Abstract
Background
Home care (HC) services are the foundational service in Taiwan, such as personal care, housekeeping, showers, meal preparation, and so on. We used population-representative data to evaluate the effects of HC services use on the long-term functional performance of older adults.
Method
This longitudinal study used latent growth curve modeling, measured as trajectories in activities of daily living (ADL) ability. We retrieved data for 1,851 care recipients from the Long-Term Care Service Management System database.
Results
Continuous use of HC services had positive effects on functional performance over time of declining functional capacity (β = .075, p < .05). While greater age was associated with slower increases in ADL scores, being female and living alone were associated with faster increases in ADL scores.
Discussion
Continuous use of the HC services provided has a significant impact on maintaining or improving functional performance among older adults in the early stage of declined functional capacity.
Background
Facing the challenge of fast-aging populations, many economically advanced countries have devoted themselves to developing effective long-term care (LTC) systems and services. At the May 2016 World Health Assembly, 194 countries agreed that every country should have an LTC system (World Health Organization [WHO], 2016). However, the long-term impacts of such a system were still being examined. Investigating the effectiveness of LTC services would be essential for further system development.
The Government of Taiwan began its National 10-Year Long-Term Care Plan (10-Year LTC Plan) in 2007 (Executive Yuan in Taiwan, 2007). Home care (HC) services were the primary services targeted for development due to cultural preferences among Taiwan’s older population (Ministry of Health and Welfare in Taiwan, 2013, 2015). HC services include services such as housekeeping, laundry, personal care, showers, meal preparation, assistance with walking, and so forth. These services are essential to a home-based LTC system (Birchenall et al., 2003) and are also relatively low-cost services compared to other LTC services (Genworth, 2019). Once Taiwan’s 10-Year LTC Plan was implemented, usage statistics demonstrated the expected high preferences for HC services, with 53.3% of all disabled older adults in Taiwan reported to use HC services (Ministry of Health and Welfare in Taiwan, 2016).
The primary goal of providing LTC services is to support and maintain individuals’ abilities to perform activities of daily living (ADLs; Ministry of Health and Welfare in Taiwan, 2013, 2015, 2016). Thus, functional performance, such as ADL function, is commonly used to evaluate the effects of LTC (Edgren et al., 2015; Imanishi et al., 2017; Katz & Akpom, 1976; Prestmo et al., 2015; Stuck et al., 2002). Past studies have shown that home-based professional medical services, such as home-based rehabilitation, home nursing, and physician visits, can support, maintain, or improve older adults’ functional performance in a short period of time (Asiri et al., 2017; Cook et al., 2013; Han et al., 2013; Imanishi et al., 2017; Edgren et al., 2015; Elkan, 2001; Schmitt et al., 2010; Stuck et al., 2002; Whitehead et al., 2015). WHO proposed a public health framework for healthy aging that emphasizes the importance of promoting older people’s functional ability by providing various support when an individual’s intrinsic capacity begins to decline. Hopefully, this will help older adults maintain functional ability and experience a slower trajectory of functional decline. Past evidence has shown that seeking resources and services related to instrumental ADL (IADLs) early increases the chance of older adults staying in the community (Chen & Thompson, 2011). Also, statistics in Taiwan show that almost 70% of care recipients with mild disabilities receive HC services (e.g., cooking and housekeeping; Ministry of Health and Welfare in Taiwan, 2016). This means that most older people in the early stage of functional decline will use HC services, but the effect of those HC services on maintaining functional performance has remained unclear. Most prior studies focused on home-based professional care or analyzed HC services in combination with other LTC services, and no study so far has evaluated the effect of HC services alone. Very few studies have examined the effects of HC services, even combined with other LTC services, on maintaining or improving functional performance over the long term. One 3-year follow-up study did not find home-based services combined HC services to be beneficial for maintaining older adults’ functional performance.
Past studies have emphasized the importance of the continuity of LTC services use (Elkan, 2001; Olivares-Tirado et al., 2012), and these variables may also be key to significant effects of HC services. We hoped that a longitudinal investigation of the effects of HC services use, taking into account continuity of usage with light needs of older adults, could shed some light on the relationships between HC services and functional performance. Therefore, this study used the population-representative data from Taiwan’s 10-Year LTC Plan to evaluate the effects of continuous use of HC services on older adults’ functional performance trends in 30 months.
Method
This longitudinal study used latent growth curve modeling (LGCM) to evaluate the effects of HC services use (such as personal care, housekeeping, laundry, showers, meal preparation, and accompaniment to medical appointments or on walks) on older adults’ functional performance of ADL.
Data and Sample
We obtained de-identified data from all care recipients who applied for and approved LTC services in Taiwan from 2008 to 2013. Samples were retrieved from the Long-Term Care Service Management System database and provided to the research team by the Ministry of Health and Welfare in Taiwan (2013). The Long-Term Care Service Management System is an online system that collects both evaluation and prescribed service information for those who receive care through the National 10-Year LTC Plan. Data are collected by care managers through face-to-face interviews at care recipients’ homes. All care managers receive professional training from the government. Care managers are responsible for conducting initial evaluations, prescribing services, and reevaluating care recipients’ status every 6 months regularly. The evaluations include care recipients’ sociodemographic information, the status of physical function in basic ADLs and IADLs, and physiological and psychological health. Based on care managers’ evaluations and care recipients’ preferences, care managers then prescribe home and community based services (HCBS) to be provided by the service agencies contracted with the government (Ministry of Health and Welfare in Taiwan, 2013).
To be eligible for services through the 10-Year LTC Plan, care recipients had to meet at least one of the following criteria: (a) be 65 years or older and have functional limitations with ADLs; (b) be Indigenous, 55 years or older, and having functional limitations with ADLs; (c) be 65 years or older, living alone, and having difficulties with IADLs; (d) be 50 years or older and have disability certification. Functional limitations with ADLs are defined as difficulties with six activities: bathing, feeding, dressing, transferring, toileting, and continence. IADL limitations are defined as difficulties with eight activities: using the telephone, shopping, preparing meals, housekeeping, doing laundry, managing transportation, using medications, and handling finances. These activities are categorized into three disability levels: light, moderate, or severe disability. For this study, we further included the following criteria for inclusion: (e) data on an initial evaluation (basic information, ADL, and approved LTC services) plus exactly five follow-up evaluations within 30 months, and (f) an ADL score based on assessments using Barthel Index >60 at the initial evaluation. A Barthel Index score >60 indicates light disability (Sulter et al., 1999). This last criterion was added for the purpose to observe the change in function over time. Also, most Taiwanese older adults who are severely disabled (i.e., with lower ADL scores) and have full-time care needs are eligible to hire foreign caregivers from other countries and pay out of pocket for 24-hour care in their own homes. However, to make good use of LTC resources, the government in Taiwan has regulated that people who hire foreign caregivers are not eligible to apply for HC services or day care services (Ministry of Labor, 2018; Wu et al., 2021). The exclusion criteria were (a) incomplete data on age and HC services use of care recipient and (b) reassessment periods between evaluations of less than 5 months or more than 7 months. (Flow chart of samples is shown in Figure 1 and Supplementary Table 1).
Flow chart of sample inclusion and exclusion.
Measurements
Taiwan’s National 10-Year LTC Plan provides many home- and community-based services, including HC, day care, respite care, adult foster care, Meals on Wheels, home nursing, home physical therapy, transportation, and home occupational therapy (the LTC services use over time is given in Supplementary Table 2). HC services were the fundamental service in the 10-Year LTC Plan and included services such as personal care, housekeeping, laundry, showers, meal preparation, and accompaniment to medical appointments or on walks (Ministry of Health and Welfare in Taiwan, 2013, 2015). Our study divided individuals’ use of HC services into two service use patterns: (A) continuous use of HC services (HC services were prescribed exactly 6 times in 30 months of follow-up) and (B) noncontinuous use of HC (HC services were prescribed 1-5 times in 30 months follow-up). Each variable was dichotomized as Yes or No (Supplementary Table 2).
The outcome variable in the current study is a score-based assessment of the Barthel Index for ADLs, which measures physical function (Mahoney & Barthel, 1965) that assesses activities including eating, transferring from bed to chair, grooming, bathing, managing indoor mobility, going upstairs and downstairs, dressing, toileting, and bowel and bladder incontinence. Performance of each activity is assessed using a Likert-type scale from 0 to 10; all scores (of each ADL performance) are summed, and the summed performance score ranges from 0 to 100. Higher scores indicate better functional performance. Care recipients included in the study were followed up 5 times after the initial evaluation for LTC services; each follow-up evaluation was 5 to 7 months after the previous.
We also collected sociodemographic data, such as age, gender, whether living alone, whether having a caregiver, household economic status: low income indicates an income of <367 USD per month, middle income is a monthly income between 367 and 550 USD (550 USD is 1.5 times the minimum living expense based on annual government determinations), and general income indicates a monthly income of at least 550 USD. Although low- and middle-income families are entitled to use HCBS with a 0 to 10% copayment, the majority of HCBS users in Taiwan are from families with general income levels (Ministry of Health and Welfare, 2016) and a number of comorbidities (0-18) for justification. These are factors that have shown importance to older adults’ LTC services and their rate of change in function disabilities (Chen et al., 2011, 2016; Yu et al., 2015).
Analysis
We applied LGCM to assess the growth trajectory in functional performance. Figure 1 shows the setup of our model. The growth process contained one latent factor of functional performance baseline and one latent factor of functional performance slope (i.e., rate of change in functional performance per evaluation). Functional performance was measured by ADL performance assessed from Time 1 to Time 6, over the 30-month study period. We hypothesized that HC services use and sociodemographic factors would have direct impacts on the functional performance baseline and slope. Measurement errors were set to be correlated (please see examples in Figure 2).
Latent growth curve model for the effect of LTC services use on functional performance.
For the analysis, we first tested a linear and nonlinear unconditional LGCM on older adults’ functional performance over the 30-month study period. Second, we added all observed variables, including HC services use and sociodemographic factors, to the model to test their impact on functional performance trajectories over time.
Next, to address our study aims, we ran the LGCM models. The model compared continuous HC services use (pattern A) to noncontinuous HC services use (pattern B). The common goodness-of-fit indexes for the models were χ2 (p ≤ .05), root mean square error of approximation (RMSEA < 0.08), comparative fit index (CFI > 0.9), Tucker–Lewis Index (TLI > 0.9), and standardized root mean square residual (SRMR < .08; Raykov & Marcoulides, 2012). We used analysis software Mplus Version 7 (Muthén & Muthén, 2012) and IBM SPSS statistics 20.0 (IBM SPSS Statistics, 2011).
Results
In total, our study included data from 1,851 people aged 50 to 97 years who had been evaluated by care managers 6 times in the 30-month follow-up period between January 01, 2010, and December 31, 2013. The average age was 75.13 years, and most (64.3%) were female. There was a significant difference between continuous HC services use and noncontinuous HC services use, such as gender, has caregiver and economic status (p < .05; Table 1).
Sociodemographic Characteristics of the Study Sample (N = 1,851).
Note. Statistics are shown as mean (SD) for continuous variables and number (percentage) for categorical variables. HC = home care; LTC = long-term care.
p < .05. **p < .01. ***p < .001.
Linear Growth Model Results
The unconditional linear LGCM fits well to ADL performance among the included older adults (χ2 = 39.35, p < .001; RMSEA = .035; CFI = .983; TLI = .98; SRMR = .059). Functional performance decreased 0.067 points at every 6-month evaluation (βADL baseline = 80.40, p < .001; βADL slope = −0.067, p < .001). The two groups started out with minor differences in functional performance (p < .05), and over time, the functional performance of the group with noncontinuous use of HC services appeared to decrease more than the functional performance of the group with continuous use of HC services (Table 2).
Unconditional Linear Latent Growth Curve Model: Functional Performance Trajectory and Activities of Daily Living Scores (N = 1,851).
Note. We used analysis of variance in 2 groups (A and B). Model fit χ2 = 39.354; RMSEA = .035; CFI = .983; TLI = .98; SRMR = .059. ADL = activities of daily living; RMSEA = root mean square error of approximation; CFI = comparative fit index; TLI = Tucker–Lewis Index; SRMR = standardized root mean square.
Significance level: *p < .05. **p < .01. ***p < .001.
Results of LGCM
The first conditioned LGCM (Model 1) fitted well to the ADL trajectory (χ2 = 97.886, p < .001; RMSEA = .028, CFI = .988, TLI = .982, and SRMR = .03). Continuous use of HC services use showed significant impact on functional performance (βslope = 0.075, p < .05) when comparing older adults in the groups without noncontinuous HC services use. It means continuous use of HC services was positively associated with a faster increase in ADL scores over time. Continuous HC use was also associated with higher baseline functional performance (βbaseline = 2.206, p < .01; Table 3).
Latent Growth Curve Model: Home Care Services Use and Functional Performance Trajectories (N = 1,851).
Note. Model fit χ2 = 97.886; RMSEA = .028; CFI = .988; TLI = .982; SRMR = .03. ADL = activities of daily living; HC = home care; Ref. = reference group; RMSEA = root mean square error of approximation; CFI = comparative fit index; TLI = Tucker–Lewis Index; SRMR = standardized root mean square.
p < .05. **p < .01. ***p < .001.
We also found that most of the sociodemographic factors were significant predictors of baseline functional performance and rate of change (slope) of functional performance as shown in Table 3. Greater age (βage slope = −0.004, p < .001) and having a caregiver (βcaregiver slope = −0.066, p < .001) were associated with slower increases in ADL scores every 6 months, while being female (βgender slope = 0.045, p < .05) and living alone (βalone slope = 0.05, p < .05) were associated with faster increases in ADL scores (Table 3).
Discussion
This is the first study to evaluate the longitudinal impact of HC services use, including continuous versus noncontinuous use, on older adults’ functional performance over time by using population-representative data of LTC care recipients in Taiwan. Our findings provide evidence that the HC services provided through Taiwan’s 10-Year LTC Plan have a significant impact on maintaining or improving older adults’ functional performance but only when the services are used continuously over time. Many factors influenced the rate of change in functional performance, but the effect of continuous use of HC services was stronger than that of most other risk factors with the exception of age.
Continuous Use of HC Improves Functional Performance
Our findings show that HC services can help older adults with declined capacity to maintain or even improve functional (ADL) performance over time but only if used continuously. Older adults with ADL disability will be likely to experience decreasing functional performance over time if they use it occasionally but not continuously.
These findings shed light on previous inconsistent research findings regarding the relationships between the use of HC services, along with other LTC services, and disabled older adults’ functional performance (Elkan, 2001; Olivares-Tirado et al., 2012). It may take more time for HC services to demonstrate effects on functional performance than it does for home-based professional care provided by doctors or nurses or other licensed health-care providers. Most important, the ADL slope increased over time among the group of older adults who used HC services early and continually, when compared to the slope among noncontinuous HC users. The effects were cumulative, and the between-group gap in the speed of progression toward poor health function increased over time. Our findings shed some light on past studies in that older adults who seek resources and services early will increase their possibility of staying in the community (Chen & Thompson, 2011) and that older adults with light LTC needs will be less likely to be hospitalized or institutionalized (Tomita et al., 2010). Our study further suggests which pattern of HC use will support functional maintenance or even a slower rate of functional decline.
Past studies that examined relationships between HC services and functional performance combined HC services with other LTC services and assessed functional performance over a short period of time, such as 1 year (Han et al., 2013; Imanishi et al., 2017; Prestmo et al., 2015; Tinetti et al., 2002). One study followed participants for 3 years of LTC services use yet did not find that the combined services—HC as well as other LTC services—were beneficial to maintaining older adults’ functional performance (Imanishi et al., 2017; Prestmo et al., 2015; Tinetti et al., 2002). Our findings suggest that the lack of effect found was probably due to the frequency of use of services, plus the small sample size, which was drawn from one suburban city in Japan. We conclude that service use is important to identifying effects on older adults’ functional performance.
In summary, these findings provide a different viewpoint for discussing frequency and LTC services use. We found that older adults who are in their early stage of function decline and used HC services continually will maintain their health better and even had a slower rate of function decline compared to noncontinuous users.
Sociodemographic Factors and Functional Performance
This study also resulted in interesting findings regarding the impact of sociodemographic factors on trends in ADL performance among older adults in Taiwan. Specifically, age, gender, living alone, and having a caregiver were found to predict the rate of change in ADL performance over time.
Greater age has been found to add burden to older adults’ speed of progression toward ADL disability if there is no intervention (Chen et al., 2016; Liang et al., 2010; Yu et al., 2015). In our study, older women seemed to progress toward better functional status faster than older men. Past studies showed that older women progressed toward greater disability faster than older men (Chen et al., 2011, 2016; Yu et al., 2015). It is possible that older women in our study were more likely to be in continuous HC use group and the types of HC services that were provided to the older adults in the current study benefit older women more than older men in terms of functional performance. Why and which types of HC services affect men and women differently and why older women seem to benefit more merits further study.
Another interesting finding was that disabled older adults who were living alone tended to make faster progress toward better functional performance than those who were not living alone while having a caregiver added to older adults’ progression toward disability. One past study suggested that disabled older adults with family caregiving support are less likely to use formal LTC services, such as HC services, and that this may add a burden to their caregivers. The study suggested that lack of formal LTC service support may be a reason older adults with family caregivers were more likely than those without family caregivers to eventually move from community living into a skilled care facility (Chen et al., 2011). Our study findings add more information to this picture: It is possible that older adults with family caregivers may be less likely to use formal HC services on a continuous basis. Given our findings regarding continuous versus noncontinuous service use, these adults’ functional performance would be less likely to improve over time, and the resulting increase in disability over time could affect their ability to age in the community.
Together, our results indicate that older adults who are female and live alone are likely to experience greater improvement in functional performance over time with continuous use of HC services.
Limitations
This study has several limitations. The data were retrieved from the Long-Term Care Service Management System database in Taiwan. In this database, some information was limited, including individuals’ actual usage and intensity of HC, reasons for interruption of HC services, and the effects of other home-based services (e.g., home nursing care and home doctor visits). For this reason, the effect of specific HC services (e.g., housekeeping, laundry, and meals), as well as different combinations of HC services, on maintaining functional performance has remained unclear. Further research is needed. In addition, the samples included for analysis consisted of older adults in Taiwan who were continuous users of at least some type of HC services over at least 30 months. These users are likely to be older adults with better functional performance because, in Taiwan, most older adults who have severe disabilities and still live in the community are receiving care from foreign caregivers (Ministry of Labor, 2020), and this disqualifies them from receiving services through the 10-Year LTC Plan. Since the current study only observes those who start with light disability and the functional trajectories of those with a severe disability might be different. Our study findings may not be generalized to those with severe disabilities. Further study will be important to determine whether the trends remain the same among people with a moderate or severe disability who have similar LTC use. Also, to examine the impact of different services on older adults’ health from a longitudinal perspective.
Conclusion
In summary, we found continuous use of HC services to have positive effects over time on older adults’ functional performance as defined by improved ADL performance scores. These results have several implications. We conclude that the HC services provided under Taiwan’s 10-Year LTC Plan (Executive Yuan in Taiwan, 2007; Ministry of Health and Welfare in Taiwan, 2016) were effective in maintaining and even improving disabled older adults’ functional performance, especially for women. Continuous use of HC services could be the key to this effect on functional performance in the early stage of function decline. Our study findings support continuous HC services use as the foundation of effective home-based LTC. This information provides valuable information and direction for future LTC policy development in Taiwan as well as in other countries engaged in developing or redeveloping LTC policy for fast-aging populations.
Supplemental Material
sj-pdf-1-jag-10.1177_07334648211032419 – Supplemental material for Continuous Use of Home Care Services and Functional Performance: A Population-Based Approach
Supplemental material, sj-pdf-1-jag-10.1177_07334648211032419 for Continuous Use of Home Care Services and Functional Performance: A Population-Based Approach by Tzu-Ying Chiu, Hsiao-Wei Yu and Ya-Mei Chen in Journal of Applied Gerontology
Footnotes
Author Contributions
T.Y.C. planned the study, performed all statistical analyses, interpreted the results, and wrote the paper. H.W.Y. helped to interpret the results and contributed to revising the manuscript. Y.M.C. supervised the data analysis, interpreted the results, discussion, and contributed to revising the paper.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Ministry of Science and Technology in Taiwan (108-2410-H-002-123-SS2, MOST-109-2634-F-002-044) Ministry of Education (109L9003), and the Health and Welfare Data Science Center for its gracious help with data access (H104146).
IRB
Research Ethics Committee of National Taiwan University (201508093W).
Supplemental Material
Supplemental material for this article is available online.
References
Supplementary Material
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