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Home and Community-Based Long-Term Care Services in Taiwan: Factors and Effects Associated with the Utilization by Community Dwelling Dependent Elderly

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Home and Community-Based Long-Term Care Services in Taiwan: Factors and Effects Associated with the Utilization by Community Dwelling Dependent Elderly HOME AND COMMUNITY-BASED LONG-TERM CARE SERVICES IN TAIWAN: FACTORS AND EFFECTS ASSOCIATED WITH THE UTILIZATION BY COMMUNITY DWELLING DEPENDENT ELDERLY By Mei-Ju Chuang A dissertation submitted to Johns Hopkins University in conformity with the requirements for the degree of Doctor of Public Health Baltimore, Maryland September, 2017 Abstract Background: The growth of population aging in Taiwan is projected to be one of the fastest aging countries in the world. In response to the increased demands of this aging society, the Taiwan government launched the 10-year Long-term Care Program (LTCP) in 2008. A variety of home- and community-based long term care services were provided to the community-dwelling dependent elderly. However, little is known about the factors related to the utilization of the long-term care program. Purpose: To understand the factors and effects of the home- and community-based long term care services utilization among community dwelling dependent elderly in Taiwan. Methodology: The study data were extracted from the database of “Long Term Care Plan- Chiayi City”. In total, 1,294 older adults who were newly eligible and applied for the 10-year Long Term Care Plan in 2013-2015 were included to explore the determinants of the factors with the utilization. Among 1,294 older adults, 680 elders who were enrolled from January 2013 to June 2014 were followed until September 2016 to describe the outcome and the utilization. Andersen and Newman’s Behavioral Model of Health Services Use was applied to guide the selection of variables, analyses, and interpretation. Based on the behavioral model, three population characteristics including predisposing, enabling and need-level factors and environmental factors were included ii in the study model. Simple statistical comparison, multiple logistic regression and Cox proportional hazard model were applied in this study. Results: Of the 1,294 participants in LTCP, 820 (63.37%) of the participants received at least one of home/community based long term care services. Among 9 types of home/community services for disable elderly, the most widely used service was homecare (57.92%) and the least used service was host family (0.37%). As for the item of home/community based long term care services utilization, 83.53% of the users used only one service. The results of logistic regression showed that elders who had lower household income level, having both geriatric conditions and having higher functional limitation were significantly more likely to use home/community based long term care services. While elders with higher education, having severe/critical disability certification, being severe cognitive impairment and unclear conscious were significantly associated with less likely to use home/community based long term care services. In addition, the use of home/community based long term care services only had a positive effect on mortality, and there were no positive impacts on nursing admission and improvement in functional status and caregiver burden. Implications: More research is required for service utilization since diversified home/community based long term care services have not yet gained popularity in Taiwan. More promotion and education for the public to use the home/community based iii services are also needed. Meanwhile, the policy about foreign worker should be reviewed and modified. Now the long term care plan 2.0 in Taiwan has been launched since 2017, future research can evaluate the effectiveness of the integrated long-term care service model. Keywords: Long term care, Ten year long term care plan, home- and community-based services, Andersen and Newman Behavioral Model of Health Services Use, Disability Advisor: Leiyu Shi, Dr.P.H., M.B.A., M.P.A. iv Acknowledgments I would like to extend my sincere gratitude for the many people who have helped me complete this dissertation. I would first like to thank my advisor, Leiyu Shi, for his support and guidance. He was always there ready to give me his guidance whenever I needed. I would also like to express my gratitude to my dissertation committee chair, Dr. Pien-Chien Huang, for his wisdom, guidance and kindness. He has broadened my view of policy making. I want to thank his especially for the many thought-provoking conversations we have had concerning long term care. I would also like to acknowledge and thank my dissertation committee members: Dr. Hsin-Chieh Yeh for her expertise in epidemiology and intellectual guidance. Dr. Yea- Jen Hsu for her statistical expertise and offering her guidance and thought provoking suggestions. Dr. Hui-Chuan Hsu for her gerontological research expertise and critical thinking. Lastly, thank you to Dr. Chao Hsing Yeh providing me with both academic and professional advice. Finally, I wish to thank my family members for their support and encouragement throughout my study. To my husband, mother and sister, thank you for your unconditional love and support throughout my journey. v TABLE OF CONTENTS Abstract.......................................................................................................................... ii Acknowledgments ......................................................................................................... v List of Tables .............................................................................................................. viii List of Figures............................................................................................................... ix Chapter 1 Introduction ................................................................................................... 1 1.1 Trends in Aging in Taiwan .................................................................................. 1 1.2 Home- and Community-Based Services in Taiwan ............................................ 2 1.3 Significance and Study Purpose .......................................................................... 4 Chapter 2 Literature Review ......................................................................................... 6 2.1 Long-Term Care .................................................................................................. 6 2.1.1. Types of Long Term Care Services ......................................................................... 8 2.1.2. Home and Community-Based Services ................................................................. 10 2.2 Long-Term Care Development in Taiwan ........................................................ 13 2.2.1. Demographic Transition in Taiwan ....................................................................... 13 2.2.2. Long Term Care Policy in Taiwan ........................................................................ 15 2.2.3. Long Term Care Resources in Taiwan .................................................................. 20 2.2.4. Long Term Care in Chiayi City ............................................................................. 23 2.3 Andersen’s Behavioral Model ........................................................................... 23 2.4 Factors Affecting Home and Community-Based Long Term Care Use .................... 27 2.5 Effect of Home- and Community-Based LTC Services Utilization .................. 33 Chapter 3 Methodology ............................................................................................... 38 3.1 Conceptual Framework ...................................................................................... 38 3.2 Study Aims and Research Questions ................................................................. 41 3.3 Data Sources and Study Population ................................................................... 43 3.4 Measurements .................................................................................................... 44 Chapter 4 Results ......................................................................................................... 53 4.1 Descriptive Analysis of the Sample ................................................................... 53 4.1.1 Sample Characteristics ........................................................................................... 53 vi 4.1.2 HCBS Utilization ................................................................................................... 56 4.1.3 Characteristics of Study Participants by HCBS Utilization ................................... 57 4.2 Factors Associated with HCBS Use .................................................................. 69 4.2.1 Association Between HCBS Use and Related Factors .......................................... 69 4.3 Outcome Associated with HCBS Use ............................................................... 85 4.3.1 Characteristics of Follow-up Cohort and HCBS Utilization ................................. 86 4.3.2 HCBS Use and Mortality ....................................................................................... 90 4.3.3 HCBS Use and Nursing Home Admission ............................................................ 96 4.3.4 HCBS Use and Change in Functional Status ......................................................... 99 4.3.5 HCBS Use and Change in Caregiving Burden .................................................... 110 Chapter 5 Discussion ................................................................................................. 116 5.1 Utilization of HCBS......................................................................................... 116 5.2 Factors Associated with the
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