralpublic to thisnewmodeoffinancingLTCserviceprovisioninHongKong.TheStudyalsoexploredthepossibility

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of encouraging dual option applicants to opt for CCS instead of RCS, so as to promoteageinginplace.

46. Nonetheless,the2009StudyalsorevealedotherpertinentissuesrelatedtothesupplyofLTCmanpower,qualitycontrolofLTCserviceproviders,andrecommendedthepromotionofCCSso as to enable older people to remain living in their familiar community providedwithsufficientqualityserviceandsupport.

47. In fact, theHongKongGovernmenthasbeen themainproviderof funding toLTCserviceseitherdirectly(throughsubventiontoNGOs)orindirectly(throughsocialsecuritypayments).In anticipation of the escalating demand for LTC service due to the ageing population,coupledwith the largely publicly funded nature of existing LTC service delivery, there isconcernonthesustainabilityofsuchafinancingmode.Furthermoreasthecurrentprovisionis primarily universal, i.e. provided based on clinical need, but not selective based onmeanstest, there is also concern as to whether public resources deployed in providingsubsidizedLTCservicesareutilizedmostefficientlyandequitably.There isthustheneedtoexplore into the possible development of alternative financingmodels for providing LTCservicesfortheolderpeopleinHongKonginthelongrun.

48. On the other hand, there has been concern in the public that there is still shortage andproblems in thecurrentCCSserviceprovisionanddeliveryand that therecouldbe furtherimprovementsinvariouswaystoimproveefficiencyandeffectiveness.

49. Againstthisbackground,thisstudyventurestocontinueexploringthestrategiesofimproving

theexistingCCSprovision,promotingCCS,andthedesirabilityandfeasibilityof introducingmoreflexiblemodesoffinancingsubsidizedCCSinHongKong.

ObjectiveoftheStudy50. In linewiththeGovernmentspolicyofsupportingageing inplaceasthecore, institutional

care as backup, the objective of the Study is to examineways to a) strengthen CCS forelders through amore flexible approach and diversemode of service delivery, and b) toencouragesocialenterprisesandtheprivatemarkettodeveloprelatedservices,withaviewto facilitating elders to age at home as far as practicable, and avoiding premature orunnecessaryinstitutionalization.

ReviewofExistingCCSandpresentsituationHistoryofdevelopment51. TheHongKongGovernmenthas since1977persistentlyupheld theprincipleof ageing in

place in the development of Long Term Care (LTC) services for elderly people. Thisprincipleemphasisesthatelderlypeopleshould,asfaraspossible,livewiththeirfamiliesorin a familiar environment as they age. Such a policy direction has also been upheld andfurtherpromotedbytheSARGovernment.

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52. CCSconstitutesasignificantpartinHongKongsLTCservicesalongsideRCS.Duetoescalatingdemandfromthecommunity,andtheneedtoensuretheequitableandefficientdeploymentof public resources, and that subsidised LTC services are targeted at elderswith genuineneeds,theGovernmenthassince2000 introducedtheStandardisedCareNeedAssessmentMechanism for Elderly Services (SCNAMES) to assess the care need of applicants forsubsidisedLTCservicesandtoascertaintheireligibility.

53. In2000,thereweresome400serviceunits,rangingfromthethenmultiservicecentres,day

care centres/units for the elderly, social centres for the elderly, and the then home helpteamsunder theadministrationofmore than100nongovernmentalorganisations (NGOs),thatwereinoperationthroughouttheterritory.Althoughtheseserviceoperatorshadinthepast contributed to fulfilling theneedsof the elderly, anumberof systemproblemshavebeen observed, such as service fragmentation, inadequate coordination, confusing andcomplex service boundaries, diseconomy of scale, large service gaps, service duplications,system rigidity, and etc. Based upon the recommendation of a consultancy study by theUniversityofHongKong(2003),SWDrevampedtheCommunitySupportServicesforEldersbyupgradingSocialCentres for theElderly (SEs) toNeighbourhoodElderlyCentres (NECs);theexmultiservicecentres (M/Es) toDistrictElderlyCommunityCentres (DECCs);and theexhomehelp,homecareandmealteamstoIntegratedHomeCareServicesTeams(IHCSTs).

54. Currently,theGovernmentsprovisionofsubsidizedCCSasLongTermCareservices includethethreeaspectsofEHCCS,IHCS(FrailCase)andDE/DCU.Thereare24EHCCSteams,60IHCSteams and 59 DEs/DCU in the 18 districts in Hong Kong (Table 2.1). In terms of servicecapacity,asatFebruary2011,thetotalnumberofserviceusersforthethreetypesofCCSare3268EHCCS,1056 IHCS(FC)and3142DEs/DCUs(includingparttimeusers, i.e.userswhoattendDE/DCUforlessthan4daysinaweek)respectively.TheGovernmenthasalsoplannedtoincrease1500placesfortheEHCCSandabout200daycareplacesinthe201112Budget.

Table2.1:Totalnumberofunits,service

forEHCCS,IHCS,DE/DCU(ascapacityandnumberatFebruary2011)

ofusers

ServiceDistrict

team/Centre EHCCS(1stBatch)

EHCCS(2ndBatch*)

IHCS DE/DCU

Island 1 N.A. 1 2CentralWestern 1 3 3WanChai 1 1 2 2Eastern 1 5 5Southern 1 2 2WongTaiSin 1 1 6 6SaiKung 1 3 2KwunTong 1 1 4 7YauTsimMong 1 3 3KowloonCity 1 1 3 3ShamShuiPo 1 7 5Shatin 1 4 4TaiPo 1 1 3 1Northern 1 3 1YuenLong 1

14 3

TsuenWan 1 2 2

KwaiTsing 1 3 5TuenMun 1 2 3Total 24 60 59ServiceCapacity 3579 1120(frailcases) 2314

noservicecapacityforordinarycases#

Totalno.ofusers 3268 1056(frailcases) 3142 20311(ordinarycases)#Remarks: #FigureasatDecember2010.AccordingtoSWD,theprovisionofIHCS(OCs)isnotpartoflongtermcareservice*EHCCS(2ndBatch)denotesthesameEHCCSteamsharedbyseveraldistricts.

55. In order to further supplement and enhance the effectiveness of CCS services, the

Governmenthasdeployedresourcesto introducevariouspilotschemes.For instance,since2007 theGovernmenthasprovidedblock grants toNGOs in launching the DistrictbasedTrialSchemeonCarerTraining,whichhashelped to train carersanddeveloppaid carerservices.Twothirdsof theTrialSchemeparticipantscompleting the trainingprogramhavejoinedthepoolofcarerhelpersinprovidingservicestofrailelderslivingnearby.

56. In2008theGovernment launchedapilotprojectcalledtheIntegratedDischargeSupport

Program for Elderly Patients (IDSP) thatwould provide elderly patients discharged fromhospitalwithsixtoeightweeksoffollowuphomesupportservices.Theinitialresultsrevealthat thepilotprojecthas effectively reducedunplanned readmission tohospitals of theseelderlypatients.TheEvangelicalLutheranChurchSocialServicesofHongKong (ELCSSHK) isoneoftheNGOswhich is implementing IDSP,andhasconductedanopinionsurveyontheusers satisfaction of the programme. The elders or the familymembers agreed that theprogramcouldprovideemergencyandenquiryservicesandactedasabridgebetweenthepatientandthehospital.Alsothefamilymembersagreedthattheprogramcouldencouragethe elders todo exercisesduring the criticalperiod for rehabilitation and the informationprovidedtothecarerswasusefulandcouldreleasecarerburden(ELCSSHK,2010).

57. Mostrecently,theGovernmenthassetaside$55millionto introducethePilotSchemeon

HomeCareServicesforFrailEldersinearly2011toprovidetailormadeservicepackagesforelderswaitingfornursinghomeplacesbutarestilllivingathome.Thepilotschemewilllastfor3years in6selectedareas, includingKwunTong,WongTaiSin,SaiKung,KowloonCity,Yau TsimMong and Sham Shui Po. The number of beneficiarieswill be 510 elders. Theschemewill apply casemanagement approach and the casemanagerwillbenurse, socialworker,physiotherapistoroccupational therapist.Eachcasemanagerwillhandleabout25cases.

Scopeofservices58. AccordingtotheservicecontractorFundingandServiceAgreementbetweentheSWDand

theoperatingNGOs, theEHCCS, IHCSandDEs/DCUsoperatorshave tomeetsomespecificservicetargetsorrequirement.Thespecificscopesofservicesofthethreetypesofservicesareasfollows:

16

59. EnhancedHomeandCommunityCareServices(EHCCS)isdesignedtoactualizetheconcepts

ofAgeinginPlaceandContinuumofCare,whichserveasanintegratedformofservicestomeetthenursingandcareneedsoffrailolderpeople(aged65orabove;andthoseaged6064 with proven needs) with the aim of enabling them to age at home in a familiarenvironment, aswell as to provide support to carers and to strengthen family cohesion.Eldersassessedtobeofmoderateorsevere levelof impairmentbytheSCNAMESwouldbeprovided with home and community support services according to their assessed needsincluding care management, basic and special nursing care, personal care, rehabilitationexercises,day care service, carer support services,day respite service,24houremergencysupport, environmental risk assessment andhomemodifications,homemaking andmealsdeliveryservices,transportationandescortservices.

60. IntegratedHomeCareServices(IHCS)providearangeofcommunitysupportservicestothe

olderpeople,peoplewithdisabilitiesandneedyfamilieslivinginthecommunitywithapoolof experienced and professionally trained staff, and via a network of service units in thecommunitywith its collaboration and support. The IntegratedHome Care Services Teams(IHCSTs)provide care and support to the target serviceusers according to their individualneedsandactualizetheconceptsofAgeinginPlaceandContinuumofCaretoenabletheserviceuserstocontinuelivinginthecommunity.Olderpeople(aged60orabove)whosufferfrom moderate to severe impairment ascertained by the SCNAMES and require acomprehensivepackageof serviceswouldbeprovidedwith IHCS as frail case (IHCS(FC))category.ThescopeofIHCS(FC)serviceisbasicallythesameasthatoftheEHCCS.

61. Day Care Centres (DEs) and Day Care Units (DCUs): DEs or DCUs provide a range of

centrebased care and support services during daytime to enable the frail and dementedolderpeople (aged60orabove)suffering frommoderateorsevere levelof impairment tomaintaintheiroptimal levelof functioning,developtheirpotential, improvetheirqualityoflifeandto live intheirownhomeswhereverfeasibleandpossible.DEandDCUprovidethefollowingservices:personalcare,nursingcare,rehabilitationexercise,healtheducation,carersupport services, counsellingand referral services,meals, socialand recreationalactivities,and transportation service to and from the centre. Besides, DEs and DCUs also providevariouskindsofsupportandassistancetothecarersinordertoenablethemtocontinuetoassumetheirresponsibilitiesasacarer.

62. Most CCS teams would provide home services at regular operating hours, Monday toSaturdayandonlymealdeliveryonSunday.TheSWDalsorequiresthatCCSoperatorsshoulddeliverservicesonSundays,publicholidaysandoutside the regularoperatinghoursof theorganisation, that is to be prearranged and agreed between the operator and serviceusers. Some EHCCS teamwould provide holiday services including buyingmeal for theelders and other simple care services, based on special request but not on a regularschedule.

63. ForDEs/DCUs, itshouldoperate12sessionsperweekwith10hoursperdayfromMondaysto Saturdays excluding public holidays, and provide extension of service hours for needycases. About 22% of DEs/DCUs provide extended services hours on regular basis andanother 32% provide extended services hours upon request from users and their familymembers. Thereshouldbeenrolled/registerednurses inDEorDCUatalltimesduringtheservice. Formost of theDEs, the average enrolment ratewithin one year is set at 105%

17

18

(parttimeusers, ie.userswhoattendDE/DCUfor lessthan4days inaweek,are included)and the average daily attendance rate (Monday to Saturday)within one year at 90% ofcapacity.

64. However, itsufficestoaddthatthere isanothertypeofservicesthat isnot included intheGovernmentsLTCserviceallocationsystem,i.e.theIntegratedHomeCareServices(OrdinaryCases)(IHCS(OC)).Thisservicecaterstoserviceuserswhosufferfromnotomildimpairmentordisability. Prioritywillbegivento individualand familieswithnoorpoorsupport fromfriendsorthecommunityandarefinanciallydisadvantaged,ordischargedcasesfromEHCCSorIHCS(FC). Theservicesinclude:personalcare,simplenursingcare,generalhouseholdordomesticduties,escortservice,childminding,homerespiteservice,environmentalriskandhealthassessment,purchaseanddeliveryofdailynecessities,provisionofmealsandlaundryservices. For service users who are assessed to be of moderate or severe level ofimpairmentbutrequireonlypersonalcare,simplenursingcareand/orothersupportservices(e.g.generalhouseholdordomesticduties,escort,mealsdelivery,etc.),IHCS(OC)shouldbearranged.AccordingtoserviceusersstatisticsofSWDandNGOproviders,thegreatmajorityoftheusersofIHCS(OC)servicesareelderlypeople.

65. ThewaitingtimeforsubsidisedCCS,ascomparedtosubsidisedRCS,isalotshorter,withan

averageofabout7monthsfordaycareservicesandabout2monthsforhomebasedservices(frailcases). There isalsohigher flexibility in theprovisionofCCS (especiallyhomebasedservices)asitislesspronetophysicalconstraintssuchasaccommodation.

66. WiththeintroductionoftheLumpSumGrantsubventionsystemsince2001,NGOsoperating

thetwotypesofCCS(i.e.IHCSandDE/DCU)canhaveflexibilityindeployingtheirsubventionin settingupdifferent staffestablishments for their services.Table2.2provides a sample,basedoninterviewswithoperatingNGOs,ofthestaffestablishmentofthethreeservices. Table2.2:ASampleofstaffestablishmentsofthreetypesofCCSatthesamedistrict

EHCCS DEs/DCUs IHCS

Servicecapacity 216 44 10(FCs)max.250(OCs)

Casesserved 216 57(including

parttimeusers)10(FCs) 222(OCs)

1.Socialworker 2 0 22.Nurse 4 2.5 03.Physiotherapist 2 1 04.Physiotherapistassistant 0 0 05.Occupationaltherapist 2 1 06.Occupationaltherapyassistant 0 0 07.Personalcareworker 18 7 198.Clerk 1 1 29.Worker 0 1 210.Driver 1 2 211.Chef 0 1 212.Others 2(careassistants) total: 30 18.5 29

ElderlyCentres67. BesidestheabovementionedCCS,DistrictElderlyCommunityCentre(DECC),Neighbourhood

Elderly Centre (NEC) and Social Centre for the Elderly (SE) also play an important part ofcommunitysupportservicesfortheelderly.AsatFebruary2011,thereare41DECC,117NEC,and53SEintheterritory,serving190000elders.ServicesprovidedbyDECCandNECinclude:carer support, counselling, dropin, educational and developmental activities, healtheducation,mealandlaundry,provisionofinformationoncommunityresourcesandreferral,reachingoutandnetworking,socialand recreationalactivitiesandvolunteerdevelopment.DECC further provide casemanagement, community education and support team for theelderly. SE services include providing recreational, social, or educational / developmentalgroups or activities, giving information and making referral to appropriate services ororganizations, encouragingmembers to organizemutual help activities and participate incommunityaffairs,providingadropinareaprovidingaplaceforsocialcontact.

68. TheDECCshouldaimatearly identificationofserviceneedsof individualelderswhomthey

come across through daily activities, programmes, and dropin service, and provideappropriateservicesand/orreferrals.DECCsandNECsalsoprovidecarersupportservicetothose family carerswhoprovide family care to their frail elderly familymembers,provideinformationoncommunityresourcesandreferralservicesforcommunitylivingolderpeople.Theseelderlycentresoperateonamembershipbasisandtheannualfeechargedissetatalow levelthatmakestheserviceaccessibletomostolderpeople;butatthesametimealsoreflectsthattheGovernmenthasbeenhighlysubsidizingtheservice.

FinancingofCCS 69. DuetothefactthatthereisstillarelativelylessdevelopedmarketofprivateprovidersofCCS

inHongKong,theprovisionofCCSischaracterisedbyapredominanceofapublicmodelinwhich services are provided by NGOs which receive funding from the Government. Thefundingmodeisbasicallytaxbasedsupplementedbyaveryminorportionofuserfees. TheGovernmentnowsubsidisesabout80%oftheservicecost.

70. There isnomeanstestedadministered to theprovisionofCCS,andeligibility for receiving

subsidized CCS is based on the level of impairment of the elder, his/her other healthproblems,copingand/orenvironmentalrisksasassessedbytheHDSHC.TheGovernmentisactuallyprovidingtheCCS(throughNGOoperators)withahighdegreeofsubsidyandchargetheusersonlyanominalfee.Tables2.3,2.4,2.5and2.6showtherespectivefeeschedulesofthe various types of services delivered by the EHCCS, IHCS,DCC and the Pilot Scheme onHome Care Services for Frail Elders services. The level of Government subsidy on therespectiveCCSservices isshown inTable2.7andthetotalGovernmentexpenditureonCCSserviceprovisionin2010/11financialyearamountedtoHK$752Million.

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Table2.3:FeescheduleofIntegratedHomeandCommunityCareServices,EnhancedHome

andCommunityCareServicesandHomeHelpServices

IncomelevelCSSAlevelbelow

or Between1.5CSSA

CSSAlevel

to Abovelevel

1.5CSSA

Mealdelivery $12.6 $15.4 $18.6

LaundryLight $0.7Medium $0.9Heavy $1.8

Directcare,homemakingandescortservicesperhour

$5.4 $11.7 $19.0

Table2.4:FeescheduleofDayCareCentre/UnitfortheElderlyTypeofservice Monthlyfee Dailyfee DayCareServiceswithprovisionofmealservice $901* $36*

$988** $39.5**Dayrespiteservice N.A. $40(includetransportservice) Parttimeservice*** N.A. $40(includetransportservice)Transportation $30 N.A.*Therateisfor50%disabledorsingleelders.**Therateisfor100%disabledelders/eldersreceivingDisabilityAllowance.***AttendDE/DCUforlessthan4daysinaweekTable2.5:FeescheduleforDayCareUnitfortheElderlyattachedtoContractHome

Service MonthlyFee Dailyfee

DayCareServices $1,000 N.A.

DayCareServices(forServicethanthreemealsaday)

Userrequiringless $900 N.A.

Transportation $30 N.A.Dailyfeeforparttimetransportation)

ServiceUser(inclusiveof N.A. $40

20

Table2.6:FeescheduleofPilotSchemeonHomeCareServicesforFrailElders

Incomelevel CSSA Between Above Above Above Above5 Above6levelor 11.5 1.53 34 45 6CSSA CSSAbelow CSSA CSSA CSSA CSSA level level

level level level levelMealdelivery $12.6 $15.4 $18.6 $25.0 $30.0 $30.0 $30.0Laundry Light $0.7

$5.5(perlb)

$11.0(perlb)

$14.0(perlb)

$14.0(perlb)

Medium $0.9Heavy $1.8

Directserviceprovidedbynursingstaff

$5.4 $11.7 $19.0 $25.0 $30.0 $40.0 $60.0

(perhour)Directserviceprovidedbyprofessionalstaff

$5.4 $11.7 $19.0 $30.0 $85.0 $120.0 $150.0

(perhour)

Table2.7:GovernmentexpensesonCommunityCareServices(201011Estimate) EHCCS IHCS DEs/DCUs

(FCs)and(OCs)*Costpercaseservedper $3,227 $1,296 $6,078month(201011Estimate) (Averageoffrail

casesandordinarycases)

Annualexpenditure $126.8M $452.8M $172.8M(201011Estimate)*Forordinarycases,theapplicantsarenotrequiredtopassthecareneedassessmentunderSCNAMES.

SelffinancingandprivateCCS 71. WithincreasedawarenessofthepotentialgreatdemandforCCSinthecommunity,therehas

recentlybeensomeemergingtrendofincreasedinterestfromamongsttheNGOsandprivateoperators in providing selffinancing CCS. Table 2.8 presents the current situation of theavailabilityofCCSprovidedbyNGOsbymeansofselffinancingmodeandprivateoperators.

Table2.8PrivateandselffinancingCCS

Selffinancing/PrivateCCS(Organisation) ServiceScopeBamboos Medicalservicesandpersonalizednursingcare

Avarietyofmedicalcareservices,e.g.Western

CentreofWellness (HongKongShengKungHuiWelfareCouncil)

andChinesemedicalconsultation,physiotherapy,etc.Tailormadehealthpromotionplansavailableforgroupsandorganisations

21

EasyHomeServices (SeniorCitizenHomeSafetyAssociation)

Housekeepingserviceincludeshomehelp,cleanup,homecarefortheelderly,patientescortservice,infantandchildcare,postnatalcare,healthmassage,occupationaltherapyandphysiotherapy,etc.

ExtaordinaryHumanResourceMarket(TheNeighbourhoodAdviceActionCouncil)

Patientescortservice,occasionalchildcare,domiciliarysupport,cleaning,babysitting,postnatalcare,gardeningandhairdressing,etc.

Home(Hong

AssistantKongEmploymentDevelopmentService)

Servicestargetsoncommunityeldersincludedescortfromhospital,clinics,andothersocialactivities

HomeCareServicesforDischargedPatients(TheTsungTsinMissionofHongKongSocialServiceCompanyLimited)

Patientescortandhomecareservicesfordischargedpatientsandpeoplewithchronicillness

LiveHealth(TungWah

ProjectGroupofHospitals)

Rehabilitation,domesticescortservices,andsaleproducts

cleaningandpatientofrehabilitation

OKLink(BaptistOiKwanSocialService)

Indoorsafetyalarm,mobilephonewithmultifunctions(e.g.emergencycallingfunction),anddomiciliarysupportservice

Professional(SAGEQuan

EscortChuen

ServicefortheElderlyHomefortheElderly)

Patientescortservicefortheelderlyinneedandaccompanyingtheelderlyoutforshoppingandoutdooractivities

QualityHealthCareCompanyLimited IntegratedhealthcareservicesSmartLiving(EmployeesRetrainingBoard)

Elderlycare,hospitalized

escortcare

services,dischargecare,

Trustease(HongKongSingleParentsAssociation)

Personalcare,patientescort,childcare,postnatalcareandcleaningservices,etc.

VersatileHomeServices(TungWahGroupofHospitalsJockeyShatinIntegratedServicesCentre)

ClubHomehelpservice,patientescortservice,childcareserviceaswellasonestophomesupportserviceforShatindistrict

Women'sHealthyLivingWorkersCooperativeSocietyLimited(HongKongFederationofWomen'sCentres)

Patientescortservicetheelderlyinneed

anddomesticservicefor

YuenYuenCheerfulFamilyLimited (TheYuenYuenInstitute)

ServiceCompanyElderlyhomecarehomehelpservice

serviceandprofessional

BaptistOiKwanSocialServiceIntegratedHealthCareservice(BaptistOiKwanSocialService)

Daycare

EvangelicalHongKong

LutheranChurchSocialServiceEscortservices,andpersonalcare

EvangelicalLutheranChurchSocialServiceTuenMunDayCareCentre(EvangelicalLutheranChurchSocialServiceHongKong)

Daycare

HavenofHopeChristianService Domiciliarycareservices

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HKCWCMadamWongChanSookYingCareandAttentionHomefortheAged(HongKongChineseWomensClub)

MemorialDaycare

HongKongAlzheimer'sDiseaseAssociation Daycareanddomiciliarycare

HongKongShengKungHuiCyrilandCheungAgedCareComplex(HongKongShengKungHuiWelfare

Amy

Council)Daycare

JockeyClub(HongKong

CADENZAHubJockeyClub)

Daycare,healthassessment,servicemanagement,andhealthserviceforthepoor

JockeyClubCentreforPositiveAgeing DaycareanddayrespiteatholidaySt.JamesSettlementKinChiDementiaCareSupportServiceCentre(St.JamesSettlement)

Daycareanddomiciliarycare

YanOiTong Domiciliarycareservices72. Among thepresent selffinancingandprivateCCS,mostof themoperateduringweekdays

and Saturdaybefore6pmwhile somemayopenuntil9pm.Very fewDayCareorRespiteservicecentreoperateduringSundayandpublicholiday.Thisisnotmuchdifferentfromthesubvented services.However,due todifferences indistrictprofileand thusdemand, someoperators may have waiting list due to high demand, and some operators would set amaximumweeklyutilization limit(e.g.2daysofDayCareCentreserviceperweek)fortheirusers.

73. Regarding the service fees, charges forday care serviceofprivate / selffinancing services

range from $2,300 to $7,200 per month and $100 to $200 per day. The charges forprofessionalcareservice,suchasNurse/OT/PT, range from$160 to$200per45minutesand$50to$100perhourforPCWorHealthworkerservice.Miscellaneousdomiciliarycareservices suchashomecleaning,homeattending,home care,mealdelivery,escort service,and etc. are charged at a range of $25 to $100 while some operators would provideconcessionarychargeforCSSArecipients(Table2.9).

Table2.9Comparisonoffeeslevel

betweensubsidizedandprivate/selffinancingCCS Subsidized Private/

selffinancingEHCCS/IHCS (Directcare, homemaking $5.419/hr $50100/hrandescortservices) ForaDCUattachedtoacontracthome:thefee $2,3002,700/ chargedis$1,000permonth/$900permonthfor monthDayCare usersrequiringlessthan3mealsaday.

ForasubventedDE/DCU:$901for50%disabled/singleelders/$988for100%disabled/eldersreceivingdisabilityallowance

23

74. While the private and selffinancing CCS services serve a supplementary role in providingmuch needed community services to communityliving frail older people and their familymembers,duetounavailabilityofdataprovidedbytheoperators,itisnotentirelysurehowfarsuchnonsubsidizedCCSservicescouldmeetthepublicdemand.Furthermore,whiletheselffinancingservicesaremostlyprovidedbyNGOsandthustheservicequalitycouldlargelybeascertained,theprivateoperatorsarenotyetunderscrutinyintheirqualityofserviceandfeeschedule.Theremightbeconcernastohowbesttoensuretherightsoftheserviceusersasconsumersoftheseprivateservices.

IssuesandchallengesImbalancebetweenhomecareandresidentialcarehighinstitutionalizationrates 75. There is a predominance of residentialcare services over communitycare services, thus

contravening theGovernments principle of ageing in place.Hong Kong currently has ahigher institutionalization rate (nearly 7% of elders aged 65 or above) thanmany othercountriesintheEastandWest(Table2.10).

Table2.10 Institutionalisationrateofinternational

elderlypopulationcomparison

(aged60orabove):

InstitutionalisationrateHongKong 6.8%(2009)

Japan 3.0%(2006)Singapore 2.3%(2006)Taiwan 2.0%(2009)China 1.0%(2008)

Australia 5.4%(2006)UK 4.2%(2004)

Canada 4.2%(2003)USA 3.9%(2004)

Source:Chui,E.W.T.ElderlyFinalReport.

etal.Hong

(2009)ElderlyCommissionsKong:ElderlyCommission.

StudyonResidentialCareServicesforthe

76. There iscurrentlyan imbalancebetweenRCSandCCS in termsofvolumeandgovernmentexpenditureonthetwotypesofservices(24746subsidizedRCSvs.7089CCSplaces;HK$2549millionvs.HK$381millionin20102011financialyearasestimatedbasedonthefiguresfrom Head 170 of the Budget of year 201112). The imbalance between residential andcommunitycarecanbe further illustratedby the following figures (Table2.11,Figure2.1):overtheperiod2003041 to201011,theratiosofgovernmentexpenditureonandnumberofplacesofsubsidizedRCStoCCS(excluding IHC(OC)which isnotregardedaspartofLongTermCareas itdoesnot involveclinicalscreeningbytheSCNAMES) isconsistentlyabove5and above 3 respectively. Nonetheless, such ratios have been decreasing over the years,

1 Thechoiceoftheyear2003/04isbasedontheconsiderationthattheIHCservicewasstartedinthatyear.

24

indicating that the relative importanceofsubsidizedCCShasbeen increasing in theoverallLTCserviceprovision.

Table2.11ProvisionofsubsidizedRCSandCCS20032011 200304 200405 200506 200607 200708 200809 200910 201011

SubsidizedplacesRCS1 26,763 26,985 25,705 24,375 23,969 23,778 23,858 24,746

CCS2 5,264 5,264 5,508 5,731 5,833 6,820 7,013 7,089

Ratio 5.1 5.1 4.7 4.3 4.1 3.5 3.4 3.5

total 32,027 32,249 31,213 30,106 29,802 30,598 30,871 31,937

DE3 1,955 1,955 1,955 1,975 2,057 2,234 2,314 2,390

EHCCS 2,189 2,189 2,433 2,636 2,656 3,466 3,579 3,579

IHCS(FC) 1,120 1,120 1,120 1,120 1,120 1,120 1,120 1120

Governmentexpenditure(HK$million)4RCS 2,183.6 2,107.5 2,064.3 2,056.7 2,205.3 2,350.8 2,450.6 2,549.5

CCS 237.0 256.4 264.7 267.1 282.5 329.6 372.1 381.1

Ratio 9.2 8.2 7.8 7.7 7.8 7.1 6.6 6.7

Total 2,420.6 2,363.9 2,329.0 2,323.8 2,487.8 2,680.4 2,822.7 2,930.61includesEBPSplaces2includesDE,EHCCSandIHC(FC),butnotIHC(OC)3numbersforDEheredenoteplacesbutnotusers4governmentexpenditureswereestimatedbasedon200304to201112.

thefiguresfromHead170,TheBudgetofyear

25

Figure 2.1 Government expenditure ($ in millions) and number of places of RCS and CCS(200311)

OverrelianceonpubliclyfundedprovisionsimbalancebetweenpublicandprivateLTCservices 77. Overall,althoughaprivatemarketexistsforresidentialcare,theprovisionofLTCservicesin

Hong Kong is largely a publicly fundedmodel in which the Government provides highlysubsidized services (both residential and community care) through financial subsidies toNGOs or private operators. Furthermore, the provision of such subsidized residential andcommunity care services is not meanstested; that is, there is no effective mechanismallowing theGovernment to target subsidized servicesatelderswhoaremost inneed.Asdetailed later, theGovernment subsidizesvirtuallyallcommunitycare services,and largelysubsidizes residential care services either directly through subsidies toNGOs or indirectlythroughComprehensiveSocialSecurityAssistance(CSSA)tousersofprivateresidentialcareservices.

78. IntheCCSdomain,therearevirtuallynoprivatesectorcommunitycareandsupportservices,

ortheyareminimalatbest.Thus,theirprovisionisessentiallyapublicmodel.Thefundingmode is basically taxbased, supplemented by a very minor portion of user fees. TheGovernmentprovidessubsidiestoNGOsranging fromHK$3,300+ forahomebasedserviceuserpermonth,whiletheuserpays$227permonthonaverage forEHCCS (fortheperiodfromApril to Sept2010).The subsidy from theGovernment constitutesabout90%of theservice cost. On the other hand, while the Government provides subsidies to NGOs tooperatedaycareservicesataunitcostofHK$6,000peruserpermonth,theuserpaysonlyabout HK$1,000 per month, which again represents about an 83% subsidy by theGovernment.

79. Itisanticipatedthat,withthehighlysubsidizednatureofservicesandthenonmeanstested

provision,theGovernmentsfiscalburdencouldbecomeimmensewiththeincreasingageingpopulation. As revealed from government statistics, the total government expenditure onlongtermcare(includingresidentialandcommunitycare)serviceshasbeenonanincreasingtrendsince2006/07:increasingfromHK$2,323.8millionin2006/07toHK$2,816.8millionin2009/10(HKSARGovernmentSocialWelfareDepartment,2010).(Figure2.2)

26

Figure2.2GovernmentexpenditureonsubsidizedRCS&CCS20032011

80. AsrevealedfromTable2.12,there isalsoaconsiderableportionofusersofsubsidizedCCSwhoareconcurrentlyreceivinggovernmentsubsidythroughtheCSSA:23%ofEHCS,33%ofIHCS(FC) and 17% of DCC. Furthermore, there is also a sizable proportion of waitlistedapplicantswhoareCSSArecipients:44%ofEHCSandIHCS(FC)and21%ofDayCareCentre.

Table2.12:CSSArecipientsinvarioustypesofCCSservice**andonwaitinglist

(asatFebruary2011)1 2 3 EHCS IHCS(FC) DayCareCentre

NoofCSSArecipientusersaged60/65+ 823(23%) 372(33%) 397(17%)Totalno.ofplaces 3579 1120 2314NoofCSSArecipientsonwaitinglist 421(44%) 296(21%)Waitlisted 957 1431 **excludingIHC(OC)/HHandrespitecare; 1,2=aged65+; 3=aged60+

81. ItistobereckonedthattheGovernmenthasdevotedmoreresourcesinthe201112Budgettofurthersubstantiateitspursuitofthepolicyobjectiveofageinginplace.Itwasproposedtoincreaseannualrecurrentfundingby$76milliontoprovideabout1700additionalplacesforcommunitycareservices forelders, including1500places for theEnhancedHomeandCommunity Care Services and about 200 day care places for the elderly, and to increaseannualrecurrentfundingfortheIDSPby$148milliontomakeitaregularserviceandextendits coverage from the current three districts to all districts, so that the number of eldersbenefited each year is expected to increase from the current 8 000 to around 33 000.Furthermore,itwasproposedtoincreaseannualrecurrentfundingby$45milliontoraisethesupplementsforsubsidisedRCHEtoprovidebetterservicesforthedementedorinfirmelders,and thecoverageof theDementiaSupplementswillalsobeextended toallsubsidiseddaycarecentresfortheprovisionofmoretargetedservicestopatientsresidinginthecommunity(The201112Budget,paras144,147).

27

82. GiventheabovereviewoftheexistingCCSandtheirlimitations,furthercoupledbythefact

thatAgeinginplaceshouldberealizedinpolicyandactualpractice,thereisindeedneedtostudythepossibledirectionsforfurtherimprovementintheprovisionofCCSinHongKong.Itis especially true for Chinese people in Hong Kong who prefer to age in a familiarenvironment and to continue enjoying the support of their familymembers, friends andneighbours.Bothoverseasand local studies (Gott,Seymour,Bellamy,ClarkandAhmedzai,2004;Lou,Chui,Leung,Tang,Chi,Leungetal.,2009)substantiate thispreferenceamongstelderlypeopletoremainlivingintheirownhomeinsteadofaninstitution.Forinstance,the2008 Thematic Household Survey of the Census and Statistics Department revealed that96.4%ofelderly respondentshadno intention tomove toa residentialcarehome for theelderlyand81.4%ofthemwould liketoremain living intheirownhomeevenwhenhealthdeteriorated(C&SD,2008).

83. The present study therefore ventures to explore the possible directions for developing aviableCCS financinganddelivery system thatbest serve thepolicydirectionofpromotingAgeinginPlaceforolderpeopleinHongKong.

METHODOLOGY

84. Thestudycoversawiderangeof issuesthatrequiresthecollectionofawiderangeofdata(bothquantitativeandqualitative).Theresearchteamthushastoadoptmultiplemethodsincollectingdataandintheanalysis.

Literaturereview85. The research team had reviewed relevant previous and ongoing studies, both local and

overseas, to provide reference for the present study. Specifically the research teamcollected a huge amount of information about the LTC policy and practices, including thefinancingmodeandtheservicescopeandvariations,insevencountriesandregions,namelyAustralia, the United Kingdom, the United States, the Netherlands, Singapore,MainlandChinaandTaiwan.Referencewasalsomadeto19membercountriesoftheOrganisationforEconomic Cooperation andDevelopment (OECD) andAsian countries / economies,whichprovidedreferenceforHongKong.

Interviews(a)Questionnairesurvey 86. Atotalof2,490elderlypeopleandcarerswereinterviewedfacetofaceand162employees

of operators returned their selfadministrated questionnaires in the study period. Also,50indepthinterviewswithsomecasesofsomecategorieswereconductedtogetmoredetailedinformationaboutthespecificsituationsofthosegroupsofstakeholders.Thesamplingframeincludes awide variety of respondentswith different backgrounds grouped under elevensamplingcategoriesasdetailedbelow(Table2.13):

28

Table2.13:Samplingframeofthequestionnairesurvey Category Samplesize#

[Actualno.ofcasesconducted]

1 Nonusershousehold(RCS)

ofcommunitycareservices(CCS)livingindomesticbutwaitingforsubsidisedresidentialcareservices

600[506]

2 ExistingfrailusersofsubsidisedCCS(notei) 500[493]

3 ExistingnonfrailusersofsubsidisedCCS(noteii) 400[329]

4 ExistingusersofnonsubsidisedCCS(noteiii) 100[31]

5 NonusersofCCSwithnolongtermcare(LTC)needs(noteiv) 400[409]

6 MiddleclasselderssuchResidenceScheme(SEN)

asresidentsoftheSeniorandretiredcivilservants

Citizens 150@[154

@]

7 ParticipantsoftheIntegratedElderlyPatients(IDSP)

DischargeSupportProgrammefor 100@[91

@]

8 Carers 400@[363@]

9 EmployeesofCCSoperatorsprovidingdirectservicestoelders 150[162]

10 Elderlypatientsofdayhospitals 100@[82@]

11 RecentapplicantsundergoneMinimum(MDSHC)assessmentwithLTCneeds

DataSetHomeCare 100@[82

@]

Total 3000[2702]

Notes:i. ExistingfrailusersofsubsidisedCCSrefertoexistingIntegratedHomeCareServices(Frail),EnhancedHome

andCommunityCareServicesanddaycareusers.ii. Existingnonfrailusersof subsidisedCCS refer to theexisting IntegratedHomeCare Services (Ordinary)

users.iii. ExistingusersofnonsubsidisedCCSrefertotheexistingusersofselffinancingCCSprovidedbyNGOs.iv. SinceweareunabletoidentifyelderswithoutLTCneed,nonusersofCCSwithnoLTCneedsrefertothose

livinginthecommunity,notusingandapplyingforanyCCS(bothsubsidizedandnonsubsidized)andisnotapplyingforanyRCS.

#Theremaybeduplicationofmembershipacrossthecategoriesbutsincethereiscurrentlynoavailabledatatocrosscheckthemagnitudeofsuchoverlappingmembership,itisthereforeassumedthatthiswillnotsignificantlyaffecttherelativeproportionofsamplesselected.@10indepthinterviewswereconductedinsuchcategories

29

(b)Informantinterviews87. In order to have a fruitful review of the existing service provision and explore into the

possible directions for improvement and future development of CCS in Hong Kong, it isimperativetosolicitviewsfromtheseNGOsoperators.Furthermore,inviewofthepotentialdemand for CCS and thus the possible development of CCS provision by nonsubventedoperators, including theNGOsoperatingonselffinancingmodeandprivateoperators, it isalso necessary to interview some of the potential providers of CCS. A total of 26 keyinformantswere interviewed and theyweremadeupof governmentofficials,operators /stakeholdersofCCS.

88. Theinterviewswereguidedbydetailedinterviewschedules(AppendixI)specificallydesigned

fordifferentgroupsofstakeholders.Thescopeofquestionsincludethecurrentproblemsandchallenges inoperating/providingtheCCS,the impactofthepossiblechanges inpolicyonoperationandfinance,aswellasthepossible impactof implementingavouchersystemforsubsidisedLTCservices(includingbothCCSandRCS).

Secondaryanalysisofexistingdata89. The research team analysed data archives provided by relevant government departments

whichincludethefollowing:

(a) SocialWelfare Department The SWDmaintains data archive of Long Term CareServiceandotherrelevantdata,whichinclude:

i. AggregateddataoftheSCNAMESfrom20042011;ii. NumberofplacesofDE,EHCCSandIHCS(FC)];iii. PercentageofCSSArecipientsinCCSusers.

(b)Census&StatisticsDepartment

i. 2006PopulationBycensus ii. 2010populationfiguresiii. Dataof the2004and2008THSson sociodemographicprofile,health statusand

longtermcareneedsofolderpersons Limitations90. Thereareanumberoflimitationsthathavetobeacknowledgedinthepresentstudy.Firstly,

astherewerenoreadilyavailablename lists insomecategoriesoftargetedsamples, itwasnot feasible to conduct random sampling for these categories. Secondly, the categoriesofrespondentsmaynotbeentirelydiscreteas therecouldbeoverlappingmembershipe.g.arespondentmay at the same time be current users of subsidized and selffinanced CCS.Thirdly, incase the selectedelderlywascognitivelyand/orphysicalunfit to respond (uponscreeningbyclinicalassessment),theproxieshadtoansweronbehalfoftheelderly.

30

CHAPTERTHREE

INTERNATIONALEXPERIENCESINCCSPROVISION

Introduction91. ThecurrentstudyreviewstheexperiencesofothercountriesintheprovisionofCCSservices,

soastoshedlightontheimprovementofCCSprovisioninHongKong. 92. AsrevealedintheElderlyCommissions2009studyonresidentialcareservices(RCS)forthe

elderly,there isan internationaltrendofpromotingageing inplacethroughtheprovisionofcommunitycareservices. Inthisregard,governmentsworldwide(atfederal,provincialormunicipallevels)provideawidevarietyofinkindservicesandsubsidies(intheformofcashor voucher) to the service users and/or their familymembers to enable them to exercisechoiceinusinglongtermcare(LTC)services,andtoencourageelderstoageathomeortheirfamilycaregiverstotakecareofeldersintheirownhomes. Insomecountries/regions,theelderscanevenchooseacombinationofbothtypesofsupport.

93. Through literature review, the consultant team has examined the provision of community

care services in seven countries and regions, namely Australia, the United Kingdom, theUnited States, the Netherlands, Singapore, Mainland China and Taiwan. Nonetheless,reference toOrganisation forEconomicCooperationandDevelopment (OECD)countries isalsomadewhenandifappropriate.

HighlightsofCommunityCareServicesintheInternationalScene94. AsrevealedfromOECDstatistics,mostofthecountriesputstrongeremphasisonpromoting

CCSrather thanRCS.Table3.1showsageneral trendofhavingmoreelderlyreceivingCCSthanRCS.HoweverTable3.2showsthattheexpenditureonRCSishigherthanthatonCCSasapercentageofGDPofthosecountries.ThisapparentlyshowsthattheaveragecostofRCSishigherthanCCS(Chappell,Dlitt,Hollander,MillerandMcWilliam,2004).Thereareavarietyofpolicytoolsandservicesthatcanpromoteageinginplaceofolderpeople.

31

Table3.1

ofRCSInternationalsceneinthedistributionofrecipients andCCSasapercentageofpopulationaged65+

Year %65+receivingRCS

Year %65+receivingCCS*

Australia 2007 6.0 2008 2.51Austria 2003 3.6 2000 14.8Canada 2007 3.5 2003 15.0China 2008 1.73 2009 19(inShenzhen)Germany 2008 3.7 2003 7.1HongKong 2008 6.8 2010 0.8#Ireland 2008 4.0 2000 5.0Japan 2009 2.9 2000 5.5Korea 2009 1.1 2000 0.2Luxembourg 2007 4.7(estimated) 2003 4.8Netherlands 2008 6.7 2008 12.9NewZealand 2009 3.6 2000 5.2Norway 2008 5.5 2000 18.0Singapore 2008 2.9 n.a. n.a.Sweden 2008 5.9 2000 9.1Switzerland 2008 6.4 2000 5.4Taiwan 2009 1.9 2006 1.0(daycare)UnitedKingdom 2004 4.2(estimated) 2002 20.3UnitedStates 2004 3.9(estimated) 2007 2.82*CCSincludeshomecareandcommunitycareservicesandmonetarybenefits#EHCCSservespeopleaged65+;IHC(FC)andDayCareservepeopleaged60+1receivingCommunityAgeCarePackagesinAustralia2receivingHomeHelpinUSSource:Huber,M.(2005b),LongtermCare:Services,Eligibility,andRecipients,OECDHealthWorkingPapers,OECD(2005).LongTermCareforOlderPeople,OECDHealthData2010,OECD,Paris;Australia:AustralianInstituteofHealthandWelfare.AgedCarePackagesinthecommunity200708.Astatisticaloverview.Canada:Rotemann,M.(2003).Seniorshealthcareuse.SupplementtoHealthReports,16,3345;HongKong:Chui,E.elat.(2009).ElderlyCommissionStudyonRCS;Taiwan:MinistryoftheInterior,Taiwan.(2010).10thWeekofInteriorNewsofStatistics2010;Singapore:IntegratedHealthServicesDivisionandHealthcareFinanceDivision.

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Table3.2PublicandprivateexpenditureonlongtermcareasapercentageofGDP,2000

Totalexpenditure Publicexpenditure Privateexpenditure HC RC Total HC RC Total HC RC Total

Australia 0.38 0.81 1.19 0.30 0.56 0.86 0.08 0.25 0.33Canada 0.17 1.06 1.23 0.17 0.82 0.99 n.a. 0.24 0.24Germany 0.47 0.88 1.35 0.43 0.52 0.95 0.04 0.36 0.40Ireland 0.19 0.43 0.62 0.19 0.33 0.52 n.a 0.10 0.10Japan 0.25 0.58 0.83 0.25 0.51 0.76 0.00 0.07 0.07Netherlands 0.60 0.83 1.44 0.56 0.75 1.31 0.05 0.08 0.13NewZealand 0.12 0.56 0.68 0.11 0.34 0.45 0.01 0.22 0.23Norway 0.69 1.45 2.15 0.66 1.19 1.85 0.03 0.26 0.29Poland 0.35 0.03 0.38 0.35 0.03 0.37 n.a. 0.00 0.00Spain 0.23 0.37 0.61 0.05 0.11 0.16 0.18 0.26 0.44Sweden 0.82 2.07 2.89 0.78 1.96 2.74 0.04 0.10 0.14UKKingdom 0.41 0.96 1.37 0.32 0.58 0.89 0.09 0.38 0.48USA 0.33 0.96 1.29 0.17 0.58 0.74 0.16 0.39 0.54HC=homecare,RC=residential/institutionalcareNote:DataforPolandareonlyroughindicationsofmagnitude;DataforAustralia,Norway,SpainandSwedenareforagegroup65+;n.a.=notavailable.Thenotionoflongtermcareusedinanationalcontextcanbesubstantiallybroader,e.g.,byincludingresidentialhomesforolderpeople(e.g.theNetherlands,Nordiccountries).Source:Canada,Germany,Norway:OECDHealthData2004;Australia:ProductivityCommission(2003);Ireland:estimatesbasedonOShea(2003)andMercerLimited(2003);Poland:Kawiorska(2004);Spain:MarinandCasanovas(2001);UnitedStates:OECDHealthData2004andGAO(2002);Austria,Japan,Norway,NewZealand,Sweden,UnitedKingdom:SecretariatestimatesbasedonrepliestotheOECDsquestionnaireonlongtermcare.(SeeHuber,2005a,foramoredetaileddocumentationofsourcesandmethods.)OECD(2005)LongTermCareforOlderPeople

Policytoolsforpromotingageinginplaceagainstinstitutionalization95. In Australia, there is a Transition Care Programme that provides a sufficient period of

transitional care forpatientsdischarged fromhospital toavoid themgodirectly tonursinghome.TheRetirementVillagesCarePackagesisfocusedonresidentsofretirementvillageswhorequireadditionalagedcareservices.CustomerDirectPackagedCareembracesalltheexisting Home and Community Care (HACC) services based on the users preference. Thesharespaidbytheelderswhoparticipateincommunitycare(CommunityAgedCarepackages)are less than those who opt for residential care. People are provided with funds frompersonalbudgets,whichisusedforhomeandcommunityservices.Thereisawholearrayofcarersupportprovisions,suchasCalamityleave,Tendaycareleave,Leavetocareforadyingperson,Careerinterruption,SavedupleaveandLongtermcareleave.

96. In theUK,different levelsofgovernmentsprovidedifferent typesofpublicly fundedhome

care services, depending on whether the services are health services or social services.Nationally,theCentralgovernment,throughtheNationalHealthService(NHS),isresponsiblefor administering health services including home health services (Dalley, 2000). DirectPayments ispayabletoolderpeoplewhoneedhomebased longtermcaretothevalueoftheirassessedneed forservicesand thesecanbeused topayrelativesand friendsascareassistantswhoarenotlivingtogether(OECD,2005:55).Variousalternativestoresidentialcare,

33

which includesheltered housing and extra care housing schemes that offer independencewithanincreasedlevelofcareandsupport,wouldbesuggestedbysocialservicesagencies.

97. IntheUSA,theCongressestablishedtheMoneyFollowsthePerson(MFP)Demonstration

in2005 toprovidestateswithanenhancedFederalMedicalAssistancePercentage (FMAP)foraoneyearperiodforeachindividualwhentheytransitfromaninstitutiontoaqualifiedhomeandcommunitybasedprogramme.In2007,theUSgovernmentsCentresforMedicare&MedicaidServices(CMS)awardedgrantsto31states.

98. InChina,thereisalsotheemphasisoncommunitycareoverresidentialcare.ThegovernmentencouragestheuseoftheCCSforelderly.Forinstance,theMinistryofCivilAffairssuggesteda 9064planningmodel in the provision of elderly service, i.e. 90% of elderly should bereceiving home care, 6% could live in elderly community and only 4% should be living ininstitutions.DuetoChinasvastterritory,therearevariationsamongstthevariousprovincesandmunicipalities in their respective policies and provisions. For instance, the Shanghaimunicipal government started from 2000 onwards subsidizing CCS in the form of buyingserviceforlowincomeelderlywhohavedifficultiesincaringthemselves.In2004,itadoptedvouchersystem inCCS for thoseelderlywhoarecoveredby theMinimumLivingStandardscheme and thosewho have low income. The ShanghaimunicipalGovernment subsidizesthoseaged80andover,whoareeither livingaloneor living inpureelderlyhouseholdandpassedtheassessmentofselfcare,50%ofthestandardallowanceforelderlyservice.

99. InSingapore,accordingtothegovernmentsEldercareMasterPlan (FY2001toFY2005),the

SingaporegovernmentonlysetS$2.6milliononresidentialcarecomparedwithS$14.9milliononhomecare for frailelderlyandS$30.6milliononprogrammes forhealthyelderly.AstheNGOsectorinSingaporeisheavilysubsidizedbythegovernment,suchapolicyofpromotingmoreCCSthanRCS isreflected inthefactthatthenumberofcentresandvoluntarywelfareorganisationsprovidingcommunitybasedcareservice in2005wasnearlydoubleof that in1998while the number of nursing homes and sheltered homes only increased by a smallpercent.

ProvisionofCCSinothercountries/regions

100. TheprovisionofCCSinthecountries/regionsreviewedarefurtherexaminedinthefollowingaspects:1)financingmodelofserviceprovision,2)formofgovernmentsubsidizedservice,3)issues related to the implementation of financial subsidy, 4) quality assurance of CCSproviders, 5) care needs assessment and service scope,6) case management, and 7)manpowerissues.

(a)Financingmodelofserviceprovision101. Similartothe2009studyonRCS,thepresentreviewalsoshowsthatCCSinvariouscountries

may be provided by a variety of financingmodels (Table 3.3 on page 47). ScandinaviancountrieslikeNorwayandSwedenprovideservicesbyapublicly(tax)fundedmodel;whereastheUSA,ishavingprivateinsurancesupplementedbysomepubliclyfundedprogrammes.Interms of the scope of provision, theNordic taxbasedmodel and the insurancemodel inGermany,LuxemburgandNetherlandsprovideuniversalcoverage;whileother taxbased

34

systems inAustralia,CanadaandUKprovide inkindservicesonaselective(usuallybasedonmeanstest)basis.

102. Even under universal public programmes, there is usually the requirement for privatecostsharing bymeans of copayment or userpaymechanisms (Table 3.3).Costsharing inuniversalsystemseithercomesasa fixedpercentageofcost,oras thedifferencebetweenthebenefitandactualspending(OECD,2005:25).Even inthecaseoftheNetherlandswhichadoptstheinsurancemodelandwherenomeanstestisinplace,pensionersarerequiredtocontribute premium in the form of deductions from their pensions or outofpocketcontributionstosharepartofthecosts.Nonetheless,asrevealed inTable3.4,costsharing(byuserpayorcopayment)constitutesarelativelyminorportionintheprovisionofpubliclyfundedCCS,asreflectedfromthesituationwhereprivateexpenditureonhome/communitycare isconsistently lower thanpublicexpenditure.TheUSA isanexception inwhichpublicandprivateexpendituresonhomecarearesomewhatsimilar.Table3.4Publicvs.privateexpenditure(asa%ofGDP)onhomecare

internationalscene Publicexpenditure Privateexpenditure@

Australia 0.30 0.08Germany 0.43 0.04Japan 0.25 0.00Netherlands 0.56 0.05NewZealand 0.11 0.01Norway 0.66 0.03Spain 0.05 0.18Sweden 0.78 0.04UnitedKingdom 0.32 0.09UnitedStates 0.17 0.16@privateexpenditurereferstouserfees,copaymentsSource:OECD(2005)LongTermCareforOlderPeople

103. Actually theUSAexhibitsanothermodelof financing theLTCserviceswithapublicprivatemix.GiventhattheUSAhasafederalgovernmentstructurethereisnonationwidepubliclyfundedLTCprogramme,unlikemanyEuropeancountries.On theotherhand, theUSAhasadopted a privatemodel of health insurance which to a certain extent covers and/oroverlaps with LTC service. However, several federal and state government programmesprovide funding to supporthomecare includingMedicare,Medicaid,OlderAmericansAct,SocialServicesBlockGrant,SupplementalSecurity Income (SSI),anda rangeof supportivearrangements (Kassner, 2006). The USAs Medicaid system, which is publicly funded, isrestrictedtothepoor;whiletheMedicare,asapublichealthsystemforthose65andolder,providesonlylimitedcoverageforhomehealthandskilledcare(Handy,2006).

104. InpubliclyfundedmodelslikethoseofAustraliaandUKthatarefinancedbytax,therewouldbe some mechanism of selection. Such selective provision is usually implemented byadministeringameanstestmechanismontherecipientsassetsandincomesonLTCserviceprovision(includingcommunitycareservices).Theadministrationofameanstestmechanism

35

is to ensure the services are targeted at some specific groups of beneficiaries, withconsiderationofthe lattersfinancialconditionsandthusaffordabilitytoLTCservices. It isalsodesignedinconsiderationofthepossibleheavyfiscalburdenposeduponagovernmentifLTCservicesareprovideduniversally,especiallyinviewofanincreasinglyagedpopulationwithhighmorbidityandtherebyescalatingdemandforservices.

105. Apart fromgeneral tax revenue,anumberof countries/regions including theNetherlands,

Singapore,USAandTaiwanhavealsoestablisheddifferentformsofregulatorycontributorysocial insurancemechanism, aimed at theworking population, to cater for the LTC needs(includingcommunitycareneeds)oftheirfrailelders. Ontheotherhand,privateinsuranceforLTCservicesisratheruncommon2.

(b)Formsofgovernmentsubsidizedservice 106. MostpubliclyfundedCCSservicesareprovidedinkind.However,thereisanemergenttrend

that governments have gradually adopted cash subsidies or incash provision as asupplementoralternativetoinkindprovision.Incountriesthatprovidebothinkind(services)and cash support, theelderlymay choosebetween the twoalternatives,or in the caseofGermany, caneven choosea combinationofboth typesof support.But inmost cases thecashalternativeissetatalowerlevelthanthevalueoftheservices.

107. Asaspecialnote,itshouldbereckonedthatmostcountrieswouldonlyprovidecashsubsidyforhomecarebutnotresidentialservice.According to theOECDs (2005)reviewof the19OECD countries, Austria is the only country that provides universal cash payment at thefederal and provincial levels to people for institutional services,while the other countriesonlyhaveinkindprovisionintheformofRCSplacement.Thisreflectsthepreferenceofthegovernment (andpeople)of thesecountries tohomecare, insteadof institutionalcare fortheirelderlypopulation.Suchpreference isgroundedupon the fact thatcommunitybasedhome care services have been demonstrated comparativemerits in promoting ageing inplaceforelderlypeople.

108. AsrevealedfromTable3.5,inmanyofthewesterncountries(andJapanbeingtheonlyAsian

country),there isavarietyoffinancialsubsidies(withsuchnamesasPersonalbudgetsorconsumerdirectedcareandpayments)providedbygovernments(atfederal,provincialormunicipal levels)payabletoelderly inpurchasingLTCservices, includingCCS.ThisservestoenablethemtoexercisechoiceinusingLTCservices,andtoencourageelderlytoageinplaceortheirfamilycaregiverstotakecareofelderlyintheirownhomes.

109. it istobereckonedthattheprovisionoffinancialsubsidy, intheformsofcashallowancetoelderlyusersand/ortheirinformalcarers(includingrelativeswhoareeithercoresidingwiththeuserornot), isprovidedeitherwithauniversalorwidecoverage incountries thatareeitherhavingahightaxregimeorhavingestablishedasocialinsuranceonLTC;orprovidedonaselectivebasisinothercountriesthatadministersomeformofmeanstestontheusers(andsometimesalsotheircoresidingspouse/relatives).

2 EvenintheUSwhereprivateinsuranceismorecommon,itonlyconstitutesabout4%ofthetotalexpensesonLTCservices(CongressofTheUnitedStatesCongressionalBudgetOffice2004).

36

110. CountriessuchastheNetherlandsoperateaPersonalBudgetschemesimilar innaturetoa

voucher scheme such that individual elders may use the amount allocated to purchaseservices from independent service providers or agencies. TheNetherlands scheme is thebiggestinscaleintheprovisionofpersonalbudgets(Lundsgaard,2005).

111. In the UK, the Direct Payments scheme, which was originally provided for people withdisability,was extended to older people in 2000.Older peoplewho are assessed to havegenuine need for services and need homebased longterm carewould be providedwithdirectpayments to the valueof theirneeded services.Suchpayments canbeused topayrelatives and friends as care assistants provided that they are not living together. Yet inAustria, such cash allowances can be paid to cohabiting relatives. Austria and GermanycommencedimplementingtheCashAllowancesforCareschemeinthe1990s,inwhichsuchcashsubsidy iscoveredbyLTC insurance inGermanywhere inAustriaallpublicsupportforLTChomecareserviceisgivenascash.

112. TheUSAhas the longestexperienceofdeveloping consumerdirected care, inwhich someprogrammeshavebeendeveloped forover20years.TheCash&CounsellingprogrammealsoprovidesabudgettoMedicaidrecipientssothattheycouldexercisetheirownchoicesaboutthepersonalassistanceservicestheyreceive,tohiretheirowncaregiversandeventopurchase care equipment. The programme has a builtin counselling element in whicheldersareprovidedwithadvice inmanagingtheirbudgetthoughtheservicesare limitedtoskillednursingcareandhomehealthaidservices(CashandCounsellinghomepage,2009).

113. Apartfromtheprovisionofcarersubsidy,therecanalsobeothersupportsrenderedtofamilycarers.Forinstance,inSweden,manymunicipalgovernmentsappointaspecialpublicofficerasconsultantforinformalcaregiversandestablishedcontactpoints(Lundsgaard,2005),soastoprovidesupporttoinformalcarers.Furthermore,thereisalsotheavailabilityofasupportsystem of professional homecare services that can help reduce the workload on familycaregivers(OECD2005:30).

(c)Issuesrelatedtotheimplementationofavoucherscheme 114. There isawholearrayof issuespertinent to the considerationof implementingavoucher

system (Steuerle,2000).Such issues, including themeritofavouchersystem inenhancingconsumerspurchasingpowerandconsumerchoice,itsimpactonincreasingservicesprices,issue of equity, of copayment, the level of subsidy and scope of application, issue ofregulationandavailabilityofinformationtoconsumers,sustainedimplementationandfiscalburdenofgovernment,havebeendealtwith intheReportofthe2009StudyonRCS (para93114).

115. Torecapitulatebuta fewcrucialones,such issuespertaintothreemajorconcerns:equity,effectivenessandefficiency.Equityboilsdowntothe fairallocationofvoucheror financialsubsidytothosewithgenuineandmosturgentneed.Thismayrelatetothechoicebetweenuniversalversusselectiveprovision:whileuniversalprovisionmayappeartobeequitabletoall people, it might not achieve target specificity and there might be the problem thatresourceswouldbe committed to thosewho canafford topay the costevenwithout thegovernments subsidization. Selective provisionmay be targeted to themost in need but

37

mightincurstigmatizationontheuserandconsiderableadministrativecostinimplementingaselectionmechanism.

116. Effectivenessofavouchersystemrelatestotheinstitutionofeffectivemechanisms,including

appropriatecareneedassessment,availabilityofamplenumberofserviceprovidersstaffedwith adequately trained care personnel, and regulatory mechanisms on both voucherbeneficiariesorendusersandserviceproviders.

117. Efficiency of a voucher scheme is concerned aboutminimising the various administrative

procedures pertaining to ascertaining the eligibility of voucher beneficiaries; for instanceadministeringclinicalassessmentandmeanstest,determiningthevouchervalue,andotherrelevantmonitoringmechanismsonusersandprovidersmentionedabove.

(d)Theregulationonvoucherusers 118. Astheintroductionofvouchertousersandtheirfamilycarershassignificantimplicationson

publicresources,thereisneedtoensureequitable,efficientandeffectiveimplementation.AviablesystemofimplementationwitheffectivemonitoringandscrutinyhastobeputinplacetoensurethatsuchfinancialsubsidiesareusedspecificallyonLTCaspectsandthatmeasureshavetobestipulatedaccordingly.

119. Reviewofoverseasexperiencesshowsthattherecanbevariouspolicytoolsthatcouldserve

thispurpose. In somecountries,especially thosewithLongTermCare Insurance (LTCI), theprovision of cash payment is administered on a rather loose or less restrictivemanner inwhich theusermayhavehighdiscretionon theuseof thecashsubsidy,withouthaving toreporttotheadministeringauthority.Nonetheless,as inthecaseofGermanythatpracticesLTCI, the health condition and wellbeing of recipients of the Cash Allowance for Care isreviewedeverythreeorsixmonths.Iftheolderpeopleconcernedarefoundtobereceivinginsufficientcare,theauthoritiesmustprovidesome inkindservices, inwhichcasethecashallowancewillbewithdrawn(OCED,2005). IntheNetherlandsthatusesaPersonalBudgets(PGBs)system, theuserhas tobeheldaccountable for thebudgetby filling ina form thatreportsthecontentofservicesprovidedandthepeopleinvolved,withinadesignatedperiodafter theendofeachadvancepaymentperiodand returning to thecare liaisonoffice.Thecareadministrationofficealsocarriesoutrandomchecksaccordingly.IntheUSA,recipientsofcashsupportarerequiredtosignundertakingstoensurethemoney istobespentonhomecareservices,andviolationofsuchwouldresultinprosecutionbythegovernment.

120. Theprovisionofcashsubsidytofamilycaregiversmayturnouttobeadisincentiveforpeople

to jointheworkforceandthuswouldadverselyaffectthe labourmarket.TheexperienceofUSArevealsthatthecombinationoftaxation,unemploymentbenefits,socialassistanceandcash allowances for care redirected informally to the informal care giver negates theincentives forsomeunemployedpersonstoactivelysearch foremploymentwhileprovidinginformal care (OECD 2005:36). To tackle such disincentive problems, the Netherlandsgovernment requiresa formalcontractbetween theolderpersonand thecaregiverwho ishis/her relativeor friend. In this regard, thepayments receivedby the caregiverwouldberegardedasincomebytaxandunemploymentbenefitauthorities.Asaresult,onlywhenthepaymentishighenoughtoexceedincomegeneratedfromgainfulemploymentwouldthedisincentivesetsin.

38

121. Inmost caseswhen carer subsidy is provided, such income support is notmeant to fully

compensate the value of the caregivers work. Such support is onlymeant to sustain aminimum levelof incomeforpersonswhoareunabletohaveanormalfulltime jobduetoprovidingcaretothe frailelders. Insomecountries,such incomesupportschemesareonlyavailable for lowincome carersand thusmeanstest is tobeadministered. These includethe Australian Carer Payment, the Japanese Allowance for Families Caring for an ElderlyPerson,andtheUKCarersAllowance.InthecaseoftheUKCarersAllowance,themeanstestisadministeredtotake intoaccountthe incomeandassetsofthecarersspouseorpartner,whichpracticallywouldexcludethosecarers frommiddleorhighincome families,soastoensure the provision of such subsidy to themost needy. There can also be some otherschemesthatprovideanoptionforthecarertohaveatemporaryleavefromwork.AsinthecaseofNorway,suchacarer leavescheme isavailabletopersonsatall income levels.Somecarerallowanceschemes,suchastheoneinAustralia,aremeanttorewardorrecognisetheworkof informalcaregiverscaring forpersonswith less severeneeds, soas toprovideanextraincentiveforthefamilynottoseekinstitutionalizationwhichwouldincurhigherpublicexpensesonLTC(OECD,2005).

(e)QualityassuranceofCCSproviders122. The administration of a voucher system requires the availability of a wide network of

accessibleserviceproviderssothattheuserscanactuallyusetheirvouchertopurchasetheservices they need. Such providers could either be nonprofitmaking NGOs or forprofitprivateoperators.Inanycase,thereisneedtoensurethatsuchoperatorscanprovidequalityservicestotheusers.Inthisconnection,thereisneedtoputinplaceservicequalityassurancemechanisms.

123. In the international scene, various countrieshave adopteddifferent strategies in achievingthis. InJapantherearenationallysetstandardsonstructureandprocessmeasures,suchason qualification and training of staff, stipulated for the service providers in theNGO andprivatesectors.Theprefecturalauthoritiesserve tomonitor theserviceprovidersbyeitherdeducting the longterm care fees payable to the provider, or cancelling the providersdesignation.

124. InCanada,theHomeCareReportingSystemrequiresnationalreportingthathascontributed

to conducting comparative analysis of home care clients and services across Canada toidentify trends inresourceuseandestablishmentsofbenchmarks formonitoring (CanadianHomeCareAssociation,2008).Currently,eightofthe13provinces/territorieshaveachievedor are planning to achieve accreditation through the Canadian Council onHealth ServicesAccreditation(CCHSA).

125. InUSA, the Federal government requires the states to certify that they havemethods for

assuringqualityofhomeand communitybased services.Although there isvariation in theactual monitoring of quality of home care across different states, there is generally anemphasis on ensuring the availability of qualified caring personnel,which can be seen asinputstandardsintheformofproviderqualification.Specificreferencecouldbemadetothe Home Care Alliance (HCA) ofMassachusetts, a nonprofit trade association, that hascreatedaHomeCareAgencyAccreditationProgramme toestablishoperationalandquality

39

standardsequivalentto licensure inmostotherstates. Inevaluatinghomecareagenciesforelderly,theprogrammeincludes14standardsrelatingto:clientrights,privacy,andcomplaintprocedures; protections against abuse; fair employment practices; caregiver criminalbackground screening; competency, training and supervision; insurance coverage; andcompliancewithallapplicablefederal,stateandlocallaws(HomeCareAlliance,2010).Asat2011,over1,000ofprivatepayhomecareserviceprovidershadbeenaccreditedbytheHCA.

(f)Careneedsassessmentandservicescope126. Mostcountries/regionsthatprovidepubliclyfundedLTCservices(includingcommunitycare

services) require some degree of care needs assessment of the elders prior to serviceprovision.Suchassessment serves thepurposeof targeting thepubliclyfunded services tothosewith genuine care needs. There appears to be an international trend in adopting astandardisedcareneedsassessmentmechanismonanational/regionallevelwhichisalreadyin place in Australia, the Netherlands aswell as Hong Kong. In UK, the Government hasplannedto introduceanationalsystemofcareneedassessment in2010,which ispartandparcel of its national care service reform. Japan is the only Asian country that hasadministeredanationalassessmentmechanisminitsLTCinsurancesystem.

127. Asregardsservicescope,bothcentrebasedandhomebasedservicesareprovidedtotheir

elders in these countries/regions. Centrebased services cover daycare, respite care andeven nightcare services where the rehabilitation and social needs of the elders can becatered for. For homecare services, these services range from lowend services such aselder sitting,housekeepingand transport serviceswith littleprofessional input tohighendprofessionalservicessuchasnursing,personalandmedicalservices,withaviewtohelpingelderstoavoidunnecessaryorprematureinstitutionalisation.

128. In more detail, the scope of services for home and community care in the variouscountries/regions would normally include the following services: Day/Respitecare,Nightcare, Homecare, Domestic assistance, Homemaintenance, Transport, Social needs,Eldersitting,EmergencyResponse,Casemanagement,Mealdelivery/preparations,Nursing/Personalcare,andSpecialdementiaprogrammes.

129. Table3.6providesa reviewof themechanismof careneedassessmentand scopeofCCS

services provided in