Experience of a demand-side subsidy scheme for residential long-term care: perspectives of elderly and their carers.

BACKGROUND: Vouchers, which are demand-side subsidies to targeted groups, are a type of consumer-led near-cash social transfer for specified benefits that have been used in education, health and other sectors. To provide better access to residential care services and an additional choice for elderly people in need, a novel means-tested residential care service voucher has been introduced in Hong Kong for elderly people to purchase places in the private sector to enable consumer-directed care. The objectives of this paper are to analyze the perspectives of voucher users and their carers toward the voucher scheme and to identify key elements in the design that will contribute to meeting the scheme's objectives. METHODS: An exploratory sequential mixed method design was adopted with initial explorative qualitative data collection of the perspectives of elderly people and their carers (Phase 1), which informed the design of the subsequent questionnaire survey (Phase 2). Thirty carers in 5 focus groups and 20 individual interviews with elderly people were conducted between April and May 2018. A total of 401 respondents (373 carers and 28 elderly people) completed the survey questionnaire. Findings from both phases were integrated both narratively and via a joint display. RESULTS: Five key themes summarized the features in two main elements of the design and implementation of the voucher scheme: awareness, meaning that inadequate knowledge and understanding of voucher schemes hinder participation; service needs and types, indicating that the urgent need for residential care services is the key reason for participation; shared responsibility, meaning that a high copayment level discourages participation; choice and flexibility, reflecting appreciation of the additional choices provided by voucher schemes although the availability of residential care beds limits choices; and service quality, indicating mixed perceptions of service quality and the impact of the voucher scheme. Voucher users believe that the voucher scheme is more helpful for relieving the financial burden (98.7%), reducing carers' stress (97.0%) and reducing the waiting time for subsidized homes for elderly people (89.0%) than for increasing choice and flexibility (78.1%) and improving service quality (62.1%). CONCLUSIONS: This study demonstrates how the design of a voucher scheme affects its take-up by targeted beneficiaries. When a voucher scheme is implemented in a long-term care system, it must consider the congruence with existing policies in long-term care provision and financing. The voucher scheme in Hong Kong has been able to generate the utilization of nonsubsidized places in homes for elderly people that were underutilized, but its effectiveness is limited by inadequate knowledge and understanding of the voucher scheme and the availability of residential care places. Giving the purchasing power and choice of providers to beneficiaries has the potential to enhance the quality of services, which will contribute to meeting the objectives. The study findings carry significant implications for long-term care policies and provide insights into the key features of the voucher scheme for residential care services and how to best design and implement a voucher scheme for elderly people in the context of policy objectives and a long-term care policy.

Preference of caregivers on residential care homes for older persons with versus without communication problems: a discrete choice experiment.

BACKGROUND: A residential care service voucher scheme has been introduced to expand the capacity and enhance choice of public-funded long-term care (LTC) in Hong Kong, enabling users to have greater choices over the types of LTC facilities. Older persons with communication problems have difficulties in understanding the care options available to them and expressing their preferences to care homes and daily service delivery, therefore hindering their ability to exercise control and choice. Thus, they may have different needs and preferences for the facilities than others due to their conditions. This study therefore aimed to investigate their preference for care homes in comparison with those without communication problems. METHODS: A discrete choice experiment was conducted to elicit preference for six attributes derived from prior studies. The family caregivers of a random sample of older voucher holders were invited to undertake face-to-face interview. Willingness-to-pay (WTP) for the attributes was estimated for those with or without communication problems separately. RESULTS: Two hundred eighty-three caregivers provided valid responses (74% response rate). Caregivers of those with communication problem preferred facilities operated by non-governmental organizations (WTP=HK$1777.4) and shorter travelling time (WTP=HK$1502.5 for <=0.5 hours), while those without the problem had greater preference for fewer roommates (WTP=HK$3048.1 for single room) and extra healthcare professionals (WTP=HK$1765.5). Heterogenous WTPs were identified from those with different income, marital status and caregivers' age. CONCLUSIONS: The reputation, greater space and staff, and proximity/familiarity of the facilities were important for those with communication problems. To help meet these preferences, the facilities could establish collaborations with local community-based service providers and build their own outreach team to familiarize themselves with older persons. Additionally, household income and informal support availability should be considered for care planning.