Jack: Hi, everyone, and welcome to this week's module,
where we will be discussing global demographic shifts
and the management of long-term services and supports.
Global healthcare delivery systems in the 21st century
face serious challenges related
to the aging of the population,
the prevalence of chronic disabling conditions,
and the growing demand for long-term services and supports
across a variety of care settings.
In this module, we will provide an overview
of the demographic, historical, and culture forces
that affect the demand for long-term care.
We'll also explore key issues related
to the supply of long-term care services.
Healthcare systems throughout the world
are facing mounting pressures from growing numbers
or older adults, many of whom have complex care needs
associated with chronic or disabling conditions.
As people live longer,
they're more likely to require long-term services
and supports, whether in home
or in various care settings,
to help manage their regular life activities.
Long-term services and supports are defined
as the care, services, and assistance provided
across various settings to help people address difficulties
in performing their activities of daily living.
So what are some of these demographic
and cultural forces affecting demand
for the supply of long-term supports and services?
Well, population aging is a global demographic shift
whereby older adults are making up an increasing proportion
of the overall population.
This trend reflects both increased longevity
and lower fertility across the various regions
of the world.
Between 2025 and 2050, in fact,
the older adult population is expected to almost double
to 1.6 billion globally,
whereas the total global population will increase
by just 34%.
So what are some types of population aging?
Population aging is a global trend,
although the speed with which the process occurs is uneven
from one region to another.
Many low- and middle-income countries,
like China and Turkey, are considered aging societies,
meaning that their older adult populations
are growing rapidly, to the point where people aged 65 years
or older make up between seven and 14% of the population.
A number of higher-income countries,
including the United States and many European nations,
are regarded as aged societies,
meaning that the population of older adults
has already reached 14 to 21% of society.
Some countries, like Japan,
are categorized as hyper-aged societies,
meaning that older adults make up more than 21%
of the population.
Growth among older populations in high-income countries
is expected to continue in the coming years,
but at a slower rate
than in low- and middle-income countries,
especially those in Asia and Latin America.
This epidemiological transition
towards older populations is largely a result
of declining fertility rates,
as well as lower mortality rates stemming
from medical advances in the 20th century.
Another factor driving the increased demand
for long-term services and supports is the growing number
of adults with chronic and disabling conditions.
In considering this factor,
let's first define some key terms.
Chronic health conditions are conditions
that last three months or longer
and affect an individual's health or independence.
A disability can be a physical, sensory, cognitive,
or intellectual impairment, or a type of chronic disease.
A disability reflects a combination
of an individual's health and social circumstances
that determines one's ability to function
within a given social context.
Levels of disability can be analyzed based
on several different factors, including:
the individual's ability to function
and carry out activities of daily living, or ADLs,
which include routine and fundamental life activities,
like eating, bathing, and dressing,
instrumental activities of daily living, or IADLs,
including cleaning, shopping, and managing finances
that enable people to live independently.
Other measures include active life expectancy, or ALE,
which is the portion of total life expectancy
during which an individual is not affected by disability,
or healthy life years, or HLYs,
which are the estimated number of years
that an individual will live
without disability-related limitations on daily activities.
And finally, health-adjusted life expectancy, or HALE,
which is a measure of life expectancy adjusted
for the severity of an individual's disability.
So with this increased need
for long-term supports and services,
there are several supply issues
which are challenges or barriers
to the provision of these services.
So in the US and other high-income countries,
the importance of long-term supports and services
is well-recognized, though many models of long-term care
in these nations are focused on the role of acute care
or the curative sector,
where individuals receive assistance from professionals
in hospitals or other institutional settings.
In lower-income nations,
long-term services and supports have remained
the responsibility of family members
and informal caregivers.
Some countries have passed laws and regulations
to formally establish the responsibilities
of family caregivers.
The US and many other high-income countries
have experienced a trend towards independence
in family relationships across the lifecycle.
As a result, many older adults in those countries live alone
or just with a spouse,
so that their care needs are not a burden on family members
who might be supporting younger dependent children.
The number of, quote, elder orphans,
or individuals living alone without a family member
available to provide care, in the US is likely
to increase as the baby boomer generation ages.
The textbook provides this informative example
of global dementia care.
Dementia care and the need for it is expected
to increase significantly in the 21st century.
Part of this is
due to the increase in memory care units,
that is the existence,
in many countries, the traditional model for caring
for people with dementia has emphasized care provided
in the home by unpaid, family caregivers.
Memory care units are units in nursing homes
that focus specifically on dementia care
and are secure areas
where individuals receiving such care reside.
There's an example this week in the reading materials
about a dementia village in the Netherlands.
So there are also workforce challenges in long-term care.
Long-term care is highly labor-intensive,
and the global delivery of long-term care depends
on both formal, trained professionals
and informal, unpaid caregivers.
Direct care workers, especially aides,
represent the largest component
of the long-term care workforce,
and the development of this workforce segment
has been identified as a key concern
facing healthcare in the 21st century.
A direct care worker is defined as an individual
in the health workforce who provides care
and personal assistance to individuals who are frail,
sick, or injured, or who have physical
and mental disabilities.
Globally, however, the majority of long-term care
is provided by family members, friends,
and other informal caregivers.
There are also, in some settings,
there's been an emphasis on individuals aging in place.
That is, the practice of remaining in one's own home
and community during old age.
As a result of this, home and community-based services
provided by direct care workers have come
to encompass increasingly broad and complex array
of physical and mental health needs
requiring skills in such areas as medication management,
palliative care, and dementia care.
So how can technology help to address some
of these challenges?
Well, one example is the delivery of long-term care
can be enhanced by telehealth capabilities
and other health-enabling
and ambient assistive technologies that collect data
and provide communication in the home.
Robotic devices may also provide some basic services
at affordable prices.
In high-income countries,
technology has helped to extend life
through a variety of devices and services,
as well as through the use of high-technology medicine.
In low- and middle-income countries,
portable technologies have enabled
the inexpensive collection of healthcare information
and improved communication between healthcare providers
and people living in remote areas.
Personal response systems can benefit individuals
affected by serious health conditions,
enabling faster emergency response, and therefore,
reduced hospital utilization and mortality.
So now let's discuss some of the main models
for care management and care transitions.
Throughout the world, long-term services and supports
are provided by a wide variety of models,
from institutional and well-defined residential settings
to people's own homes in the community.
These models are also influenced
by the healthcare system in a certain country.
So under universal coverage systems,
national and local governments fund
and administer long-term care coverage for all citizens.
Under mandatory insurance programs,
the government requires people of certain age groups
or employment statuses to pay premiums towards insurance
for long-term care.
Some countries have mixed systems,
in which public means-tested elements
and private insurance both play important roles.
In other countries, services may be provided
with few public funds or with no formal system.
The table on this slide and in your textbook helps
to summarize these different models.
Now, we will briefly go over some vignettes
of different countries and how they manage
their long-term supports and services.
So to begin with, Japan, as we mentioned,
is a hyper-aged society.
It stands at the forefront of the population aging trend,
and in 2015, people aged 65 or older represented 26.6%
of Japan's population,
making it the oldest country in the world.
Additionally, Japanese culture
has traditionally emphasized filial piety,
with the idea that younger family members have an obligation
to take care of their elders.
As a result, families have taken on
significant caregiving responsibilities,
and care throughout the hospital systems has been used
for more serious illnesses.
In recent years, however,
family structures have begun to change,
and older adults now sometimes live separately
from their families, which has necessitated a restructuring
of service networks.
In 2000, Japan introduced a national long-term care policy
that redefined the role of government
in providing care for older adults.
The country established
a national long-term care insurance program,
known as Kaigo Hoken, that is administered separately
from the national health insurance policies
and is funded by general tax revenues,
as well as insurance premiums.
These policies are mandatory.
All citizens older than age 40 must contribute.
This insurance covers long-term care services
for people aged 65 or older with severe disabilities.
Now, let's turn to Sweden.
So Sweden has long been recognized
as the first European country to have a long-term care plan
and a publicly funded welfare state.
And it ranks among the top European nations
in investment in long-term services and supports
as a percentage of GDP.
Swedish municipalities planning housing
and residential areas are required
to ensure that they meet the needs
of all kinds of individuals with disabilities,
regardless of age.
These accessibility requirements
have been given greater prominence in legislation
over the years, and a growing number of older adults
want to live in, quote, senior housing,
ordinary homes for people aged 55 and older
where accessibility's a priority.
Now, let's turn to China.
So China is an aging society
with changing social structures,
and it faces daunting challenges in meeting the demand
for long-term services and supports.
China's older adult population's growing rapidly,
up to 136.9 million in 2015.
Older adults represent 10.1% of China's total population,
and the percentage is projected to increase
to 17.2% by 2030.
Additionally, the number of Chinese adults
aged 85 or older is expected to grow at a rate
of one million per year until 2025.
China has two broad systems that provide care
to older adults: a social welfare system
of community-based elder clinics,
residential facilities, and nursing homes,
and a medical system consisting of physicians,
hospitals, and primary care clinics.
The services provided include long-term institutional care
in non-acute settings with significant levels
of medical and support services,
as well as non-institutional senior care services
encompassing a wide range of home
and community-based services.
When we look at the example of Turkey, we see that,
like many other low- and middle-income countries,
Turkey faces a variety of concerns related
to population aging and sociodemographic transition.
Historically, elder care services
in Ottoman Turkish society evolved in parallel
to Western experience over the course of four periods:
the traditionally Ottoman period,
the period of stagnation and the opening of nursing homes,
nursing homes becoming alternative to home-based care,
ushering in a transitional period, and finally,
the modern period, which began in 1980,
in which institutional care became prevalent
in large cities.
So finally, let's turn to the US.
The US, like other countries discussed in this module,
is undergoing significant demographic shift
with major implications for the delivery
of long-term services and supports.
I encourage you all to review the textbook chapter
for more information about the demographic shifts going on
in the US.
But some key developments in common residential arrangements
available in the US include assisted living facilities,
skilled nursing facilities,
and medical homes, or CCRCs,
which we've discussed earlier in this module,
that are related to independent living,
assisted living, and skilled nursing.
And finally, here are some conclusions from this module.