Research On The Development Of Nursing Home Care: Demand And Supply

BackgroundAccording to the international standards of aging, China has become an aging society since 2000. As population are rapidly aging and the demand for elderly care are increasing, government encouraged for-non-profit organizations and individuals to provide nursing home services for the elderly since the traditional family supports for elderly people were decreasing due to the socioeconomic development and one child policy. In recent years, nursing home care has evolved rapidly in China. It's necessary to conduct researches on demand and supply for nursing home care deeply and systematically, considering the rapid aging population in China.Although a number of researchers have carried out lots of studies in the field of nursing home care, there are still some limitations in terms of research design, selection of sample, research contents and analysis methods. For the majority of sampling methods in the researches on nursing facilities are non-probability sampling or case study, it's difficult to draw a representative sample. Current studies tend to focus on the demand or supply of the nursing home care and the comprehensive analysis are lacking, so it's difficult to measure the gap between demand and supply of nursing home care in China. The relationship between factors such as service environment, services offered, staffing in nursing homes and the occupancy rate, as well as the efficiency and quality of nursing home care in China are not well understood. A study on the development of nursing home care in China based on the demand and supply was conducted in the city of Jinan. It's supported by grant from National Institutes of Health of the USA.Research ObjectivesThe goals of this research are to analyze the current status of nursing home care in China in terms of demand of elderly people and supply of nursing facilities, using qualitative and quantitative research methods. Specific aims of the research are to:1) investigate the perceived nursing home care demands of elder residents in urban and rural areas, as well as current supply in Jinan China, and examine the potential gap between nursing home care demand and supply; 2) identify the predictors of demand for nursing home care and determinants of occupancy rate in nursing facility; 3) evaluate the efficiency and quality of nursing home care; 4) provide recommendations on nursing home development for government and policymakers.Study DesignDocument analysis and focus group interview were conducted to collect qualitative materials, while field investigation and self-administrated questionnaire survey were carried out for quantitative study. Purpose of focus group interview was to measure the perceptions of stakeholders of nursing homes regarding the demand and supply of growing nursing home care. Five focus groups were organized (for community and institutionalized elderly, nursing home providers and administrators as well as government officers) including a total of 49 participants. Purpose of field investigation was to collect data of the demand for nursing home care of elderly people aged 65+ in both rural and urban area. Based on multistage sampling method, in urban area a total of 709 questionnaires were returned from five districts, and in rural area a total of 362 questionnaires were returned from nine villages. Purpose of self-administrated questionnaire survey was to collect data of service environment, staffing, financing, and services offered in nursing homes in Jinan, China. A total of 45 questionnaires were returned. Statistical analysis methods included descriptive analysis, multilevel model analysis, cumulative logistic regression model, data envelopment analysis and Tobit regression model, using statistical analysis software of SPSS16.0,HLM6.08,SAS9.0,Max DEA 5 and Eviews3.1.Principal Findings1. Demand for nursing home care of the elderly and predictors:Among the 1071 elderly residents surveyed, only a small number were willing to reside in nursing home, and the percentage was 7.60% in urban area and 5.00% in rural area. The expected nursing home services were focused on daily care and medical care. Predictors of demand for nursing home care included three explanatory variables of resident level in multilevel model, which were fewer adult children (odds ratio[OR]=2.00; 95% confidence interval[CI]:1.40-2.86), better physical health status(OR=1.68; 95%CI:1.22-2.32), comprehension of nursing home care (OR=1.65; 95%CI:1.32-2.06), and one contextual variable of community level in the model, which was whether there was a nursing home established around community in which the elderly resident lived (OR=2.99; 95%CI:1.02-8.76).2. Current supply of nursing home care:There were 48 nursing facilities located in five districts in Jinan with approximately 5,000 beds. Out of 45 nursing facilities investigated, nine were owned by the government or non-for-profit organizations, and 36 were owned by individual. Service environments in the majority of nursing homes can meet the requirements of regulations and standards made by the government. Generally, service environment in nursing home with larger bed size was better than that in nursing home with small bed size. Nursing aids was the majority among staffing in nursing home (51.74%), and the lacking of nursing staffing was a popular issue in nursing facilities in China. Furthermore, majority of nursing staffing were laid-off workers or rural migrant workers with lower educational level and without skilled training of elderly care, and frequent turnover of nursing staffing was another issue affecting the administration of nursing home care. Seventy percent of nursing homes provide elderly care, medical care, recreational activities, and rehabilitation service. Nursing homes owned by government, non-for-profit organizations or with more than 150 beds had the advantage of providing better medical care for residents. Charging standard for residents was established by nursing home administrators and the average charging standard ranged from 800 yuan to 1100yuan in Jinan, China. Generally, charging standards of nursing facilities with larger bed size were higher.3. Qualitative analysis of nursing home care quality:Most participants in focus groups for administrator were satisfied with the quality of nursing care; however, some participants of focus groups of nursing home residents concerned the quality of nursing home care.4. The gap between demand and supply:There was a huge gap between the demand for nursing home of elderly people and the beds supply in nursing homes in Jinan. Theoretically, the bed size of nursing facility should increase by 1.72 times in order to meet the demand for nursing home care. Gap also remained between the level of service, the quality of nursing home care and the demand of the elderly. In general, charging standards of nursing facilities could accord with income levels of elderly people in urban area, while exceeded the paying capacity of elderly people in rural area.5. Utilization of nursing home care and determinants:Average occupancy rate of nursing facilities in Jinan was approximately 70 percent. Determinants of occupancy rate included ownership, services offered and financing support from government. Nursing home owned by the government or non-for-profit organizations, offering abundant services, achieving financing support from the government had a probability to get higher occupancy rate. Of 2971 residents in 45 nursing homes, the elderly aged 70-79 accounted for 47.36%, aged 80+ accounted for 31.71%, the elderly who are requiring assistance in daily life accounted for 35.54%, and the elderly who are totally dependent in daily life accounted for 31.57%.6. Evaluation of nursing home care efficiency and predictors:Out of 45 nursing homes analyzed in Jinan China,28 (accounting for 37.78%) were found be inefficient with an average relative efficiency score of 80.65%(quartile range=22.61%). Six of nine nursing homes owned by government or non-for-profit organizations and 22 of 36 private nursing facilities were DEA-inefficient with average relative efficiency scores of 83.92%(quartile range=12.90%)and 77.70%(quartile range=32.46%) respectively, however the difference was not statistically significant. We found that facility characteristics including location, ownership, hospital affiliation, as well as services offered, financing support from the government did not affect efficiency of nursing homes in Jinan, China. Categories of recreational activities and the number of administrators in nursing home were potential influencing factors of nursing home care efficiency and their coefficients of Tobit regression were 0.041 and-0.113 respectively, indicating that higher categories of recreational activities provided in nursing home contributed to greater efficiency, while higher number of administrators led to lower efficiency.Conclusions and RecommendationsPercentage of elderly people who were willing to reside in nursing home ranged from 5% to 8%, and the expected nursing home services were focused on daily care and medical care. Predictors of demand for nursing home care included fewer adult children, better physical health status, and comprehension of nursing home care and whether there was a nursing home established around community in which the elderly resident lived. There was a huge gap between the demand for nursing home and the beds supply in nursing homes in Jinan. Gap also remained between the level of service, the quality of nursing home care and the demand of the elderly. Majority of nursing homes were DEA-inefficient, and abundant recreational activities, as well as less administrators in nursing home contributed to greater efficiency. We suggested that government should give more support to nursing home care industries, and pay more attention to training for nursing staffing in nursing facilities. Quality and efficiency of nursing home care should be improved.Innovations and LimitationsWe conducted a comprehensive and systematic study on demand and supply of nursing home care in China for the first time. The research experience and findings were helpful to lay a foundation for further study and provide recommendation for the government to make policies regarding nursing home care. The innovations including: 1. In the aspect of research framework, we established a research framework including demand and supply of nursing home care and measured the potential gap between demand and current supply, establishing a platform for further study. It's helpful to get better understanding regarding the development of nursing industry in China and provide recommendations for policymakers.2. In the aspect of research design, we evaluated the efficiency of domestic nursing home care for the first time and explored the determinants of occupancy rate and efficiency in nursing homes. A multilevel model was used to analyze the predictors of demand for nursing home care to improve the reliability of the results. We selected input and output variables in data envelopment analysis by means of determination coefficient, combining the situation of nursing facilities in China in order to improve research objectivity.3. In the aspect of research findings, we examined the relationships between facility structure, service environment, staffing, services offered, financial condition of domestic nursing homes and occupancy rate, as well as efficiency. We calculated DEA-efficiency scores of nursing facilities and found that input resource underutilization, especially physical properties, were existed in most nursing homes. These new findings were helpful to get better understanding of nursing home care and provide innovative evidence for the development of nursing facilities and useful data for the administration and construction of nursing homes.The limitations of the research including:1. This dissertation study is the first part of serial researches concerning nursing home care in China. Quantitative analysis on nursing home care quality evaluation will be conducted in further researches.2. The effect of community variable on demand for nursing home care of the elderly and the interactive effect with individual variables, as well as the relationship between external factors of nursing home (e.g. credit, cooperation with charity organizations) and service efficiency will be analyzed in further study.