1. 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 11 th Global Conference on Ageing | Prague, Czech Republic | 31 May 2012

2. 2 Singapore Population: 5,183,700 – Citizens: 3,257,000 77% Chinese, 14% Malay, 8% Indian GDP Per Capita: $59,900 USD (5 th ) 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

3. 3 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

4. 4 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

5. 5 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) Partially- subsidized nursing homes and community care services Private Sector Full fee hospitals and nursing homes State Finances intermediate and LTC Provides subsidies for VWOs

6. 6 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

7. 7 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?

8. 8 Methods 1.Developed a preliminary System Dynamics (SD) model of LTC in Singapore – 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

9. 9 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

10. 10 InputsValueSource Proportion of families with FDW helping with eldercare 0.3Author estimate using SSIC data Proportion of elderly Singaporeans with institutional care needs 0.03Singapore Ministry of Health Primary caregiver hours for elderly residing in a nursing home 0Author estimate Attractiveness of HCBS (proportion of referrals accepted by elders and their families) 0.2Estimated with help of stakeholders Current nursing home beds (2012)9,900Singapore Ministry of Health Proposed nursing home capacity needs Year:Beds:Inter-Ministerial Committee on Health-care for the Elderly: 1999 (Report) 202014,900 203022,400

11. 11 Inputs: Average Total Care Hours for People with ADL Limitations Source: Singapore Survey on Informal Caregiving

12. 12 Results: Projected Number of ADL-Limited Elderly Needing Human Assistance

13. 13 Policy Levers 1.Attractiveness of home and community- based services (HCBS) 2.Fraction of families with a foreign domestic worker (FDW) 3.Nursing home capacity

14. 14 Results: Average Primary Caregiver Hours by ADL Limitations of Care Recipients

15. 15 Results: Projected Number of Primary Caregivers

16. 16 Results: Primary Caregivers Likely to Drop Out of the Labor Force

17. 17 Results: Percentage of Primary Caregivers Likely to Drop Out of the Labor Force by 2030 Policy:Percentage: No policy or capacity changes38% Double attractiveness of HCBS37% Double proportion of families with a FDW33% Planned nursing home bed capacity28%

18. 18 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

19. www.duke-nus.edu.sg Thank You! sean.love@duke-nus.edu.sg

20. 20 Appendix I: Projecting the size of the ADL- limited elderly population Population 65+ becoming 65 deaths Population 65+ with ADL limitation(s) ADL incidence deaths from ADL pop population 65+ with no ADL limitation incidence rate mortality rate

21. 21 Appendix II: LTC Model

22. 22 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

23. 23 Appendix IV: Total Work Hours Lost to Caregiving of Those Who Stay Employed