A Proposal for a Voucher System for Long-Term Care in Hong Kong

Experience of a demand-side subsidy scheme for residential long-term care: perspectives of elderly and their carers

BACKGROUND

Vouchers, which are demand-side subsidies to targeted groups, are a type of consumer-led near-cash social transfer for specified benefits that have been used in education, health and other sectors. To provide better access to residential care services and an additional choice for elderly people in need, a novel means-tested residential care service voucher has been introduced in Hong Kong for elderly people to purchase places in the private sector to enable consumer-directed care. The objectives of this paper are to analyze the perspectives of voucher users and their carers toward the voucher scheme and to identify key elements in the design that will contribute to meeting the scheme's objectives.

METHODS

An exploratory sequential mixed method design was adopted with initial explorative qualitative data collection of the perspectives of elderly people and their carers (Phase 1), which informed the design of the subsequent questionnaire survey (Phase 2). Thirty carers in 5 focus groups and 20 individual interviews with elderly people were conducted between April and May 2018. A total of 401 respondents (373 carers and 28 elderly people) completed the survey questionnaire. Findings from both phases were integrated both narratively and via a joint display.

RESULTS

Five key themes summarized the features in two main elements of the design and implementation of the voucher scheme: awareness, meaning that inadequate knowledge and understanding of voucher schemes hinder participation; service needs and types, indicating that the urgent need for residential care services is the key reason for participation; shared responsibility, meaning that a high copayment level discourages participation; choice and flexibility, reflecting appreciation of the additional choices provided by voucher schemes although the availability of residential care beds limits choices; and service quality, indicating mixed perceptions of service quality and the impact of the voucher scheme. Voucher users believe that the voucher scheme is more helpful for relieving the financial burden (98.7%), reducing carers' stress (97.0%) and reducing the waiting time for subsidized homes for elderly people (89.0%) than for increasing choice and flexibility (78.1%) and improving service quality (62.1%).

CONCLUSIONS

This study demonstrates how the design of a voucher scheme affects its take-up by targeted beneficiaries. When a voucher scheme is implemented in a long-term care system, it must consider the congruence with existing policies in long-term care provision and financing. The voucher scheme in Hong Kong has been able to generate the utilization of nonsubsidized places in homes for elderly people that were underutilized, but its effectiveness is limited by inadequate knowledge and understanding of the voucher scheme and the availability of residential care places. Giving the purchasing power and choice of providers to beneficiaries has the potential to enhance the quality of services, which will contribute to meeting the objectives. The study findings carry significant implications for long-term care policies and provide insights into the key features of the voucher scheme for residential care services and how to best design and implement a voucher scheme for elderly people in the context of policy objectives and a long-term care policy.

An evaluation of the pilot scheme on community care service vouchers for the elderly in Hong Kong

The Pilot Scheme on Community Care Service Vouchers for the Elderly (CCSVs) from 2013 onward aims at empowering users with autonomy in choosing services and service providers, enhancing financial sustainability of community care services (CCSs) and encouraging participation by service providers. This article analyses the effectiveness of the CCSVs in terms of utilization rate, attrition rate and reasons for withdrawal, and provides sound short-, medium- and long-term recommendations for CCSs. Secondary data from the annual survey conducted by the Social Welfare Department with all voucher holders in the first (2013-2017) and second phases (2016-2020) were used. The utilization rate of the CCSVs in the first phase was satisfactory, but the second phase was constrained by a low utilization rate, as 17%-35% of the CCSV holders did not use their vouchers to purchase CCSs. Moreover, the high attrition rate of CCSV holders in both phases warrants special attention.

Preference of caregivers on residential care homes for older persons with versus without communication problems: a discrete choice experiment

Background

A residential care service voucher scheme has been introduced to expand the capacity and enhance choice of public-funded long-term care (LTC) in Hong Kong, enabling users to have greater choices over the types of LTC facilities. Older persons with communication problems have difficulties in understanding the care options available to them and expressing their preferences to care homes and daily service delivery, therefore hindering their ability to exercise control and choice. Thus, they may have different needs and preferences for the facilities than others due to their conditions. This study therefore aimed to investigate their preference for care homes in comparison with those without communication problems.

Methods

A discrete choice experiment was conducted to elicit preference for six attributes derived from prior studies. The family caregivers of a random sample of older voucher holders were invited to undertake face-to-face interview. Willingness-to-pay (WTP) for the attributes was estimated for those with or without communication problems separately.

Results

Two hundred eighty-three caregivers provided valid responses (74% response rate). Caregivers of those with communication problem preferred facilities operated by non-governmental organizations (WTP=HK$1777.4) and shorter travelling time (WTP=HK$1502.5 for <=0.5 hours), while those without the problem had greater preference for fewer roommates (WTP=HK$3048.1 for single room) and extra healthcare professionals (WTP=HK$1765.5). Heterogenous WTPs were identified from those with different income, marital status and caregivers’ age.

Conclusions

The reputation, greater space and staff, and proximity/familiarity of the facilities were important for those with communication problems. To help meet these preferences, the facilities could establish collaborations with local community-based service providers and build their own outreach team to familiarize themselves with older persons. Additionally, household income and informal support availability should be considered for care planning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03073-9.

Preference of Older Adults for Flexibility in Service and Providers in Community-Based Social Care: A Discrete Choice Experiment

Empowerment of control and choice of the service users in health and social care has been incorporated into service provision in various countries. This study aimed to elicit the preference of community-based long-term care (LTC) service users on levels of flexibility in service provision. A discrete choice experiment was performed among older community care service users to measure their preference for attributes of LTC services identified from a prior qualitative study. Each participant was asked to make choices in six choice tasks with two alternatives of hypothetical LTC services that were generated from the attributes. A generalized multinomial logistic model was applied to determine the relative importance and willingness to pay for the attributes. It found that the participants preferred multiple flexible providers, determining services by themselves, meeting case managers every month and social workers as sources of information on service provision. Significant preference heterogeneity was found for flexibility in providers and flexibility in services between those with and without activity of daily living impairment. The findings highlighted the preference of older adults for greater flexibility in LTC, while they rely heavily on social workers in decision making. The enhancement of flexibility in LTC should be supported by policies that allow the older service users to make decisions based on their own preferences or communication with social workers instead of determining the services and providers for them. Options should be offered to users to decide their preferred level of flexibility to better reflect their divided preferences.

What Affects the Demand for Long-Term Care Insurance? A Study of Middle-Aged and Older Adults in Hong Kong

Despite the potential of private insurance in financing long-term care (LTC), its coverage remains rather limited. This study is built on a comprehensive framework to examine the demand for LTC insurance in Hong Kong, a rapidly aging Asian society. A telephone survey was conducted in 2016 to collect data that formed a sample of 1,474 middle-aged and older adults. Multivariate analysis reveals more nuanced characteristics of Hong Kong middle-aged and older adults who tend to show a demand for LTC insurance, including: (a) being younger, better educated, relatively high status, and financially literate; (b) living with children but reluctant to be a burden on the family; (c) being in a better financial situation and able to afford premiums; and (d) anticipation of LTC needs and dependence, and a preference for formal care. This study offers preliminary evidence to understand the demand structure of the LTC insurance market in an Asian society.

Long-term care service needs and planning for the future: a study of middle-aged and older adults in Hong Kong

Long-term care (LTC) planning is important in helping the older people tackle their future needs better. The needs for LTC services represent generational characteristics as they may be different between the current and upcoming cohorts of older adults. However, very few studies have examined the cohort differences in terms of their expected utilisation of LTC services, while understanding the patterns is crucial in helping policy makers prepare for the development of LTC services. This study fills the research gap by examining the plans and expectations for LTC services of 1,613 middle-aged and older persons in Hong Kong with data collected from a telephone survey. By applying the Andersen Model to examine LTC expectations, this study analyses the LTC needs and plans of the middle-aged and older cohorts of Hong Kong adults, as well as their associated factors, with a multiple logistic regression method. Both gender and birth cohort were examined individually and in combination. Birth cohort and gender have been found to exert an impact on all aspects of LTC needs and planning to varying degrees. The findings are interpreted and contrasted with those of a key study based in the West, with reference to the contextual characteristics of Hong Kong. This study furthers the scholarly understanding on LTC needs and planning and their cohort effect, and draws evidence-based recommendations for LTC development in Hong Kong, a rapidly ageing East Asian society.

Applying Resource Utilization Groups (RUG-III) in Hong Kong nursing homes

Resource Utilization Groups III (RUG-III) is a case-mix system developed in the United States for categorization of nursing home residents and the financing of residential care services. In Hong Kong, RUG-III is based on several board groups of residents. The aim of this study was to examine the reliability and validity of the RUG-III in Hong Kong nursing homes. A cross-sectional survey was conducted in seven residential facilities operated by one agency. Residents ( N = 1,127) were assessed by the Minimum Data Set (MDS) and nursing as well as auxiliary staff care times were recorded within 2 weeks before or after the completion of MDS assessment. Forty-five out 1,127 residents were re-interviewed by an independent assessor to assess the inter-rater reliability. The inter-rater reliability of MDS assessment was excellent (kappa = 0.76) and the original RUG-III accounted for about 30 per cent of nursing staff time. Results provide preliminary evidence to support that RUG-III is a reliable and valid case-mix system for Hong Kong nursing homes, but future studies must be explored to reduce the variance of resource use explained by this case-mix system.

Disability trends in Hong Kong community-dwelling Chinese older adults: 1996, 2000, and 2004

OBJECTIVE

This article examines the trends of disability in six activities of daily living (ADLs) among Hong Kong community-dwelling older adults during the period from 1996 to 2004 by using three independent cross-sectional surveys of representative samples.

METHOD

Logistic regression was performed to assess the association between the year of survey and the presence of any ADL limitation with a wide range of covariates.

RESULTS

We found that older adults in 2004 were more likely to report ADL disability than their counterparts in 1996, and the results would remain valid after considering the prevalence of ADL disability in nursing home residents. In addition, we found that age, education, the use of proxy, and the presence of six medical conditions were significantly related to ADL limitation.

DISCUSSION

In general, public health efforts to prevent ADL limitation should be supported to reduce the demand for long-term care services in the coming decades.