课件文稿案例chang liu cuhk presentation

1、Planning for the Aging Population:Community Based Long-Term Care Services and Care Integration in SingaporeChang LiuAssistant Professor, Program in Health Services & Systems Research Managing Director, ACCESS Health InternationalEmail: .sgApril 16, 2015 The Chinese University of

2、 Hong KongMy Research InterestsHealth Insurance Policy and Financial IncentivesLong-Term Care and Elder Care PolicyDecision AnalysisFinancial Economics: Profit Maximization Health Economics: Cost-effectiveness Social WelfareUncertaintyInformation AsymmetryPrincipalAgent ProblemMy Research InterestsO

3、utlineDemographic challenges of agingSingapores “whole-government effort” approachExamples of research studies Demographic ChallengesLower fertilityIncreased longevityLater marriageHigher rate of non-marriage and divorce Source: World Population Prospects: The 2010 Revision, Demographic ChallengesTh

4、e number and proportion of highly disabled elderlies are rising.5-7 ADL limitations3-4 ADL limitationsSource: Ansah JP, Matchar DB, Love SR, et al. 2013.1-2 ADL limitationsDemographic ChallengesThe number and proportion of highly disabled elderlies are rising.Family are getting smaller1-2 ADL limita

5、tionsSource: Ansah JP, Matchar DB, Love SR, et al. 2013.Demographic ChallengesThe number and proportion of highly disabled elderlies are rising.Family are getting smallerMore caregivers will have significant depression attributable to caregivingSource: Malhotra C, Malhotra R, stbye T,et al. 2012.1-2

6、 ADL limitationsIndividuals with depression attributable to caregivingIndividuals with depression irrespective of caregivingSource: Straits Times.PolyclinicSpecialtyOutpatientClinicAcute HospitalCommunity ServicesGeneral PractitionerHow much can the system handle? Temporary beds in air-conditioned t

7、ent Changi General OutlineDemographic challenges of agingSingapores “whole-government effort” approachExamples of research studies Singapores ApproachInter-ministerial Committee on AgingCulture, Community, and YouthHealthTransportationHousingManpowerFinanceA Framework for Addressing the ChallengesPo

8、lyclinicSpecialtyOutpatientClinicAcute HospitalCommunity servicesGeneral PractitionerService integrationTransitionalcareCommunity ServicesGeneral PractitionerPolyclinicSpecialtyOutpatientClinicAcute HospitalEnhancedCommunity servicesSelf-careFamily Medical Clinic/CommunityHealth CenterAgency for Int

9、egrated CareAging In Place (AIP)Transitional Care Program (TC)Care Integration and Continuous of Care The Agency of Integrated Care (AIC): Linkage to services; information and facilitation; access to financial aidSilver page: Hospital-initiated or community-based innovation care models Examples incl

10、ude aging in place (AIP) program, transitional care (TC) program, and care coordinators (CC) in the hospitals, etc. Transforming to regional healthcare systemsRegional Healthcare SystemsGeneral HospitalCommunity HospitalsSpecialty Outpatient ClinicsPolyclinicsPrivate PractitionersVoluntary Welfare O

11、rganizationsOutlineDemographic challenges of agingSingapores “whole-government effort” approachExamples of research studies A Study to Understand Singaporeans Attitudes Towards Long Term Care (LTC) ServicesStudy BackgroundLong-Term Care Service (LTCS) utilization is low compared to Western societies

12、1AIC: take-up rate for some community services is less than 50%Koh GC-H, et al, 2012; Wee, Liu et al. 2014. William Haseltine, Affordable Excellence: the Singapore Healthcare Story, 2013.Khiaocharoen et al, 2012; Saka et al, 2009; Yuan et al, 2014Study BackgroundLong-Term Care Service (LTCS) utiliza

13、tion is low compared to Western societies1AIC: take-up rate for some community services is less than 50%Governmental investments on formal LTCSProvide higher subsidies in 2012Invest S$ 500 million on eldercare facilities from 2013-16 Add 3000+ NH beds by 20161Planned to increase NH beds by 70% by 20

14、20 from 9,000 today to 15,6002Pioneer Package provides cash payments for individuals with ADL deficitsShould we promote take-up LTCS?Limited information and awareness of the servicesLTCS can be cost-effective for the society3 but incentives may be misalignedKoh GC-H, et al, 2012; Wee, Liu et al. 201

15、4. William Haseltine, Affordable Excellence: the Singapore Healthcare Story, 2013.Khiaocharoen et al, 2012; Saka et al, 2009; Yuan et al, 2014Study Design A Longitudinal study Dyads of Care Recipients (CR)/Proxies and their Caregivers (CG)Three waves over a 12-month periodStratified sampling by:Serv

16、ice types - Day Rehabilitation, Dementia Day Care, Home Medical, Home Nursing, Home Therapy, and Nursing HomeSocio-economic characteristics Seven Mosaic Singapore groups*Overall Response Rate in Wave 1: 43% Loss to follow-up rate of Wave 1 cohort in Wave 2: 30% Loss to follow-up rate of Wave 2 cohor

17、t in Wave 3: 36%Gathered information on both CR and CG: demographic, health status, financial resources, living arrangement, knowledge and awareness, etc* Mosaic Singapore is a geo-demographic consumer segmentation system, developed based on more than 20 years of segmentation development expertise.

18、It classifies all Singapore households and neighborhoods into 7 groupings that share similar demographic and socio-economic characteristics. It paints a rich picture of Singapore consumers in terms of their socio-demographics, lifestyles, culture and behaviors.Specific AimsTo identify factors Influe

19、ncing on Referred Service Utilization.To study the relationship between perception of long term care services and Referred Service Utilization. To evaluate the impact of Referred Service Utilization on Caregivers Health es.To examine the impact of Referred Service Utilization on Care Recipients Heal

20、th.Majority of Participants Used Formal LTC Services (Wave 1)Referred ServicesCenter-BasedHome-BasedNursing HomeCurrent UseNone163 (21.7%)113 (19.4%)9 (5.3%)Informal LTC ServicesMaid86 (14.5%)73 (12.5%)0Family and Friends72 (9.6)%48 (8.2%)7 (4.1%)Formal LTC ServicesNursing Home2 (0.3%)9 (1.5%)152 (8

21、9.9%)Home-Based1 (0.1%)337 (57.8%)1 (0.6%)Center-Based426 (56.8%)3 (0.5%)0Total750583169Among users of formal LTC services, the majority of them used the referred LTC service as opposed to other services.Determinants of Use of Long-term Care ServicesCare RecipientsCaregiversYoungerFemaleEducation: S

22、econdary or higherFewer number of family members living with CGHaving Medisave AccountMore need in social supportHaving higher number of Activities of Daily Living (ADL) LimitationCare RecipientsCaregiversBigger housing (5 rooms)OlderHigher household eNot workingHigher number of comorbiditiesCenter-

23、Based ServicesHome-Based ServicesWee SL, Liu C, Goh SN, et al. Determinants of Use of Community-Based Long-Term Care Services. JAGS 2014;62(9):1801-3. Impact of Caregivers Perception on Referred Service UtilizationLiu C, Eom K, Matchar DB, et al. Community-Based Long-Term Care Services: If We Build

24、It, Will They Come? Journal of Aging and Health, ing.Household e and Affordability Self-Rated General HealthStress LevelQuality of LifeImpact of Referred Service Utilization on CG Health es Coefficient of Change in Each Health e 95% CICenter-BasedHome-BasedNot Residing with CRResiding with CRNot Res

25、iding with CRResiding with CRStress Level0.920.08, 1.75*-0.15-0.60, 0.290.02-1.10, 1.14-0.70-1.23, -0.17*Quality of Life-0.01-0.05, 0.030.01-0.02, 0.040.00-0.05, 0.060.050.02, 0.08*Self-rated General Health0.03-5.11, 5.181.84-1.07, 4.796.07-0.87, 13.003.880.50, 7.25*p-value0.05 *p-value0.01Impact of

26、 Referred Service Utilization on CR Health esCoefficient of Change in Each Health e 95% CIADL3.91*0.70, 7.13N=611IADL0.46*0.13, 0.79N=610Quality of Life-0.02-0.13, 0.10N=135Adjusted for CRs gender, living arrangement, age, marital status, housing type, education level, number of comorbidities, and w

27、hether or not CRs have foreign domestic worker.Future StudiesSystem Dynamics modeling the demand of formal LTCS for lower e, moderate to high ADL populationDesign a randomized controlled trial (RCT) to improve the uptake of and adherence to outpatient rehabilitation service among stroke patientsAffo

28、rdability and convenience scoresImpact of Transitional Care Program on Hospital Utilization An Interim AnalysisA charged service that offers personalized post-discharge care management by a team of doctors, nurses and therapistsAims to help patients with complex and chronic medical conditions transi

29、tion from hospital to homeTransitional Care ProgramTarget Population: Patients with post-hospital medical issues that place them at risk, requiring intensive outpatient services:Complex and dependent elderly patients with multiple medical problems, frequent admissions and geriatric syndromePatients

30、with specific medical problemsPost-operative patientsTransitional Care ProgramHome VisitsDoctorsTherapistsNursesPatients ReferredComplex and dependent elderly patients with multiple medical problems, frequent admissions and geriatric syndromesPatients with specific medical problemsPost-operative pat

31、ientsOptimization of medical conditionsCaregiver competencyImproved Health es& Reduce Hospital UtilizationTransitional Care ProgramEvaluation ObjectivesEvaluate the impact of the Transitional Care Service in reducing hospital utilisation over 6-months post-discharge, comparing users and non-usersIde

32、ntify patient characteristics associated with TC service utilisationCompare the difference in the total cost of hospital services utilisation between TC patients and control patients in the 6 months post-dischargeData SourcesData SetVariablesLevel of DataElectronic Data(SAP, SCM, AIMS)Gender, ethnic

33、ity, age, primary diagnosis code, secondary diagnosis code, hospital length of stay, functional state, social history (home ownership, occupation, smoking, ethanol use), number of medications, frailty biochemical measures (Hb, creatinine, albumin), discharge type, discharge reason, admission status,

34、 discharge within 24 hrs, hospital admissions, DEM visits, outpatient SOC visits, Medifund statusIndividual-level dataNurse Assessment DataMore detailed socio-demographic characteristics, living arrangement, caregiver, ADL and IADL, cognitive function, level of care (low, medium, high)Individual-lev

35、el dataMinistry of Health DataHospital admissions, Primary diagnosis code, Hospital length of stay, MortalityIndividual-level dataStudy PopulationPatients who have been referred to TC from 1 April 2012 to 31 March 2014 N = 695 (533 intervention; 162 control)Patients ReferredComplex and dependent eld

36、erly patients with multiple medical problems, frequent admissions and geriatric syndromesPatients with specific medical problemsPost-operative patientsCongestive cardiac failure with frequent admissionsCOPD with frequent admissionsPoorly controlled diabetes mellitusAcute stroke with new disabilityIn

37、fections (pneumonia, UTI, cellulitis, wound infections)Thrombo-embolism needing anticoagulationOrthopaedic patientsPost-surgery patients with new stoma, wound complications or medical problemsPost-neurosurgery patients who need high level of carePost-tracheostomy patientsSample ExclusionsExclusion c

38、riteria:Gone to nursing home, community hospital or inpatient hospice Under or more appropriate for home medical, home nursing, home hospice, or center-based careUnder ACTION care coordinator or community nurse (AIP program)Died in hospital during index admissionReferral withdrawn by primary teamUnc

39、ontactableRe-admitted or died within 7 days after discharge from hospitalBaseline and Follow-upStudy PeriodNumber of Hospitalizations in Baseline Period: Total number of admissions, including index hospitalizationLength of Stay: Total duration of all hospitalizations with admissions within baseline

40、(follow-up) periodVariableTypeDefinitionNumber of hospital admissions during the follow-up periodcountNumber of hospital admissions during the 180-day period subsequent to index discharge.Number of A&E visits during the follow-up periodcountNumber of A&E visits during the 180-day period subsequent t

41、o index discharge.Was re-hospitalized during the follow-up periodbinaryVariable takes on the value of “1” if subject was re-hospitalized during the 180-day period subsequent to index discharge.Had any A&E visit during the follow-up periodbinaryVariable takes on the value of “1” if subject had an A&E

42、 visit during the 180-day period subsequent to index discharge. e Variables e VariablesVariableTypeDefinitionHad any readmission during the follow-up periodbinaryVariable takes on the value of “1” if subject had a readmission during the 180-day period subsequent to index discharge. Readmission is de

43、fined as re-hospitalization due to the same primary diagnosis (same first three digits ICD10 codes) as index hospitalization.Length of stay (LOS)continuousLength of stay is defined as the total number of bed days for hospitalization with admission dates falling within both the baseline and follow-up

44、 periods.Death during the follow-up periodbinaryVariable takes on the value of “1” if subject died during the 180-day period subsequent to index discharge.Variables DefinitionsPrimary Independent Variables (DID)Indicator Variable: Case or ControlIndicator Variable: Baseline Period or Follow-up Perio

45、dThe interaction termCovariatesGender, age, ethnicity, Singapore citizenship, index hospitalization length of stay, patient class for the index hospitalization, number of activities of daily living limitations, Charlson comorbidity index as severity of illness, cognitive status, assigned level of ca

46、re and number of re-hospitalization during baseline period as proxy for stability of conditionStatistical AnalysisBivariate analysisContinuous variables: t-testsBinary variables: Chi-square tests or Fishers Exact TestMultivariate analysisCount or Continuous Variables: difference-in-difference analys

47、isControl for secular trends in es (and potential mean reversion bias) by comparing longitudinal difference in e measures between treatment and controlsFor binary es, we fit logistic modelsSensitivity analysis (LOS outliers, different follow-up period)Patients BaselineCharacteristicsVariableTC Treat

48、 Group(n=533)Rejecter Group(n=162)P-ValueAge82.0 (10.0)80.1 (12.0)0.046*Race (%)ChineseMalayIndianOthers4.967.30.882Female (%)64.967.30.579Singaporean Citizen (%)97.997.50.756LOS of index admission 16.0 (16.0)13.9 (11.9)0.122Charlson Comorbidity Index1.6 (1.2)1.6 (1.3)0.868Patie

49、nts BaselineCharacteristicsVariableTC Treat Group(n=533)Rejecter Group(n=162)P-ValuePatient Class (%)AB1B2CNon-resident4.330.358.02.50.069ADL Limitations (0-4)2.4 (1.7)1.7 (1.7)0.000*With Medifund (%)00*Level of Care1234.548.547.05.658.835.60.040*Intensity of Resource U

50、tilization (%)IntensiveNon Intensive24.875.229.670.40.216Difference-in-Differences: No. of Hospital AdmissionsDifference-in-Differences: Number of A&E VisitsDifference-in-Differences: Length of Stay*Excluding Outliers Yields Similar ResultsVariableAdjusted different-in-difference coefficient# of hos

51、pital admission0.02 (-0.32, 0.35)# of A&E visit0.14 (-0.20, 0.48)Total LOS-3.46* (-6.45, -0.48)Excluded FFs with total length of stay more than 60 days in either baseline or follow-up period.Subgroup Analysesby Level of Careby Frequent Flyer Statusby Medifund StatusLevel of CareLargely subjective me

52、asureLevel 1 care caters to medically stable patients who require basic nursing care and social supportLevel 2 care caters to complex patients such as elderly patients with geriatric syndromes, or patients with complex nursing needsLevel 3 care caters to patients with chronic diseases who are unstab

53、le or prone to frequent exacerbations, elderly patients with multiple geriatric syndromes or thrombo-embolic conditions requiring anti-coagulationStudy Population(n=695)Level of Care 1 & 2(n=385)TC Treat Group(n=283)Rejecter Group(n=105)Level of Care 3(n=307)TC Treat Group(n=251)Rejecter Group(n=59)

54、Binary e Variables by Level of CareVariableAdjusted Odds Ratio(Level of Care 1 & 2)Adjusted Odds Ratio(Level of Care 3)Re-hospitalized (%)0.60*(0.37, 0.98)1.97*(1.05, 3.68)Had any readmission (%)0.84(0.37, 1.91)1.18(0.42, 3.36)Had any A&E visit (%)0.99(0.61, 1.59)1.86*(1.01, 3.44)Death during the fo

55、llow-up period0.73(0.41, 1.31)0.67(0.34, 1.31)Study Population(n=695)Level of Care 1 & 2(n=385)TC Treat Group(n=283)Rejecter Group(n=105)Level of Care 3(n=307)TC Treat Group(n=251)Rejecter Group(n=59)Continuous e Variables by Level of CareVariableAdjusted DID(Level of Care 1 & 2)Adjusted DID(Level o

56、f Care 3)# of hospital admission-0.10(-0.54, 0.35)0.35(-0.22, 0.93)# of A&E visit0.08(-0.36, 0.53)0.12(-0.45, 0.69)Total LOS-3.24(-8.19, 1.70)-3.85(-10.73, 3.03)Study Population(n=695)Frequent Flyers(n=180)TC Treat Group(n=132)Rejecter Group(n=48)Non Frequent Flyers(n=515)TC Treat Group(n=401)Reject

57、er Group(n=114)Continuous e Variables by FF StatusVariableAdjusted DID(Frequent Flyers)Adjusted DID(Non Frequent Flyers)# of hospital admission-0.21(-0.99, 0.56)0.03(-0.22, 0.28)# of A&E visit-0.38(-1.22, 0.46)0.20(-0.07, 0.47)Total LOS-9.89*(-19.02, -0.76)-2.96(-6.93, 1.00)TC Treatment Group(n=533)With Medifund(n=66)Without Medifund(n=467)With vs. Without Medifund in TC Treatment GroupVariableAdjusted DID# of hospital admission-0.32(-0.81, 0.18)# of A&E