Council of Labor Affairs in Taiwan is Piloting A Programme That Will Provide The Elderly Accessibility To Foreign Caregivers on An Hourly Basis
Taiwan, like other places in Asia, is experiencing rapid ageing. According to some estimates, by 2025, the population of those over 65 years-of-age will be 20 percent, up from 8 percent in 2008. With a population just over 25 million, this represents a huge increase in a relatively short period of time–a problem further exacerbated with population trends such as increased women in the work-place, increased people living alone –being separated from the elderly, and decreased fertility.
Adequate manpower continues to represent a challenge, in part due to Taiwan’s strict laws on foreign immigration and caregiving but also due to the aforementioned trends, such as low fertility rates. Taiwan typically provides good care to veterans and old people, but little community support is available. Little government support is also provided to those who wish to age at home.
Despite this, most elderly Taiwanese prefer to age at home and, many of them, prefer to stay at home rather than go out and partake in community services. Given this fact, recently, Taiwan is undertaking a series of building projects aimed at building age-friendly environment to keep elderly energetic and age successfully at home.
However the issue still remains–with informal caregiving structures on the decline from more women participating in the work force and more elderly ageing at home, who will be able to care for the elderly as they choose to age at home?
Starting 2013, the Council of Labor Affairs will test out a pilot programme that will allow foreign workers to work part-time by the hour.
Citizens over the age of 80 who score 60 or less on the Bartel Index will be eligible to apply for part-time foreign caregiving services. Currently, due to immigration laws, only the elderly who suffer from 1-10 severe mental or physical disabilities and score lower than 35 on the Bartel Index/require around-the-clock care are eligible to employ a foreign caregiver.
Typically these caregivers are hired full-time and the employer is responsible for providing food and accommodation. With the new pilot, the arrangement will be quite different: rather than making employers responsible for housing and accommodation, part-time foreign workers will be employed by NGOs who will take responsibility for their well-being and care.
While there will be no limits on how many hours foreign caregivers can be hired for, their employment needs to be in-line with Taiwan’s Labor Standards Act. All agreements between caregivers and non-profit organisations are to be covered in a contract, stipulating what is expected on the part of both the employee and the employer.
Reimbursement issues are still to be defined at a later time between two parties: local governments and the non-profit organisations (the prospective employers).
Receiving full-time local home-based caregiving care, is available for those elderly at a much higher income bracket. However, there are also government-supported long-term care services available to the elderly, particularly for the veterans, the poor, and those with disabilities. If the elderly is a veteran, the veteran affairs commission provides homes and long-term care services. The Council for Agriculture provides some assistance for aged farmers. For poor elderly with mild-disabilities, the Ministry of Interior provides long-term care support such as step-down care facilities, home services, dementia day care and care in a community setting, and the Bureau of Nursing and Health provides long-term care services, such as nursing home care and home nursing/home care rehabilitation to the poor and disabled.
The new pilot programme then has the potential to cater to a new market of elderly–to allow elderly who are slightly more affluent but still low to middle, middle class, who may not be in need of full-time caregiving support and who wish to age at home–the ability to receive long-term care services from a foreign caregiver who may not be as costly as a local one and only for when needed. It still remains to be seen how this programme will be operationalised and will ensure that local caregivers are adequately provided for. Also, whether or not foreign caregivers will accept the contractual terms and be willing to be part-time caregivers in Taiwan.
According to the WHO definition of Palliative Care: “Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual” (WHO Definition of Palliative Care).
In Singapore, palliative care started as a grassroots movement in the mid-1980s to meet the needs of patients dying of cancer at home. The first home care team worked out of a university lecturer’s apartment in Gillman Heights. No doctors were trained in palliative care and there were limitations on the kind of care and setting where care could be provided.
Things changed a few years later. Singapore saw its first doctor trained in palliative care in the late 1980s. The first palliative care home provider – the Hospice Care Group – was formed in 1987. In 1988 Assisi Home and Hospice was established. This was followed by Agape Home and Hospice and the Hospice Care Association in 1989, Dover Park Hospice in 1995, Metta Hospice Care in 2001 and the palliative arm of Bright Vision Hospital in 2002. In 2007, the Lien Centre for Palliative Care was established to promote research and education in palliative care in Singapore and the region. Since 1996, the restructured hospitals have also been building up expertise to support palliative care for their patients.
Palliative care has now advanced to the point that it can help manage and stabilise patients’ symptoms, and reduce their suffering. Due to greater and more structured training opportunities for healthcare professionals (palliative care is a subspecialty of medicine now), and a steady expansion of palliative care services, even treatments such as blood transfusions and intravenous infusion can be provided to patients in hospice care.
Palliative care is primarily provided by hospices (at an inpatient, home, or day-care setting). There are four palliative care providers that offer inpatient hospice care, six providers that offer home hospice care and two that offer day hospice care.
Many restructured hospitals, as well as some community hospitals and nursing homes have also developed palliative care services, including to meet the needs of certain specialty groups, such as children (for example, in KK Women’s and Children’s Hospital). These services have largely evolved to meet the needs of patients admitted; the provision of palliative care services is not the main function of these institutions.
Palliative care is financed primarily by government subsidies and charity dollars. Most home hospice services are free-of-charge for patients. Day hospice services, hospital-based services, and inpatient hospice services are offered at nominal fees, which can also be partly or fully waived depending on the patient’s financial ability.
Palliative care education is provided by a variety of organisations and institutions. For doctors, palliative care is part of the undergraduate medical curriculum. Subspecialty training is also available for some residency programmes. Palliative care is also incorporated in the formal generalist nursing curriculum for nurses and there are options for them to obtain an advance diploma in palliative care at the polytechnics. A number of different training programmes/certificates on palliative medicine/care are also run by different organisations for all health professionals (doctors, nurses, pharmacists, social workers and other health allied workers).
Public awareness and understanding of palliative care is still quite low. Many people still associate palliative care with giving up hope and treatment. The Singapore Hospice Council recently launched a new community outreach program to increase public awareness of inpatient, home and day hospice services available for end-of-life patients here.
Healthcare providers’ willingness to discuss end-of-life care and dying is also low. Research suggests that, even in hospitals, there seems to be some unwillingness of both patients and healthcare staff to talk about the potential of death. Since 2009, health professionals have started utilising Advanced Care Planning (ACP) as a tool to start having open discussions with dying patients and their families. ACP is currently being piloted at a few restructured hospitals, nursing homes and other end-of-life programmes.
These changes as well as some others implemented suggest that although willingness to discuss death still remains low, there has been improvement over the last few years.
In late 2011, MOH commissioned the Lien Centre for Palliative Care at Duke-NUS Graduate Medical School to formulate a National Strategy for Palliative Care in consultation with key stakeholders in the healthcare system. The report reaffirms the important role of palliative care in the health sector as well as the importance of delivering such care in a coordinated and affordable manner. The report lists ten strategic goals and associated recommendations that address the importance of supply-side interventions such as training and ensuring adequate capacity as well as demand-side interventions such as the need for greater awareness and research. It also calls for greater leadership and governance to guide the development of palliative care services in Singapore.
MOH recently accepted the report on the national strategy for palliative care. Presently, the Government has committed to expand the workforce and hospice care services to make end-of-life care more accessible to patients by committing to:
- Incorporate a greater degree of palliative care training into courses offered in universities, polytechnics and Institutes of Technical Education.
- Expand public education drives and awareness of the services to the terminally ill.
- Promote specialised research and improve understanding of palliative care, by learning and adapting models used abroad.
- Set up an implementation taskforce to put the strategies set forth by the Report on the National Strategy for Palliative Care into action in a country-wide coordinated manner.
- Ensure that palliative care remains a key part of each regional health system.
Singapore’s ageing population and the effect it will have on epidemiological trends (increased burden of non-communicable disease, frailty and dementia, etc) and the subsequent needs required of the health system (increased demand for preventive services, long-term and end-of-life care), coupled with trends of increasing affluence, demand for more choices and declines in informal care-giving structures, suggest that the case for a greater role for palliative care, to meet the needs of patients who will face terminal illnesses, is strong.
Thus, a National Strategy for Palliative Care is welcome. To fully develop, palliative care needs more measures to promote the awareness of palliative care options, ensure that there are an adequate number of skilled healthcare professionals in the sector, introduce standards of care
across providers and settings, improve the coordination of care and ensure that there is adequate capacity to meet the demands for its care.
A greater role of palliative care will help increase the options, visibility, medical and social support for people facing end-of-life and enable decision-making based on preferences. It also allows for a more efficient use of resources for the health system.
HLC 2012. Briefing: Palliative Care in Singapore, July 26, 2012 version. Healthcare Leadership College, MOHH Holdings, Inc., Singapore.
Lien Centre for Palliative Care, Duke-NUH Graduate Medical School “Report on the National Strategy for Palliative Care,” Submitted to the Ministry of Health, Singapore, 4 Oct 2011.
World Health Organization (WHO). WHO Definition of Palliative Care .Accessed April 27 2012
 2011 Report on the National Strategy for Palliative Care http://www.dukenus.edu.sg/sites/default/files/Report_on_National_Strategy_for_Palliative_Care%205Jan2012.pdf
Centrally planned communities, “new towns,” have been around in Japan since the 60s. However unlike the 60s many of these “new towns” are increasingly becoming more integrated, age-friendly. They are increasingly also built with the goal of ensuring sustainability and with helping communities successfully manage the rising social challenges, in mind.
An example of one such community is Yukarigaoka. Yukarigaoka was extensively planned back in the 1970s by Yamaman, a private company. It is located in the north-central Chiba city of Sakura. However unlike some other “new towns” that were also built around the 1970s (for example, Tama New Town, which is composed of mostly elderly persons), Yukarigaoka is specifically designed to allow for the elderly to live close to their families and friends in their communities with the hope that such integration will foster opportunities for younger generations to benefit from the old and vice versa (Yukarigaoka has a balanced population aged structure, which means that it provides a living environment for residents at all stages of life).
To date, Yukarigaoka has a total land area of 245 ha. and a population of 17,000. The distance to the nearest train station is no longer than 10 minutes by foot. Doctor’s offices and child care centres are also easily accessible and close to public transport. Electric bus transportation is available for the elderly in residential areas, so the aged have direct access to residential areas and can stop where they want to. Also, Yamaman directly intervenes to help maintain the relatively balanced population structure between the young and the old. Yamaman handles the sale of both new and older housing units in Yukarigaoka so that that the transition to new accommodation can occur seamlessly within the community and the value of property does not change too much.
Kashiwa-no-ha is a new “new town” that builds on this model. It is developed with a view to the future: to pioneer solutions for social challenges. The town has a planned population of 30,000 and is situated between Tokyo and Tsukuba. Similar to Yukarigaoka, Kashiwa-no-ha is a public-private academia partnership that aims to develop a city of health and longevity, a smart city, and a new industry-creating city. The city promotes ageing-in-place, wellness and health promotion in a community setting, and allows for middle-aged residents to benefit from mutual assistance within the community. Age-friendly services provided in communities include the provision of transportation, buildings, libraries, and shopping centres, among other support structures that are specifically catered to meet elderly and youth needs.
Large investments and multiple investors are increasingly common for the development of integrated communities that can address social challenges, such as environmental sustainability and population ageing. That these communities can be sustainable and can grow are important.
Enabling the elderly to successfully age-in-place and for the youth to have connection to the old, goes down to the design of a community in Japan: of creating the appropriate physical and social environments to ensure that the appropriate interconnections exist at the local level: between the service user, informal carer and professional; between various aspects of the healthcare system and across all relevant sectors, even though such coordination may not exist at the national level. Promoting inclusiveness of elderly ensures community sustainability and growth over time. It also enables the elderly to stay in the same communities as their families as they continue to age.
With one of the highest proportions of elderly in the world, Japan undoubtedly has more structures, funding mechanisms and institutions in place to support the aged. The importance of tackling the aged society is recognised at the national level in Japan (even though local communities have their own successful initiatives targeting aged people in highly rural areas). The Ministry of Health Labour and Welfare is the agency responsible for policy making and administration of the workforce, national pension system, national healthcare system, national nursing care insurance system, etc. While most initiatives related to ageing and planning involve and have been initiated by the national government, who has the authority to secure budget and distribute it to each local government, national/state/local governments also pay. The ventures are also open to other partners. Thus, while the Japanese Government seems to take on a large burden of caring for the aged, so do the other stakeholders in Japanese society.
The benefit of multi-stakeholder engagement to create these integrated communities is that the burden of the elderly is shared among a wide variety of stakeholders. Another advantage is that elderly needs can be provided more downstream at the community level, assuming that enough support structures are present in the community and home setting to enable that to occur. This ensures that all people in society can continue to remain productive, socially engaged and age-in-place in urban settings. It also helps ensure that the communities that are built or redesigned can successfully grow to address the rising social challenges facing Japanese society in the years ahead.
Field diary: Yukarigaoka by catforehead
Notes from AAIF Conference in Singapore, April 2012
Notes from unpublished research brief.
This will be the first posting of more postings of real-live lessons we can learn from Japan and other countries in Europe and Asia, on the ageing issue.
Today, living to a ripe old age used to be a rare occurrence, but it is becoming more mainstream. Surviving to these great ages represents a victory over life and speaks to the accomplishments of modern medicine and technology. On the flip side, living to these great ages will increasingly call for a change in the way we structure our lives. For instance, our idea of ageing-in-place, of retiring, of what is considered ‘old,’ of how we age, structure our society and community in general, and more!
Just take one example: the Western notion of retirement.
When we think of retirement in the West, we think of relatively young healthy happy mobile elderly moving away to the countryside or to one of those all-inclusive retirement community resorts to spend the last few decades/years of life. Stereotypically, the idea conjures up visions of men playing golf all day and of women painting, visiting their grand-children and possibly traveling the world. Behind this image are the company pension plans, IRA savings accounts and the financial backing of reliable national pension and health systems that underpin the support of this retirement machinery.
However, changes in epidemiology, living and working structures, the financial crisis, data and budget constraints, suggest that while this kind of retirement may have been applicable to our parents and grandparents, it may not be the way the current young generation (or those under 40) will retire and live out the last days of their lives.
For one, increasing liberal values such as women’s liberation, widespread urbanisation, communication technology, and increased longevity have meant that families have become smaller, more dispersed and varied. People are increasingly living alone, marrying later and ageing alone. They also tend to move from one job to another and work for a wide range of different companies in their lifetimes.
State social pensions and health benefits in many countries, are also now not as sustainable or reliable as they used to be. In the US for example, the latest study from the SSA projects that there will only be enough revenue to pay for about 75% of scheduled social security benefits after 2033. Also, with all the disagreements in policy on the recently passed ACA (click here for my previous posting), there is a chance that there will be more changes and possible backtracking on progress made on the health care front.
Finally, for at least this cohort of elderly, data trends of increased longevity seem to be going hand-in-hand with a growing incidence of chronic disease, which suggests that for many, the idea of ‘healthy ageing’ into ones 80s and beyond may not be feasible—increased longevity may not necessarily translate, as nicely as theory suggests, into many years of healthy full-functioning. To date, data and studies suggest that if one survives to age 85 without the incidence of a chronic illness, there is a high probability that one will not die from a chronic illness. The killer in this case (if not sudden death), will be one of general frailty or mental/cognitive decline (i.e. dementia).
The point is this: we do not live forever! There will always be a killer and, increasingly, it will be a more expensive killer– unlike the past, where most of us died from acute episodic diseases, today when we increasingly get older, and surpass living to beyond our 70s and 80s, technology or medicine will only really be able to only marginally improve the quality and longevity of our lives, and only be able to do so at a greater marginal cost.
Given these conditions, and the fact that the population over 65 in some ageing countries keeps on surpassing what it used to be, retiring at 65 can no longer feasible or affordable. Can you really expect countries to survive providing similar benefits at similiar retirement ages when 5% of the population was over 65 years of age to a scenario when over 20% of the population will be over 65?
My next few blogs will rely less on academic theories –we have too many unproven ones — but more on real-life lessons we can learn from countries with high ageing populations and the approaches they are taking to tackle ageing challenges in their countries.
To put the urgency of ageing challenges in perspective, according to the latest figures, Japan’s elderly proportion (proportion of over 65 year olds) was 22.68%, the highest proportion of elderly in the world, followed by Germany (20.38%), Italy (20.35%) and Greece (18.55%). According to projections for just Japan, in 2030, the ratio of people over 50 years of age will be 54%–so ageing challenges are ongoing, and are already real and impactful in many of these countries.
I do not like the situation these countries are in/will be in, nor do I wish any country to face this kind of reality. Large proportions of an aged population affect not only us in healthcare. It affects our society, economy and, ultimately, the survivability of our civilisation!
In the past, civilisations crumbled due to famine, war, disease, etc., if countries do not adequately prepare to face the rising challenges of an ageing society, they may be forced to enter a new era of history–where population ageing will take a more active and leading role in the downfall of their civilisations.
Forbes: “What Young People Need to Know About Retirement”
http://www.forbes.com/sites/financialfinesse/2012/07/25/what-young-people-need-to-know-about-retirement/ by Liz Davidson, 7/25/2012.
World Bank. 2012. HNP Indicators.
In no other country does public responsibility for health costs provoke such emotional chanting of ideological warfare. While many European countries have resolved and accepted the notion of public intervention in healthcare, after many failed attempts at reform and countless public debates, the issue of US Government involvement in the healthcare sector has clearly still not been fully resolved. Not only that, but this very issue affects the very nature of the American psyche!
‘Warfare’ is the correct word to use as EVERYONE in the US seems to have an opinion on the role of the Government in health! Whether it is seen as endangering the American free-enterprise system and the doctor-patient relationship or as a social and ethical obligation to make healthcare accessible and affordable (we are not even talking about what people think about the US Affordable Care Act of 2010 yet)!
Why has the Government’s role in health care become such a contentious issue? Why is there such a lack of trust of the Government and politics/politicians in general? Due to space and content restraints, I will leave you to ponder this as I address how I think these underlying issues factor into the implications for elderly care as outlined in the 2010 Affordable Care Act (ACA) and beyond.
First, it is worth mentioning that ACA does not make an attempt to overhaul the existing US health care system. In its essence, ACA essentially maintains the private, market-based health insurance system. It keeps the existing Medicare programme intact (albeit some incremental changes), it expands Medicaid eligibility for to cover a greater number of legal residents (up to 133 percent of the federal poverty level (US$14,404 for a single adult or US$29,327 for a family of four)) and also includes provisions such as: (1) an individual mandate, (2) regulations, (3) subsidies, and (4) adjusted community premium ratings.
So what does all this mean for the elderly?
Benefits pertaining specifically to the elderly are introduced in a number of sections. Some benefits address gaps in Medicare, and others are introduced as standalone programmes. For example, the ACA includes financial incentives to reduce healthcare acquired conditions in the hospital setting and to reduce readmissions of Medicare patients to hospitals after discharge (hospital readmission programme). The ACA also introduces voluntary, self-funded, long-term care insurance through the workplace for the elderly and for people with disabilities. It allows Medicare recipients, who fall under the “donut hole,” to get a 50% discount on brand name prescription drugs and to get access to free prevention and wellness services each year. These are just some of many examples, but from these there are key takeaway points worth pondering.
Firstly, many of these programmes will not come into effect immediately. Rather implementation is set to take place over a period of years, through 2019 (the phasing out of the “donut hole” for Medicare Part D coverage, is an example).The challenge with having implementation set further into the future is that it subjects the policy to a problem known as the saliency bias (where the urgency to take action diminishes over time). Given the fact that this issue also is unresolved and evokes so many mixed emotions from such a wide variety of stakeholders, suggests that the decision to delay ACA implementation introduces higher political risk: it creates the opportunity for progress to be circumvented, changed, potentially even reversed!
Secondly, in addition to delaying implementation, congress left many specific decisions and rulemaking on ACA for the regulators to establish. In many respects, this makes sense. Compared with congress, regulators are better equipped with the technical expertise to address this issue and are in a better position to ‘theoretically’ make technical decisions devoid of politics. However, one only needs to see what is happening with Dodd Frank implementation to know that in actuality, similar to the finance sector, leaving specific decisions on ACA for regulators to establish at a later date, may not work as intentioned in practice. This can hold true for a myriad of reasons: health regulators are not completely immune to lobbyist influence, there tends to be a revolving door of regulators from the industry itself and the decision to do so can lead to the unintended effect of diminishing the sense of greater accountability to the public to ensure effective health system reform.
Thirdly, while ACA represents a potential tool for the elderly to receive more comprehensive benefits and access to care, the Act takes minimal steps to reduce the many moving parts of the system, put more bluntly, its complexity. The lack of standardized rules regulating payment, coverage and provision, translates to an operational challenge to beneficiaries, especially the elderly. It will require them to single-handedly navigate and coordinate their services as they move from one benefit programme to another. Understanding ACA remains daunting to me, and I am a mid-career policy analyst, so you can imagine, how much more challenging and confusing it must be for the elderly to fully comprehend and experience! The sheer complexity, fragmentation, distrust and differing opinions on ACA, open the benefits provided to misunderstanding, misrepresentation and unintended consequences. On the latter, ACA may lead to the disruption of care services as eligibility requirements for different programmes may differ. Reimbursement differences may affect incentives for the provision and utilisation of services. To elaborate on this point, George Washington University’s School of Nursing Assistant Research Professor Ellen Kurtzman, lists some examples of unintended negative consequences in provision of care for the elderly under the ACA in an article (I have chosen to just list two of them):
• The National Pilot Programme on Payment Bundling reimburses a fixed amount to a hospital system for an episode of care and is aimed at delivering high quality outcomes at lowest possible cost, while avoiding post-acute stays and preventable rehospitalisations. However, the programme does not include bundle payments for long-term services and support so there are no incentives to coordinate care before or beyond the bundle.
• The Community-Based Care Transitions Programme, allow hospitals to serve as the “hubs” of care. However, it may prevent frail older adults who are not hospitalised or who live outside the geographic regions served by these organisations to have adequate access to transitional care services.
Thus, despite its benefits, ACA does seem to further complicate healthcare financing and delivery in the US health system. The sheer complexity of different programmes and initiatives fragments the system, causes greater room for misconceptions and misinterpretations and introduces some unintended consequences, all to the detriment of serving the population at-large.
The US has gotten itself in a bit of a muddle: while many Americans believe healthcare reform towards universal health coverage is needed to allow healthcare to be available at a price that is affordable, due to the unresolved issues surrounding the appropriate role of Government in health, everyone has a differing opinion on how to get there.
By the current nature of ACA’s design, it is clear that policy-makers made some sacrifices. In the need to design a policy that will pass congress (i.e. to maintain status quo, not offend too many stakeholders), ACA ended up not really doing much to fundamentally address the much needed health system overhaul that underlying dynamics in US population structures, costs and epidemiological conditions, require.
What will it take to bring about the needed change in health reform in America? Will the land of opportunities continue to allow itself to be mired in this ideological policy trap, amidst a clear need for reform?
Email from Joe Albers Summarizing a Policy Analysis Brief of Affordable Care Act of 2010 dated July 17, 2012.
Medicalxpress. 2012. “The Affordable Care Act Could Have Negative Consequences for Elderly Recipients” By Ellen Kurtzman, June 22, 2012 http://medicalxpress.com/news/2012-06-negative-consequences-elderly-recipients.html#jCp Accessed July 25 2012
Starr, Paul. 2011. Remedy and Reaction: The Peculiar American Struggle over Health Care Reform (Yale University Press, October).