Determinants of Use of Community‐Based Long‐Term Care Services

To the Editor: Singapore, like many Asian countries, is rapidly aging, and the government is accelerating the development of long-term care (LTC) services. Determinants of health services use offer insights into characteristics of users and ways to assist nonusers.1 Care recipients' age and disability status2, 3 are shown to be important determinants of LTC use. Families are the foundation of LTC. Formal LTC may complement family care or provide respite to family caregivers. Qualitative studies suggest that psychosocial factors,4, 5 caregiver needs, and ability to undertake informal care are determinants of formal LTC use.6, 7 The importance of these factors needs to be confirmed in quantitative studies. In Singapore, a national agency assesses people and refers them to specific LTC services. The assessment considers the care recipient's disability and needs and the availability of a family caregiver but not the needs of family caregivers. Nursing homes record high occupancy, but utilization rates by people referred to community-based LTC (CBLTC—day rehabilitation, dementia day care, home medical, home nursing, home therapy) are lower than in the West.5 To understand how formal CBLTC can complement family care, a cross-sectional study of the determinants of CBLTC use was conducted in a population of older people assessed and referred to CBLTC services. This study used baseline data from the Singapore Longitutidinal Survey for LTC Use conducted from December 2011 to December 2013. The study population was a representative sample of 4,402 people from the national referral database. The baseline survey comprised 1,416 respondents (546 care recipients, 870 proxies of care recipients, 1,333 caregivers) who made the decision whether to use the referred CBLTC services between December 2011 and July 2012. Andersen's Model for LTC Use4 was modified by adding caregiver factors.5, 7 The relationship between CBLTC use and care recipient and caregiver predisposing factors, need and enabling factors, and psychosocial factors were examined using logistic regressions. Stratified analyses for use of center-based services (day rehabilitation, dementia day care) and home-based services (home medical, nursing, physical therapy, occupational therapy) were also conducted. The results showed that care recipient age, housing type, education, income, availability of medical savings account, and activities of daily living and caregiver age, sex, living arrangement, social support needed, and working status were significantly associated with the use of CBLTC. These factors also differ across services (Table 1). The main finding of this study was that enabling and need but not psychosocial factors are significant determinants of CBLTC use in Singapore. The finding also highlights the importance of caregiver-related factors. Enabling factors that influenced CBLTC use were higher care recipient education and household income, higher caregiver socioeconomic status, and care recipient living arrangement (co-residence of caregiver and care recipient; household of three or more other family members). That co-residence of care recipient and caregiver influenced CBLTC use confirms that the services complemented family care.5 Policy to support co-residence of older adults with their children (especially for small families) or senior housing can enhance use of CBLTC. Older people who lived alone were more likely to use center-based LTC (Table 1). It is likely that these people welcomed the opportunity for social interactions at these centers.5 The use of home care services is associated with higher household income, and the use of center-based care is associated with care recipients having personal national medical saving accounts (or Medisave, Table 1). Unlike day care services, home care users could not use these savings to offset service fees. This may explain why the use of home care services is associated with higher household income. There is heavy reliance on informal LTC by mainly female family caregivers in Singapore.8 Care recipients younger than 65 and those with female caregivers were more likely to use center-based LTC. Because of other commitments, younger caregivers experienced more stress.8 The only caregiver need associated with use of center-based care was their need for social support. This finding suggests the need for formal caregiver support services to moderate the negative effect of caregiving9 and better complement family care. Center-based care can also offer caregiver services such as befriending, support groups, and self-care and management to better support family caregivers. Improvement in LTC financing can also assist payment for CBLTC and support informal caregiving. In 2013, elderly policy offices in Singapore were consolidated from separate government ministries to the health ministry. Agencies that plan and fund services were also integrated.10 This should offer greater opportunities for accessible and innovative services where care recipients and families are perceived as partners in LTC. This study was funded by a grant from the Agency for Integrated Care. Conflict of Interest: Shiou-Liang Wee and Wayne Freeman Chong were employed by the Agency for Integrated Care Pte Ltd which funded the study. Shiou-Liang Wee was the Head of Research until October 2013 and Wayne Freeman Chong was senior research analyst at the Agency for Integrated Care. Amudha Aravindhan was partially supported by the grant from Agency for Integrated Care. None of the other authors had any other conflict of interest. Author Contributions: Shiou-Liang Wee contributed to the original study design, supervised survey data collection and analyses, interpreted the data, and wrote and revised the manuscript. Chang Liu performed the analyses, interpreted the data, and revised the manuscript. Wayne Freeman Chong and Amudha Aravindhan contributed to the original study design and performed the data management. Soon-Noi Goh contributed to the original study design and literature review and interpreted the data. Angelique Chan contributed to the original study design, supervised data collection and analyses, interpreted the data, and revised the manuscript. Sponsor's Role: None.