Case-mix and quality indicators in Chinese elder care homes: are there differences between government-owned and private-sector facilities?

Deep learning model for the prediction of all-cause mortality among long term care people in China: a prospective cohort study

This study aimed to develop a deep learning model to predict the risk stratification of all-cause death for older people with disability, providing guidance for long-term care plans. Based on the government-led long-term care insurance program in a pilot city of China from 2017 and followed up to 2021, the study included 42,353 disabled adults aged over 65, with 25,071 assigned to the training set and 17,282 to the validation set. The administrative data (including baseline characteristics, underlying medical conditions, and all-cause mortality) were collected to develop a deep learning model by least absolute shrinkage and selection operator. After a median follow-up time of 14 months, 17,565 (41.5%) deaths were recorded. Thirty predictors were identified and included in the final models for disability-related deaths. Physical disability (mobility, incontinence, feeding), adverse events (pressure ulcers and falls from bed), and cancer were related to poor prognosis. A total of 10,127, 25,140 and 7086 individuals were classified into low-, medium-, and high-risk groups, with actual risk probabilities of death of 9.5%, 45.8%, and 85.5%, respectively. This deep learning model could facilitate the prevention of risk factors and provide guidance for long-term care model planning based on risk stratification.

"It's your Liangxin that tells you what to do": Interpreting workplace-induced emotions in a Chinese nursing home

How Direct Care Workers (DCWs) interpret their work and perform care activities undeniably impacts the well-being of institutionalized older adults. Despite the emotionally charged nature of paid care work, little is known about how Chinese DCWs talk about their work and construct meaning within China's unique social context of a burgeoning institutional care market and changing cultural expectations for long-term care. This study qualitatively explored Chinese DCWs' emotion work as they navigate among institutional pressures and low social recognition in an urban government-sponsored nursing home in central China. Results revealed that DCWs used Liangxin (the good heart/mind) - a ubiquitous Chinese moral notion emphasizing the unity of feeling, thought, and action - as an interpretive framework, including its four dimensions (ceyin, xiue, cirang, and shifei), to inform care practice, manage emotions, and find dignity within what can be personally demeaning and socially devalued work. Our study delineated the processes through which DCWs sympathized with the pain and struggles of the older adults in their care (ceyin xin), shamed unjust attitudes and behaviors embedded in institutional care (xiue xin), delivered family-like relational care (cirang xin), and formed and reinforced principles of good (versus bad) care (shifei xin). We also revealed the nuanced role that the cultural value of xiao (filial piety), working in tandem with liangxin, both shaped the emotional terrain of the institutional care setting and impacted how DCWs engaged in emotion work. While recognizing the effect of liangxin for incentivizing DCWs to provide relational care and renegotiate their role status, we were also alerted to the risks of overburdening and exploiting DCWs who relied solely on their liangxin to meet complex care needs.

Evolutionary Game Analysis of Behavior Strategies of Multiple Stakeholders in an Elderly Care Service System

As the aging of Chinese society continues to deepen, it is particularly important for the development of the national elderly care service industry to further strengthen the government's supervision of private pension institutions and improve their management awareness of standardized operations. The strategic behaviors among the participants of senior care service regulation have not been well studied yet. In the process of senior care service regulation, there is a certain game association among three stakeholders, namely, government departments, private pension institutions, and the elderly. This paper firstly constructs an evolutionary game model including the above three subjects and analyzes the evolutionary path of strategic behaviors of each subject and the evolutionary stabilization strategy of the system. On this basis, the feasibility of the evolutionary stabilization strategy of the system is further verified through simulation experiments, and the effects of different initial conditions and key parameters on the evolutionary process and results are discussed. The research results show that (1) There are four ESSs in the pension service supervision system, and revenue is the decisive factor that affects the evolution of the stakeholders' strategy. (2) The final evolution result of the system is not necessarily related to the initial strategy value of each agent, but the size of the initial strategy value will affect the rate of each agent's evolution to a stable state. (3) The increase in the success rate of government regulation, subsidy coefficient and punishment coefficient, or the reduction in the cost of regulation and the fixed subsidy for the elderly can effectively promote the standardized operation of private pension institutions, but the large additional benefits will lead to their tendency to operate in violation of regulations. The research results can provide reference and a basis for government departments to formulate the regulation policy for elderly care institutions.

The path to healthy ageing in China: a Peking University-Lancet Commission

Around the world, populations are ageing at a faster pace than in the past and this demographic transition will have impacts on all aspects of societies. In May 2020, the UN General Assembly declared 2021–2030 the Decade of Healthy Ageing, highlighting the importance for policymakers across the world to focus policy on improving the lives of older people, both today and in the future. While rapid population ageing poses challenges, China’s rapid economic growth over the last forty years has created space for policy to assist older persons and families in their efforts to improve health and well-being at older ages. As China is home to 1/5 of the world’s older people, China is often held up as an example for other middle-income countries. This Commission Report aims to help readers to understand the process of healthy ageing in China as a means of drawing lessons from the China experience. In addition, with the purpose of informing the ongoing policy dialogue within China, the Commission Report highlights the policy challenges on the horizon and draws lessons from international experience.

Predicting Chinese older adults' intention to live in nursing homes using an integrated model of the basic psychological needs theory and the theory of planned behavior

The growing number of aging populations has become a major problem worldwide. Nursing homes play an essential role in the later life of older adults. Previous research indicated potential associations between external factors and older adults' intention to live in nursing homes. However, intrinsic motivation has yet to be fully understood. This article addresses an academic void that integrated the Basic Psychological Needs Theory (BPNT) and the Theory of Planned Behavior (TPB) to explore older adults' intentions to live in nursing homes. More specifically, it tested the effects of autonomy, competence, and relatedness needs satisfaction as defined in the BPNT on attitudes, subjective norms, perceived behavioral control, and live-in intentions toward nursing homes in the TPB. An online survey provided quantitative data from 425 aging people. The results indicated that the higher the satisfaction of the basic psychological needs (i.e., autonomy needs, competence needs, and relatedness needs) of the older adults, the lower their intention to live in nursing homes. Furthermore, social pressure partially mediates this relationship. That is, the higher the satisfaction of the basic psychological needs of older adults, the lower the pressure from society. Thus, they should be admitted to the nursing home, and the lower their intention to live in nursing homes. The results contribute to a better understanding of the deep psychological motivation of the older adults' intention to live in nursing homes and support further development of the BPNT-TPB model in older adults' health research.

Validation of the Chinese version of the resident satisfaction in long-term care facilities

BACKGROUND

Accurate measurements of resident satisfaction in long-term care settings can provide administrators with valuable information to improve the quality of care. However, such assessment has been insufficient in long-term care facilities of China due to limited validated measuring instruments. We aim to translate and validate a Chinese version of the resident satisfaction assessment based upon the Ohio Long-term Care Resident Satisfaction Survey (OLCRSS).

METHOD

An external specialist team assessed the translated items of OLCRSS and provided content validation scores (CVI). Criterion-related validity was determined by measuring the correlation between the Chinese version OLCRSS, a global satisfaction, a quality-of-life questionnaire, and a depression measurement. The reliability was assessed by Cronbach alpha and intra-class correlation coefficients. We conducted an exploratory factor analysis to examine the structure of the Chinese version OLCRSS. A total of 172 older adults recruited from Shanghai, China, participated in this study.

RESULTS

The Chinese version OLCRSS demonstrated excellent validity, with the CVI = 1.0, ICC = .96, p < .001, and a Cronbach alpha = .96. The Chinese version OLCRSS was significantly correlated with quality of life (r=.267 p < 0.01), with the global satisfaction (r=.309, p < 0.01), and had negative correlation with depressive symptoms (r = -.044, P = .498). The exploratory factor analysis implied a slightly different structural relationship between items. Possible explanations were discussed in the discussion section.

CONCLUSIONS

The Chinese version OLCRSS is a valid and potentially useful instrument for assessing resident satisfaction in long-term care facilities among the older Chinese population and Chinese contexts.

Strategic Analysis of Participants in the Provision of Elderly Care Services-An Evolutionary Game Perspective

Population aging poses challenges to the immature elderly care service system in many countries. The strategic behaviors of different participants in the provision of elderly care services in a long-term and dynamic situation have not been well studied. In this paper, an evolutionary game model is developed to analyze the strategic behaviors of two types of participants—the government sectors and the private sectors in provision of elderly care services. Firstly, eight scenarios are analyzed, and the evolutionary process and stable strategies are identified. Then, the behavioral strategies of the two types of participants under demand disturbance and dynamic subsidy strategy are analyzed. Simulation experiments are conducted to explore the influence of different initial conditions and parameter changes on the evolutionary process and results. The obtained observations are not only conducive to a systematic understanding of the long-term dynamic provision of elderly care services but also to the policymaking of the government.

Nursing home residents' ADL status, institution-dwelling and association with outdoor activity: a cross-sectional study

Introduction

The Norwegian regulations for nursing homes consider access to meaningful activities to be an indicator for the quality of nursing homes. Activities of daily living (ADL) provide important basic self-care skills for nursing home residents. Due to the physical changes caused by ageing and comorbidities, nursing home residents may experience functional decline over time, which may affect their ability to perform meaningful ADL, such as outdoor activity, which is considered a valuable and meaningful activity in Norwegian culture. This study aimed to investigate the association between ADL status, institution-dwelling and outdoor activity among nursing home residents.

Methods

This cross-sectional study included 784 residents aged >67 years living in 21 nursing homes in 15 Norwegian municipalities between November 2016 and May 2018. The Barthel Index was used to assess the nursing home residents' ADL status. Other variables collected were age, gender, body weight and height, visits per month, institution, ward, and participation in weekly outdoor activities. Descriptive statistics were used to provide an overview of the residents' characteristics. A Poisson regression model was used to test the association between the outdoor activity level as the dependent variable and ADL score, institution, and other control variables as independent variables.

Results

More than half (57%) of the nursing home residents in this sample did not go outdoors. More than 50% of the residents had an ADL score <10, which indicates low performance status. Further, we found that residents' ADL status, institution, ward, and number of visits had an impact on how often the residents went outdoors.

Discussion

The nursing home residents in this study rarely went outdoors, which is interesting because Norwegians appreciate this activity. Differences in the number of visits might explain why some residents went outdoors more often than other residents did. Our findings also highlight that the institutions impact the outdoor activity. How the institutions are organized and how important this activity is considered to be in the institutions determine how often the activity is performed.

Conclusion

The low frequency of the outdoor activities might be explained by a low ADL score. More than 50% of the residents had an ADL score <10, which indicates low performance status. Despite regulations for nursing home quality in Norway, this result suggests that organizational differences matter, which is an important implication for further research, health policy and practice.

Long-term care system for older adults in China: policy landscape, challenges, and future prospects

In China, the population is rapidly ageing and the capacity of the system that cares for older people is increasingly a concern. In this Review, we provide a profile of the long-term care system and policy landscape in China. The long-term care system is characterised by rapid growth of the residential care sector, slow development of home and community-based services, and increasing involvement of the private sector. The long-term care workforce shortage and weak quality assurance are concerning. Public long-term care financing is minimal and largely limited to supporting welfare recipients and subsidising the construction of residential care beds and operating costs. China is piloting social insurance long-term care financing models and, concurrently, programmes for integrating health care and long-term care services in selected settings across the country; the effectiveness and sustainability of these pilots remain to be seen. Informed by international long-term care experiences, we offer policy recommendations to strengthen the evolving care system for older people in China.

Using the Delphi Method to Identify Risk Factors Contributing to Adverse Events in Residential Aged Care Facilities

Purpose

This study aimed to identify risk factors associated with adverse events in residential aged care facilities in China.

Patients and Methods

After compiling a list of risk factors for adverse events generated from in-depth interviews with managers of residential aged care facilities, a three-round Delphi method was used to reach consensus. The synthesized risk factors were presented on a Likert scale to the expert panelists three times to validate their responses.

Results

The list identified 67 items as risk factors for adverse events, attached to four first-level indexes (ie, environmental facility, nursing staff, older adults' characteristics, and management factors). The experts' authority coefficient was 0.87. The positive coefficients were 82.76%, 91.67%, and 100%, and the coordination coefficients were 0.154, 0.297, and 0.313 in the first, second, and third rounds, respectively.

Conclusion

Using a Delphi method, this study established a consensus on risk factors contributing to adverse events and developed a risk assessment grade for use in future aged care practice and research. The resulting list is useful in prioritizing risk-reduction activities and assessing intervention or education strategies for preventing adverse events in residential aged care facilities.

Impact

This study fills the gap in risk identification in the Chinese residential aged care system to ensure provision of best-practice care to this vulnerable population. Nursing staff and management factors at the top of the list are not only the most common causes of adverse events but also the core elements in creating a secure and error-free environment. This list was intended to support predictive and prevention-oriented decision-making by managers and nursing supervisors to reduce preventable adverse events.

Resident Challenges With Pain and Functional Limitations in Chinese Residential Care Facilities

BACKGROUND AND OBJECTIVES

Pain and functional limitations can severely impede older adults' quality of life. In Chinese residential care facilities, limited research suggests that residents potentially have significant unmet care needs with pain and related functional limitations. Therefore, we aimed to explore residents' challenges and self-management strategies in these two areas. This knowledge is essential to developing care interventions to improve quality of care and quality of life in Chinese residential care facilities.

RESEARCH DESIGN AND METHODS

We conducted semi-structured open-ended interviews with residents (n = 21) in two facilities in eastern and central China and assessed their pain and functional status using self-report measures from Minimum Data Set 3.0. We applied descriptive statistics to the self-reported data and analyzed the interview data using thematic analysis by drawing on the Adaptive Leadership Framework. This framework proposes that individuals living with chronic conditions need to engage in work to address their complex health concerns and that they need support from the environment to facilitate problem-solving.

RESULTS

Residents described significant unmet care needs with pain and functional limitations. To address these care needs, they adopted a substantial number of self-management strategies. While doing so, they faced significant barriers, including service gaps and inadequate direct care.

DISCUSSION AND IMPLICATIONS

The findings suggest further research to explore long-term care policy change that is needed to provide comprehensive health and medical services and adequate direct care in these facilities. The importance of establishing various types of long-term care facilities is also highlighted.

The Quality of Caregivers for the Elderly in Long-Term Care Institutions in Zhejiang Province, China

China is facing challenges in caring for older adults. This paper aimed to understand knowledge, attitude, and practice (KAP) regarding the quality of caregivers for the elderly in long-term care institutions in Zhejiang Province, and also to find related factors to improve the quality of caregivers. A cross-sectional survey was conducted from April to June 2016 in Zhejiang Province. In total, 84 caregivers were interviewed face-to-face with questionnaires on KAP towards elderly care. Multiple linear regression was used to find the related factors to KAP. A conceptual model was made to process path analysis among KAP and influencing factors using structural equation modeling. The study found that most caregivers in Zhejiang Province were middle-aged, female, and with a diploma below middle school. Many caregivers had not received any pre-employment training. Their salary was low although they undertook high-intensity work. Education and working years had a positive effect on knowledge and practice scores, and pre-employment training had a positive effect on knowledge and attitude scores. Knowledge and attitude regarding elderly care could positively affect elderly care practices. The quality of caregivers in Zhejiang Province was at a low level compared to developed countries. Continuous and regular elderly care training should be provided for caregivers to improve their elderly care knowledge and hence the quality of elderly care.

Development of a quality of life questionnaire for nursing home residents in mainland China

OBJECTIVE

To develop and validate a quality of life (QOL) questionnaire for nursing home (NH) residents in mainland China.

METHODS

A cross-sectional study including a development sample (n = 176) and validation sample (n = 371) of NH residents aged 60 and older was conducted between 2015 and 2016 in Jinan, Shandong Province, China. Resident interviews, literature reviews, expert panels, and pilot studies were used to identify QOL domains and items pertinent to NH life. Exploratory and confirmatory factor analysis were used to develop and validate a QOL questionnaire. Reliability (internal consistency, spilt-half reliability, and test-retest reliability) and validity (construct and criterion validity) were evaluated for the questionnaire.

RESULTS

The self-report Chinese NH QOL questionnaire had 9 domains and 38 items including physical health (4 items), food enjoyment (6 items), security (3 items), environmental comfort (5 items), autonomy (2 items), meaningful activity (3 items), interrelationship (6 items), family relationships (3 items), and mood (6 items). The nine-factor model was confirmed with the following fit indices: χ²/df = 1.872, root mean square error of approximation = 0.049, comparative fit index = 0.913, and Tucker-Lewis index = 0.903. The 38-item NH QOL questionnaire showed satisfactory construct validity, criterion validity, internal consistency (Cronbach's alpha = 0.89, spilt-half reliability = 0.73, test-retest reliability = 0.76).

CONCLUSIONS

The NH QOL questionnaire appears to be a reliable and valid instrument and should be incorporated into a set of quality measures for use with NH residents in mainland China.

Aged care clinical mentoring model of change in nursing homes in China: study protocol for a cluster randomized controlled trial

Background

Residents living in nursing homes usually have complex healthcare needs and require a comprehensive care approach to identifying and meeting their care needs. Suboptimal quality of care is reported in nursing homes and is associated with the poor health and well-being of the residents, the burden on acute care hospitals and the high costs of healthcare for the government.

The aim of this study is to test the hypothesis that an Aged Care Clinical Mentoring Model will create and sustain evidence-based quality improvement in priority areas and will be cost-effective in nursing homes in Hunan Province, China.

Methods

A cluster randomized controlled trial will be applied to the study. Fourteen nursing homes will be randomly allocated to either the intervention group (n = 7) or the control group (n = 7). Forty staff will be recruited from each nursing home and the estimated sample size will be 280 staff in each group. The intervention includes a structured, evidence-based quality improvement education program for staff to facilitate knowledge translation in evidence-based quality improvement targeting urinary incontinence, pressure injury and falls prevention. The primary outcomes are nursing homes’ capacity to create and sustain quality improvement, staff perceptions of person-centered care, self-reported quality of care by residents and selected quality indicators at 12 months follow-up adjusted for baseline value. Secondary outcomes are residents’ quality of life, residents’ unplanned admissions to acute care hospitals, quality of care reported by staff, staff job satisfaction and staff intention to leave adjusted for baseline value. A mixed linear regression model will be adopted to compare the significant differences between groups over a 12-month period.

Discussion

Although the Aged Care Clinical Mentoring Model has been tested as an effective model to bring positive changes in nursing homes in a high-income country, factors affecting the adaptation of the model in nursing homes in low- and middle-income countries are unknown. The carefully planned intervention protocol enables the project team to consider enablers and barriers when adapting the Model. Therefore, strategies and resources will be in place to manage challenges while demonstrating best practice in this study.

Trial registration

Prospectively registered via Chinese Clinical Trial Registry (ChiCTR), ChiCTR-IOC-17013109, Registered on 25 October 2017.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3596-6) contains supplementary material, which is available to authorized users.

What factors influence older people's intention to enrol in nursing homes? A cross-sectional observational study in Shanghai, China

OBJECTIVES

Given the increasing need of long-term care and the low occupancy rate of nursing homes in Shanghai, this study attempts to explore what factors influence older people's intention to enrol in nursing homes.

DESIGN

A cross-sectional observational study based on the theory of reasoned action was conducted. Survey data were collected from subjects during face-to-face interviews. Structural equation modelling was employed for data analysis.

SETTING

This study was conducted in six community health service centres in Shanghai, China. Two service centres were selected in urban, suburban and rural areas, respectively.

PARTICIPANTS

A total of 641 Shanghai residents aged over 60 were surveyed.

RESULTS

Structural equation modelling analysis showed that the research model fits the data well (χ²/df=2.948, Comparative Fit Index=0.972 and root mean squared error of approximation =0.055). Attitude (β=0.41, p<0.01), subjective norm (β=0.28, p<0.01) and value-added service (β=0.16, p<0.01) were directly associated with enrolment intention, explaining 32% of variance in intention. Attitude was significantly influenced by loneliness (β=-0.08, p<0.05), self-efficacy (β=0.32, p<0.01) and stigma (β=-0.24, p<0.01), while subjective norm was significantly influenced by life satisfaction (β=-0.15, p<0.01) and stigma (β=-0.43, p<0.01).

CONCLUSIONS

This study advances knowledge regarding the influencing factors of older people's intention to enrol in nursing homes. It suggests that Chinese older persons' perceived stigma has the strongest indirect effect on their intention to enrol in nursing homes. This is unique to the Chinese context and has practical implications for eldercare in China and other Asian countries with similar sociocultural contexts.

Quality Changes after Implementation of an Episode of Care Model with Strict Criteria for Physical Therapy in Ontario's Long-Term Care Homes

OBJECTIVES

To describe the proportion of residents receiving rehabilitation in long-term care (LTC) homes, and scores on activities of daily living (ADL) and falls quality indicators (QIs) before and after change from fee-for-service to an episode of care model; and to evaluate the effect of the change on the QIs.

DATA SOURCES

Secondary data were collected from all LTC homes in Ontario, Canada, between January 1, 2011 and March 31, 2015. Variables of interest were the proportion of residents per home receiving physical therapy (PT), and the scores on seven ADL and one falls QI.

STUDY DESIGN

Retrospective, longitudinal study.

DATA EXTRACTION

All data were extracted from the Resident Assessment Instrument Minimum Data Set.

PRINCIPAL FINDINGS

Fewer residents received PT after the policy change (84.6 percent, 2011; 56.6 percent, 2015). The policy change was associated with improved performance on several ADL QIs. However, having a large proportion of residents receive no PT or little PT was associated with poorer performance on two of the QIs measuring improvement in ADLs [No PT: -0.029 (-0.043 to -0.014); -0.048 (-0.068 to -0.027). PT <45 minutes per week: -0.012 (-0.026 to -0.002); -0.026 (-0.045 to -0.007); p < .01].

CONCLUSIONS

While controversial, the policy and subsequent PT service delivery change appears to be associated with improved performance on several ADL QIs, except in homes where a large proportion of residents receive no PT and low time-intensive PT.

Care services for elderly people with dementia in rural China: a case study

Objective

To determine the state of the health and supportive services available to elderly people with dementia – and their families – in rural Lanxi county, in the province of Zhejiang, China.

Methods

In November 2014 and January 2015, we interviewed 14 key informants on dementia care face-to-face, using a semi-structured questionnaire. The informants included three rural physicians, an urban geriatrician, seven directors of institutions for the care of the elderly and three officials of the civil affairs bureau. We also completed in-depth interviews with five family caregivers of elderly people with dementia.

Findings

The interviewees indicated that there was a lack of specialized services designed specifically to address the needs of individuals with dementia and their family members. Non-psychiatric medical services and the available facilities for long-term care appeared to be ill-equipped to manage these needs. They lacked both clinical staff and standardized, evidence-based practices for the diagnosis, care, treatment and rehabilitation of patients with dementia. As care facilities often refused to admit elderly people with dementia, families were generally forced to care for elderly relatives with dementia at home.

Conclusion

In Lanxi county – and probably in much of rural China – more public resources are needed to support family caregivers and to improve the capacity of care facilities for the elderly to care for individuals with dementia.

The "leap forward" in nursing home development in urban China: future policy directions

In the past decade, the number of nursing beds in China has increased annually by an average of 10%, reaching 4.3 million in 2013. Although the State Council pushed for further increases to a ratio of 30 nursing home beds per 1000 persons by 2015, service utilization, quality assurance, and regulatory oversight are the inherent challenges in developing an equitable long-term care (LTC) system that can safeguard older persons' rights. We review and analyze both laws and policies in light of demographic and socioeconomic changes and advocate 3 policy directions for LTC development in China: allocating LTC resources with comprehensive eligibility criteria, with particular consideration of family needs; establishing viable quality standards for outcome-driven evaluation; and highlighting standardized monitoring mechanisms in both institutional and home LTC settings.

Changes of Health Status and Institutionalization Among Older Adults in China

OBJECTIVE

To examine rates of institutionalization of Chinese older adults aged 65+ and the impact of changes in health status on the likelihood of institutionalization.

METHOD

Using data from the 2002, 2005, 2008, and 2011 waves of the Chinese Longitudinal Healthy Longevity Survey (CLHLS), admission rates for each 3-year interval between waves were calculated. Logistic regression models were used to assess the changes of five health status variables as risk factors.

RESULTS

Between the first (2002-2005) and third (2008-2011) intervals, the institutionalization rate increased from 0.5% to 0.8%. Risk of institutionalization increased 70% for respondents with declining ability to perform activities of daily living, 53% for those with declining cognitive function, and 44% for those with increasing number of chronic diseases.

DISCUSSION

Development of policies and programs to improve older adults' health status is essential to delay institutionalization. Quality of workforce is also critical in meeting the care needs.