The Impact of Long-Term Care Policy on
Caregiving Hours and Labor Force Participation
in Singapore
David Matchar, John Ansah, Sean Love, Young Do, Kelvin Foo, Rahul Malhotra,
Angelique Chan, Robert Eberlein
Department: Health Services and Systems Research Program
IFA’s 11th Global Conference on Ageing | Prague, Czech Republic | 31 May 2012
Singapore
• Population: 5,183,700
– Citizens: 3,257,000
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•
•
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77% Chinese, 14% Malay, 8% Indian
GDP Per Capita: $59,900 USD (5th)
Median age: 40.1 years
Total fertility rate: 1.20
Life expectancy at birth: 83.75
Public health expenditure: 4% GDP
Unemployment: 2%
CIA World Factbook 2012, SingStat 2012
2
Background
• By 2030, the proportion of elderly Singaporeans (≥65
years) is expected to reach 19%
• The prevalence of disability (≥1 ADL limitation)
among older Singaporeans is 10.8%
• Demand for long-term care (LTC) is expected to
increase
• Meanwhile, the resident workforce is expected to
contract
Asher et al 2008, Ducanes et al 2008, Koh 2007
3
LTC Services in Singapore
Formal LTC Options
Institutionalized
Residential Care
Community Hospitals
Nursing Homes
Chronic Sick Facilities
Respite Care
Hospice Inpatient Care
Community-Based
Services
Center-Based Services
Day Rehabilitation
Dementia Day Care
Psychiatric Day Care
Hospice Day Care
Home-Based Services
Medical/Nursing Services
Home Help
Hospice Care
Home Therapy
4
Who Are the Providers of LTC in Singapore?
Family
• Main provider of
care for the
elderly
• Sometimes
assisted by
foreign domestic
workers (FDWs)
Voluntary Welfare
Organizations
(VWOs)
• Partiallysubsidized
nursing homes
and community
care services
Private Sector
• Full fee hospitals
and nursing
homes
State
• Finances
intermediate and
LTC
• Provides
subsidies for
VWOs
5
LTC Policy
• “Ageing in place”
– Limited access to nursing homes
– Maintain frail elderly at home
• Promote home and community-based services
• Grants for eligible households w/ frail elderly to employ FDW
• Potential consequences?
– Increased burden (care hours) on families and caregivers
• Caregiver depression
• Increased caregiver healthcare utilization
• Reduced caregiver labor force participation
Ministry of Community Development, Youth and Sports 2008/2009, 2012, Khalik 2012
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Research Question
Given the growing population of
ADL-limited elderly, what is the
projected impact of LTC policy on
caregiving hours and labor force
participation in Singapore?
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Methods
1. Developed a preliminary System Dynamics (SD)
model of LTC in Singapore
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SD is a methodology for modeling dynamic problems
Admits many variables, causal factors, incorporates feedback
loops, policy levers
2. Presented model to LTC stakeholders for critique
and for help identifying policy levers
3. Formulated and parameterized model to simulate
observed system behavior
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Constructing the LTC Model
1. Generate projection of ADL-limited elderly
population
–
Look at number of people becoming 65, use prevalence of
ADL-limitations, and mortality data
2. Simulate use of community and institutional
services
–
Incorporate referral and uptake rates, number of elderly living
at home with and without services, use of nursing homes, etc.
3. Add capacity constraints, model inputs, policy levers
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Inputs
Value
Source
Proportion of families with FDW
helping with eldercare
0.3
Author estimate using SSIC data
Proportion of elderly Singaporeans
with institutional care needs
0.03
Singapore Ministry of Health
Primary caregiver hours for elderly
residing in a nursing home
0
Author estimate
Attractiveness of HCBS (proportion of
referrals accepted by elders and their
families)
0.2
Estimated with help of stakeholders
Current nursing home beds (2012)
9,900
Singapore Ministry of Health
Proposed nursing home capacity
needs
Year:
Beds:
2020
14,900
2030
22,400
Inter-Ministerial Committee on
Health-care for the Elderly: 1999
(Report)
10
Inputs: Average Total Care Hours for People
with ADL Limitations
120
109
97
100
85
Hours/Week
80
60
40
20
0
1-2 ADL Limitations
3-4 ADL Limitations
5-6 ADL Limitations
Source: Singapore Survey on Informal Caregiving
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Results: Projected Number of ADL-Limited
Elderly Needing Human Assistance
70,000
60,000
Person
50,000
40,000
Total
5-6 ADL Limitations
30,000
1-2 ADL Limitations
3-4 ADL Limitations
20,000
10,000
0
2010
2012
2014
2016
2018
2020
Year
2022
2024
2026
2028
2030
12
Policy Levers
1. Attractiveness of home and communitybased services (HCBS)
2. Fraction of families with a foreign domestic
worker (FDW)
3. Nursing home capacity
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Results: Average Primary Caregiver Hours by
ADL Limitations of Care Recipients
70
65
60
55
51
50
46
Hours/Week
43
40
53
36
30
20
10
0
1-2 ADL Limitations
No Policy or Capacity Changes
3-4 ADL Limitations
Double Proportion of Families with FDW
5-6 ADL Limitations
Double Attractiveness of HCBS
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Results: Projected Number of Primary
Caregivers
60,000
50,000
Person
40,000
30,000
20,000
10,000
2010
2012
2014
2016
2018
No Policy or Capacity Changes
2020
Year
2022
2024
2026
2028
2030
Planned Nursing Home Bed Capacity
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Results: Primary Caregivers Likely to Drop Out
of the Labor Force
13,000
11,000
Person
9,000
7,000
5,000
3,000
2010
2012
2014
2016
2018
2020
Year
2022
2024
2026
No Policy or Capacity Changes
Double Attractiveness of HCBS
Planned Nursing Home Bed Capacity
Double Proportion of Families with a FDW
2028
2030
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Results: Percentage of Primary Caregivers Likely
to Drop Out of the Labor Force by 2030
Policy:
No policy or capacity changes
Percentage:
38%
Double attractiveness of HCBS
Double proportion of families with a FDW
37%
33%
Planned nursing home bed capacity
28%
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Conclusions
• By 2030, elderly requiring human assistance will nearly triple
• The number of caregivers likely to drop out of the labor force is
expected to rise
– All considered policies would reduce caregiver burden and help keep
caregivers employed
– Second to expanding nursing home capacity, increasing the proportion
of families with a FDW has the greatest impact
• Additional challenges may include:
– Financial hardship for caregivers as result of withdrawing from labor
force
– Caregiver depression
– Increased caregiver healthcare utilization
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Thank You!
[email protected]
www.duke-nus.edu.sg
Appendix I: Projecting the size of the ADLlimited elderly population
becoming 65
Population 65+
deaths
population 65+ with
no ADL limitation
ADL incidence
mortality rate
Population 65+ with
ADL limitation(s)
deaths from ADL
pop
incidence rate
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Appendix II:
LTC Model
effect of carehours
demand on HCBS uptake
rate
referral rate
mortality rate
attractiveness of home and
community-based services
(HCBS)
uptake rate
available HCBS
capacity
demand for HCBS
deaths
HCBS gap
capacity HCBS
total care hours home
without services
incidence ADL
total care hours home
with services
Elderly at Home
without Services
carehours nursing
home
fraction of families
with FDW
net change
demand for
nursing home
deaths from
HCBS
admission to nursing
home HCBS
admission to
nursing home
indicated family
eldercare hours
fraction care hours by
FDW
to HCBS
Elderly at Home
with Services
Elderly in Nursing
Home
mortality rate HCBS
deaths nursing
home
nursing home capacity
Family Eldercare
Hours
effect of carehours
on demand
gap
available nursing
home beds
mortality rate
nursing home
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Appendix III: Limitations
• Some inputs were based on survey data from an
older population
• The use of mean values to represent the population
may under or over-estimate certain values
• The outcome values are only as reliable as the
Singapore population projections
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Appendix IV: Total Work Hours Lost to
Caregiving of Those Who Stay Employed
210,000
190,000
Hours/Week
170,000
150,000
130,000
110,000
90,000
70,000
50,000
2010
2012
2014
2016
2018
2020
Year
2022
2024
2026
No Policy or Capacity Changes
Double Attractiveness of HCBS
Planned Nursing Home Bed Capacity
Double Proportion of Families with a FDW
2028
2030
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