Legislative Council Panel on Welfare Services

Meeting on 14 September 1998
Consultancy Study on Needs of Elderly in Hong Kong
for Community Support and Residential Care Services

PURPOSE

To present to members the findings and recommendations of the consultancy study on needs of the elderly for community support and residential care services conducted by Deloitte and Touche Consulting Group.

BACKGROUND

Objectives

2. The Working Group on Care for the Elderly appointed in 1993 to review elderly services recommended, inter alia, that a comprehensive study should be conducted to assess the needs of elderly people for residential care and community support services" so that future planning of elderly services can be formulated on the basis of needs.

3. In accordance with the Working Group's recommendations, Deloitte and Touche Consulting Group was commissioned in May 1996 to conduct a study on the needs of the elderly for residential care and community support services. The objectives of the study are :

1. to assess the needs of the elderly people in Hong Kong for residential care and community support services;

2. to propose whether and how current services should be modified or replaced by new services to meet the needs of the elderly; and

3. to propose ways in which the services identified could be provided in a cost-effective manner by Government, the subvented and private sectors.

4. The study is now complete. Enclosed at Annex A is a copy of the Executive Summary of the consultancy report for members' reference. Copies of the full report are deposited in the LegCo library.

Methodology

5. The consultancy study conducted two surveys, one on elderly living in the community and the other on elderly in residential care institutions, followed by a series of focus group discussions. These studies aimed to obtain an understanding on elderly people's needs for residential care and community support services. The Community Survey covered over 2,000 elderly people aged 60 or above living in the community. The Residential Care Survey covered 120 residential care homes with a total of more than 8 000 residents. The Focus Group Discussions were held amongst selected groups of the soon-to-be old, i.e. those aged 50-59, to find out their expectations for care services when they grow old.

6. Two main factors were employed by the consultant to determine an elderly person's need for formal care, namely the levels of physical or cognitive impairment and the availability of informal carers. An elderly person's levels of physical impairments are measured on the basis of his ability to perform activities of daily living (ADL) ¹. A test, known as the Short Portable Mental Status Questionnaire, was used to determine the levels of cognitive impairment of the elderly.

MAJOR FINDINGS

Health conditions

7. The physical health of our elderly population is relatively good, with about 4 % of those living in the community requiring assistance with more than one ADL. However, 25% are found to have some degree of cognitive impairment, with 5% with moderate or severe impairment. The proportion of demented elderly aged 60 or more in Hong Kong is estimated at 5%. Almost 22% of the respondents achieved scores which implied a psychological state of "probable depression". This figure should, however, be treated with caution as a diagnosis of depression could only be made through a full clinical evaluation of an individual.

8. 76% of the residents of care and attention (C&A) homes have varying degrees of impairment, with 23% carry some form of mental impairment. 82% of the residents of subvented homes for the aged are impairment free ². In comparison, residents of private homes have the worst health conditions, with over 50% having severe impairments ³.

Preferences for Family Support

9. The elderly people of Hong Kong enjoy strong family support, with 91% of them living with a spouse or other family members. About 9% reported that they were living alone, but many of them are helped by family members in activities such as shopping and household chores.

10. Most elderly people (76%) prefer to continue to live at home even if their health deteriorates. Only 19% prefer residential care. The majority of the caregivers (66%) also prefer to care for their elderly family members at home; only 20% prefer institutional care. Two-thirds of the latter group change their attitude when home assistance is available.

The Caregivers

11. 94% of the primary caregivers surveyed are family members of the elderly. Amongst them, 36% are spouses, 39% are children and 14% are daughters-in-law. One-half of the primary caregivers receive assistance from other family members for caring the elderly. About one-third of the caregivers are in full time employment. A similar figure reported that they felt some or much stress in the two weeks prior to the interview. 62% of the caregivers are not in employment, and more than one-third of them consider themselves in need of financial support in caring for the elderly.

Financial disposition and ability to pay

12. About half of the elderly people living in the community rely on their children's support as the main source of income, about one-fifth rely on CSSA or OAA, 15% are earning a salary, and less than 10% are of independent means even after retirement. 23% of those living in the community reported that they did not have enough money to cover daily expenses. Only one-third of the respondents indicated a willingness to pay for care services when they need them. It is noted that the majority of residents of either subvented or private care homes (more than 70%) are receiving CSSA.

Need for assistance for elderly living in the community

13. 41% of the elderly living in the community do not believe that they have any particular need for care services. 23% considered financial support to be most useful, followed by housing (14%). Only a very small number have expressed a need for care services.

14. Of the 531 elderly people found to have some impairments in the community survey, only 10% reported that they were using some type of formal care service. On the other hand, the majority of those using various types of non-residential care services, with the exception of grooming and bathing, do not have any impairment.

15. The above suggests that only a portion of those genuinely in need of care service are coming forward to demand for the service. However, as found out in the focus group discussions, there is a growing expectation in the soon-to-be old that they are entitled to services provided by Government because of the contributions they have made to Hong Kong's development. This group of soon-to-be old would be more aware of public services available as they are better educated.

CONSULTANTS' RECOMMENDATIONS

16. The consultant's major recommendations comprise the following aspects:

(a) Ageing in place and role of the family

17. The findings of the community survey provide monumental evidence that the majority of the elderly and their carers prefer to remain at home for as long as possible and that the family is the predominant provider for the elderly in meeting their various needs. The consultancy study reaffirms Government's policy of "Ageing in Place" and recommends that the Government should improve community support services to render assistance to families caring for elderly members at home. Informal care should be the mainstay of care to the elderly people and the traditional Chinese values of respect and care for the elderly should be promoted.

(b) Continuum of care

18. The consultancy study confirms the merit of the continuum of care concept in the provision of services for the elderly. Applying this concept to residential care and community support services, the consultants recommend :

• removing the distinction between nursing homes and care and attention homes;

• increasing the availability of medical and health professional support in the community and in the residential care sector;

• targeting infirmary services on elderly people in need of rehabilitation;

• increasing the provision of site-based and domiciliary rehabilitation services; and

• increasing the provision of weekend, holiday and after hour services for day services like day care centres.

(c) Mixed economy of service provision

19. The consultants endorse the concept of welfare pluralism advocated by the Working Group on Care for the Elderly and recommend pluralist provision of welfare services, i.e. services provided by a wide range of public, self-financing and private providers, as an efficient model of service provision in Hong Kong. Through a mixed economy of provision, users will benefit from wider choices being made available by a range of public and private providers. Users may also benefit through the lower costs and greater flexibility thus realised.

20. The Residential Care survey demonstrated the significant part played by the private sector in caring for highly dependent elderly people. However, the private sector's current limitations are widely recognised. The consultants recommend that Government should encourage development of a high quality private sector. The following initiatives should be considered :

• an extension of the Bought Place Scheme in the private sector, with prices paid that are comparable to the cost of supporting clients in the subvented sectors;

• assist the private sector in identifying suitable premises;

• increase CGAT and community nurse support to private homes; and

• increase primary medical care support.

(d) Enhancement to services

21. The consultants have also conducted a comprehensive review of the level and mode of delivery of services, and recommended the following enhancement of services :

(i) Care for the more severely impaired elderly in the community

22. In order that the "Ageing in Place" policy can be successfully implemented, the capability of community support and home help services to care for more dependent clients needs to be expanded. In this connection, the consultants recommend :

• extending the provision of day hospitals where elderly people can receive more intensive medical, nursing, and paramedical treatments;

• developing psychogeriatric day hospitals and increasing the provision of day care services for the cognitively impaired elderly people by rendering professional psychogeriatric support to day care centres;

• home-help service should be re-oriented towards providing long-term care and support to carers and assistance with ADL; and

• home-help service be supported by nurses and paramedical staff where necessary.

(ii) Residential Care

23. The consultants noted that more than one-half of the elderly people in subvented homes are ADL impairment free, which indicated that there is a need to tighten up the admission control to these homes so that only those in genuine need of residential care would be admitted in future. On the other hand, the study showed that about 55% of the residential beds provided were in private care homes, the standard of service of which varies. There is an urgent need to upgrade the quality of these homes.

(iii) Psycho-social support for the impairment-free elderly in the community

24. To provide better services to the healthy elderly in the community, the consultants recommend that a more dynamic model be adopted in developing the programmes and organisations of the social centres (S/Es) and multi-service centres for the elderly (M/Es). It is also suggested to integrate the social and recreational programmes in these centres with other community services that are provided by, for instance, the municipal councils. Furthermore, social centres should continue to act as a drop in facility for elderly people and that they should become a nucleus for :

• a citizens' advice service staffed by elderly volunteers who would use their pre-retirement work and life experience to provide support and advice on various matters;

• administration and organisation of outreach social programmes;

• training and development of social centre staff and volunteers;

• administration of elderly volunteer programmes such as networking, visiting and escort;

• better collaboration between the M/Es and S/Es with the latter operating as satellites of the former.

(iv) Medical Services

25. The consultants are of the view that the limited access to primary and outreach medical care is a barrier to the development of elderly care services based on community care and continuum of care. It is proposed that primary medical care to elderly people in the community should be enhanced by expanding the role of the elderly health centres by :

• charging them with the responsibility of managing the chronic medical conditions that are prevalent amongst the elderly i.e. diabetes, arthritis, hypertension, heart disease and depression;

• developing a domiciliary and institution visiting service; and

• charging them with the responsibility of providing primary medical support to other domiciliary services such as home help service.

FUNDING

26. Based on their recommended mix of services to meet the needs of the elderly people, the consultants have calculated the total cost of providing these services using cost assumptions derived from the public sector. Compared with the current Government expenditure on elderly services, the study shows that the community as a whole would have to spend much more (about 150% of 1996 public sector expenditure) to obtain all the care services that are needed. The cost will escalate as the population continues to age. As it will be impossible for the Government to shoulder the full cost of all care services for the elderly, the consultants recommend that users with means should be expected and required to pay in future. As the majority of the elderly people in Hong Kong have always been relying on their family for financial support, the consultants recommend that means-testing should apply to the extended family of the elderly people.

ADMINISTRATION's RESPONSE

27. The Administration have considered the findings and recommendations of the consultancy report in details. We have earlier briefed the Elderly Commission and the Social Welfare Advisory Committee on the Report. We have vigorously pursued a number of recommendations. A list of the follow-up action undertaken is at Annex B. However, there are a number of recommendations that may involve longer term planning and we are considering their implications.

Health and Welfare Bureau
September 1998

Annex B

Recommendations	Follow-up actions
Policy
(I) Ageing in Place
--To facilitate elderly with no or low impairment to remain at home by :
- providing more appropriate housing plus appropriate domiciliary care	We plan to launch pilot projects in the coming years to upgrade the existing home help services through re-engineering the meal delivery service and provision of training and incentives to encourage home helpers to provide more home care services.
- converting home for the aged (H/A) places to provide for clients with higher impairment	We have consulted the Ad Hoc Committee on Housing and Residential Care of the Elderly Commission on our proposal to apply the care-and-attention (C&A) home admission criteria to H/A. The proposal was endorsed in principle. We are following up on the detailed arrangement. SWD is working with operators to convert planned H/A places into C&A places.
--Carers to be made a special focus of Government policy - access to training and counselling for carers - respite service in residential care homes or day care centres	We are considering introducing a new respite service in day care centre (D/Es). We will review the existing respite service in residential care homes to identify areas for improvement.
(II) Development of a quality private sector
--Extend the Bought Place Scheme (BPS)	Enhanced BPS to purchase 2 400 additional places. The first batch of bought places to be delivered in November 1998.
--Access to Government grants and land privileges --Assistance in identifying and increasing the supply of suitable premises	This is under consideration among government bureaus and departments. A Strategic Group chaired by Director of Social Welfare has been tasked to identify suitable premises for operation of residential care homes.
--Strengthen Community Geriatric Assessment Teams (CGATs) and Community Nurse support	We have increased one CGAT in 1998/99. Further addition will be subject to resource availability.
--Strengthen primary medical care support	Visiting Health Teams (VHTs) were established in July 1998. They provide health education, health promotion, disease prevention, and annual influenza vaccination to residential care homes.
--Expand licensing scheme to include measures that relates to care of clients.	We are moving towards this direction. SWD is working on plans to extend quality assurance measures to private residential home.
(III) An entity to co-ordinate policies for the elderly	The Elderly Commission was set up in July 1997.
(IV) Means-testing
--Services to be provided to the most needy :
- current means-testing system to be applied rigorously - higher charges to be applied through means-testing	We are working on the proposals and will seek consultation when we are ready.
- develop self-pay and self-financing private sector provision	On-going. Suitable premises will be identified for subvented as well as private and self-financing home operators. We will consider extending BPS to self-financing homes to provide a steady source of income to the operators. The Elderly Commission will put forward recommendations to develop these sectors in its Report to the Chief Executive.
--Involvement of volunteer to provide care services, such as escort and meal delivery	Involvement of volunteers in the re-engineered home help services will be explored.
Enhancement to Services
Continuum of Care Model
Residential Service :
--Re-define the admission criteria for subvented C&A homes to admit the more-impaired	Review of admission criteria to be conducted in consultation with the service sector.
--Retain the Infirmary Care Supplement and ensure amount of subvention paid for places reflect impairment and the likely intensity of services required.	Infirmary Care Supplement for 460 cases has been allocated to care homes in 1998/99. The funding formula for pilot projects on continuum of care in residential services is being considered. This will enable the homes to provide care to elderly of different degrees of frailty. A pilot scheme in selected homes will be conducted in 1999/00.
--Remove distinction between Nursing Homes and C&A Homes.	The pilot projects on continuum of care will take care of elderly of different degrees of impairment.
--Increase the scale of pre-discharge planning programme	We are reviewing the manning ratio of Medical Social Workers.
--Increase the availability of medical and health support to all residential care sectors. Position infirmary to focus on active rehabilitation rather than for long-term care.	Physiotherapy support to residential care homes has been strengthened by the upgrading of physiotherapist posts and creation of the Physiotherapy Artisan rank. Elderly Health Centres (EHCs) and VHTs may provide additional health support. Further medical support can be purchased through the provision of more financial resources. The interface between infirmary and other residential care homes will be reviewed at a later stage.
--Planning ratios to be met in part by Government increasing the proportion of private sector bought places	2 400 Enhanced BPS places to be purchased over three years. We are looking into the possibility of further increasing the number of places to be bought, having regard to the response of the elderly and the private care home industry to the Enhanced BPS.
--To remove distinctions between sectors and to move away from the current input control model to the output, service-purchase model	This will be further considered at a later stage.
--Adopting a case management approach.	We will adopt a structured approach to assess the care needs of the elderly.
Community Services :
--Increase the availability of medical and health professional support in the community.	EHCs expanded to become Integrated EHCs (IEHCs). The role of CGATs to be further considered.
--Increase the provision of site-based and domiciliary rehabilitation services	We plan to launch pilot projects in the coming years to upgrade the existing home help services through re-engineering the meal delivery service and provision of training and incentives to encourage home helpers to provide more home care services.
--Increasing the attention to district planning and deployment of community support services	To be further considered in the on-going review of care services for the elderly living at home.
--Increase the provision of weekend, holiday and after hours services	D/E service will be expanded to cover Saturday afternoons.
Changing Impairment Profile of Elderly in Residential Care
--Increasing proportion of places bought from the private sector	2 400 Enhanced BPS places to be purchased over three years. We are looking into the possibility of further increasing the number of places to be bought, having regard to the response of the elderly and the private care home industry to the Enhanced BPS.
--Alter criteria of subvented care services to reflect higher impairment level	Review of admission criteria to be conducted in consultation with the service sector.
--Move towards bought place model for the subvented sector	To be considered at a later stage.
Medical Services
Primary medical care
--Expanding the role of EHCs :
- to be responsible for managing chronic illness of the elderly	To be covered under the expanded IEHC service.
- as a base for CNS and domiciliary and institution-visiting service - primary medical support for domiciliary service - integration with CGAT service through case management	These issues will be considered in the current review of care services for elderly people living at home.
- special responsibility for: --raising awareness and identifying depression among their clients; --including psychological health within their portfolio of health education and maintenance programme; and --providing counselling to elderly and carers	Clinical psychological service will form part of IEHCs.
CGATs
--Increase the scale of CGATs, through a combination of expansion of numbers and size of teams, and increase the scope of CGATs to provide service to private homes and to support D/Es	We have provided one additional CGAT in 1998/99. Further addition and increase in scope will be further considered.
--Vesting the role of Gatekeeping in CGATs for residential care	Gatekeeping arrangements for residential care being reviewed.
Caring for the More Severely Impaired Elderly in the Community
--Develop the provision of community rehabilitation services through the model of the Community Rehabilitation Centre for the Elderly	To be further considered in the on-going review of care services for the elderly living at home.
--Extend the provision of day hospitals where elderly can receive more intensive medical, nursing, occupational therapy and physiotherapy treatments than can be provided in day care centres --Provide psychogeriatric support for D/Es to serve cognitively impaired elderly --To achieve a ratio of 1 facility : 51 000 elderly for Psychogeriatric Day Hospitals to support the outreach psychogeriatric service.	We will further consider the issue of integration of medical and health services and care services provided to elderly people living at home.
--Expand home-help services :
- to provide more support to carers and assistance with activities of daily living (ADLs) - to enable some home helpers to provide basic occupational therapy and physiotherapy service - to develop a network of volunteers to provide escort service - to enable more clients to receive meals outside of home in restaurants or other meal facilities	We are developing pilot projects to upgrade the existing home help service. Enhanced home care services and involvement of volunteers are issues to be addressed in the pilot projects.
--Explore the potential for private sector to provide transport for escort service and meal preparation and delivery	To be considered in the context of the review of care services for the elderly living at home.
--Increase service hours of D/Es and home help services, especially during weekends and holidays.	D/Es now open on Saturday afternoon. Home help teams also provide services during weekends and holidays when necessary.
--Integration of D/Es and home help services into a single delivery mechanism to refer and co-ordinate services --Expand home help service to be supported by nurses and have direct access to EHC service	To be considered in the context of review of care services for the elderly living at home.
--Explore further provision of transport resources for D/Es	One additional bus already provided in accordance with the recommendation of the Working Group on Care for the Elderly in 1995. Whether further transport resources should be provided to D/Es would depend on whether the scope of services provided by D/E will be expanded, e.g. to form a base for home help teams.
Care for the Less Severely Impaired in the Community
--Assistance with laundry and bathing provided through expanded domiciliary care services rather than Multi-Service Centres (M/Es)	To be further considered in the context of the pilot project to upgrade home help to home care.
Psycho-social Care
M/Es:
--Act as a major focus of social support --To cease to provide laundry and bathing	To be considered in a proposed review of the relationship between M/Es and S/Es and the scopes of their services.
S/Es :
--To act as satellites of M/Es --Provide citizens' advice service by elderly volunteers --Administer and organise outreach social programmes --Train and develop social centre staff and volunteers --Administer networking, visiting and escort --Develop a more dynamic model for social and recreational programmes in the wider community with the involvement of the municipal councils	We will consider the role of S/Es vis-a-vis M/Es in the context of a review of the relationship between the two bodies at a later stage. On the other hand, we have been exploring the possibility of S/Es working more closely with relevant government departments in providing recreational programmes for the elderly to help meet their social and recreational needs.
Outreaching
--To be adopted as a service approach rather than a mode of service delivery	On-going. VHTs and social networking service carry a strong outreach element. To introduce domiciliary care service to reinforce this service approach.
Case Management
--A case management model appropriate for Hong Kong be developed through pilot testing	We will be adopting a structured approach to assess the care needs of the elderly.

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1.The elderly's level of physical impairment is measured on the basis of his/her ability to perform six basic Activities of Daily Living (ADL), including bathing, toileting, transferring between bed and chair, mobility, eating and dressing.

2. Homes for the aged are originally designed to cater for the housing and social needs of the elderly people, as opposed to their care needs. Therefore a high proportion of impairment free residents should be expected.

3. For comparison, 22% of residents of subvented C&A homes have severe impairments.