KWDI Korean Women’s Development Institute

The Korean government implemented the Long-Term Care Insurance(LTCI) since July of 2008 in order to improve the quality of life among older adults and to decrease the caregiving burden among family caregivers. In Korea, the LTCI system provides support in physical and/or housework activities for individuals who have difficulty with daily living for a period of at least 6 months due to old age (age 65+) or those with geriatric diseases. Beneficiaries are supported through the following long-term care(LTC) services once they receive an approval certificate of LTCI (grade 1, 2, 3): (1) in-home care services such as home-visit care, home-visit nursing, short-term respite care, home-visit bathing, day and night care, and welfare equipment, (2) LTC facility (e.g., aged care facility, senior congregate housing) service where older adults are provided with meals, care, and other daily activities, (3) special cash benefits (e.g., family care expense, exceptional care expense, nursing expenses of LTC hospitals). Although the implementation of LTCI is evaluated as a major step in supporting family caregivers, few studies have evaluated to what extent the goals of LTCI have been achieved. Instead, previous research has focused mainly on the expansion of LTCI infrastructure, the financial issues associated with the LTCI system, and the satisfaction with LTC services rather than examining the impact of the system on beneficiaries and their family members. The aim of this study was to respond to this research gap by examining the impact of LTCI on older adults and their family members, and to provide policy recommendations for policy makers and LTC service providers. Our research questions were as follows: 1) Does the LTCI system improve the quality of life among older adults who are the beneficiaries of the LTCI? 2) Does the LTCI system improve the quality of life among family caregivers by decreasing their caregiving burden? 3) Does the LTCI system improve the family relationship among older adults, major caregivers, and other family members? 4) To what extent are family caregivers satisfied with the current LTCI system, and what are the challenges associated with the current LTCI system? Both quantitative and qualitative methods were utilized in this study. Data were collected from a purposive sample of 600 family caregivers who were the major care providers for their dependent spouses or parents living in Seoul and GyeongGi Province, stratified by beneficiaries’ LTC grade and types of LTC services that they use. Data collected for this study also consisted of structured interviews (n=28) carried out by our research team. The structured interviews for family caregivers lasted approximately 60-180 minutes, depending on the number of participants in each group, and full recordings of sessions were obtained and transcribed. Major questions that were asked to our study participants included, but were not limited to: sociodemographic characteristics of the participants, characteristics of the care-recipient, caregiving burden, overall LTC utilization, and the impact of LTC services on their lives. With respect to quantitative analysis, descriptive statistics as well as multivariate models were obtained using PASW Statistics software. In order to assess the statistical significance of associations, analysis of variance for continuous variables and Pearson chi-square analysis for categorical variables were conducted to examine differences among in-home care service users, aged-care facility users, and those who do not use LTC services. For the qualitative analysis, a comprehensive content review of all data, including line-by-line analysis, was conducted. Our sample composed of family caregivers who used in-home care services (52.5%), those who used aged-care facility (22.5%), and those who did not use any type of public LTC services (25.0%). Major findings of our study are as follows: First of all, two major reasons for using the LTCI services among family caregivers were “to reduce physical burden associated with caregiving work (in-home care service users: 35.9%, facility care users: 46.7%)”, and “family members are not available to take care of the elderly (in-home care service users: 24.8%, facility care users: 19.3%)”. Among the family caregivers who did not use public LTC services, two main reasons for not using the LTC services were “unable to receive approval certificate of LTCI (42.0%)”, and “the services that family caregivers wanted to receive were not covered through the current LTCI system (28.7%)”. Among the various in-home care services, the two most widely used services were home-visit care (94.0%) and home-visit bathing (28.9%) in our sample. On average, beneficiaries used home-visit care for about 20.9 times per month (about 3.4 hours per visit). With respect to home-visit bathing service, beneficiaries reported that they used the service for an average of 3.9 times per month (1.3 hours per visit). For those who used facility care services, the average length of stay was 25.8 months. In terms of the cost sharing, respondents who used in-home care services reported that they spent about 122,740 won per month as a user-cost while respondents who used facility care reported that they spent about 543,203 won per month as a user-cost. More than 70% of respondents reported that these cost sharing were burdensome. With respect to the family caregiver’s satisfaction with the LTC services, more than half of the respondents in this study reported that they were satisfied with the overall services. Yet, satisfaction level was relatively low in the area of service adequacy (i.e., quantity) and service quality. In particular, approximately 20% of respondents who used in-home care services (13% of respondents who used facility care) reported that they were not satisfied with the adequacy of care. Likewise, approximately 7% of respondents who used in-home care services (10% of respondents who used facility care) reported that they were not satisfied with the quality of care. With respect to the quality of life among older adults who were the beneficiaries of the LTCI system, about one-third of family caregivers reported that the functioning of the older adults improved (in-home care users: 31.1%, facility care users: 20.0%), whereas more than one-thirds of family caregivers reported that the psychological/emotional status of older adults improved after the use of LTC services (in-home care users: 41.6%, facility care users: 25.5%). With respect to caregiving burden of the family caregivers, the level of the burden among family caregivers who used LTC services were higher than those who did not use the LTC service. Yet, most respondents reported that their caregiving burden reduced significantly once they had received the LTC services. Specifically, the majority of respondents reported that their physical burden associated with caregiving work reduced significantly. For example, 79.3% of those who used facility care services reported that their physical burden associated with caregiving was reduced. In addition, 81% of family caregivers who used in-home care services (83.7% of family caregivers who used facility care services) reported that the psychological/emotional burden associated with caregiving have been reduced after the use of LTC services. In terms of family relationship, most respondents reported that their family relationship improved significantly after the use of LTC services. Specifically more than half of family caregivers in our study reported that their relationship with the care recipient (e.g., dependent older adults) improved after the use of LTC services. Despite the positive impact of the LTCI policy on the family caregiver’s burden and family relationship, a significant number of family caregivers also pointed out that there is a need for developing a financial support system for informal family caregivers and for expanding in-home services. Specifically with respect to financial support, respondents in our study showed their preference for care allowance and support for nursing-care costs. In regard to in-home care services, respondents reported that there is a need to expand home-visit care and home-visit nursing services. On the other hand, those who used facility care reported that the government should expand facility care services where reliable and systematic care is provided. Those who did not use LTC service showed relatively high preference for the expansion of family support programs such as respite care and counseling programs. In summary, the results of this research suggest that the Korean LTCI system has a positive impact on older adults and their family caregivers in that the use of LTC services 1) improved the quality of life among the beneficiaries, 2) decreased the caregiving burden among family caregivers, and 3) improved family relationships among caregivers and care recipients, as well as other family members. However, the current LTCI system should be modified in order to better meet the needs of beneficiaries and their family caregivers. Policy recommendations are as follows: First of all, the breadth and depth of LTC service coverage should be expanded based on social consensus. Second, more specific, elaborate and reliable assessment tools should be developed. Third, measures to ensure the quality of LTC services should be developed. As the quality of care becomes increasingly important, various quality management systems such as accreditation, development of national standards and guidelines for delivering LTC services, and improved monitoring should be carefully adopted. In addition, measures that can be used to improve the LTC formal workforce such as wage increase and retraining should be introduced. Fourth, although current user payments are set up based on a means test on household income and assets to some extent (i.e., beneficiaries must pay 20% of total costs in institutional care and 15% of total costs for in-home care services; low-income recipients may pay half of the standard personal contribution rates, and social-assistance recipients are exempt from cost sharing), flat cost sharing can raise distributional considerations because lower-income dependent individuals are typically required to spend a great share of their income on LTC user costs. Thus, more attention should be given to balance between collective and individual responsibility for user cost. Fifth, measures to compensate and recognize informal family caregivers (e.g., tax incentives, caregiver’s allowance, cash benefits for the care recipients) should be considered although it is difficult to set up an eligibility criteria and to fix an appropriate compensation level. Lastly, various programs that support family caregivers should be designed and implemented. Such policies include, but are not limited to: respite care that provides caregiver a break from normal caring duties for a short period (e.g., day-care services, in-home respite, institutional respite), counseling and training services, and information and coordination services. It is appropriate that we acknowledge some of the limitations of this study. First, the voices of beneficiaries were heard indirectly from the family caregivers because our sample included only family caregivers. Although we initially intended to include LTC service beneficiaries in our sample, it was not possible to recruit them within a given project time due to their health issues. Another limitation is that the sample in this study is not nationally representative, and therefore, these findings may not be completely applicable to the general population. Therefore, additional outcome studies on the impact of LTC service utilization on the quality of life among the beneficiaries and family caregivers are needed, using nationally representative samples. In addition, the cross-sectional nature of this study requires cautious interpretation of the findings, and therefore, longitudinal studies are needed to detect the impact of LTCI system on older adults and family caregivers. Despite these limitations, the current study adds value to earlier findings because this research explored the way in which the LTCI system influences the quality of life among older adults who have significant limitations with functioning and also to their family caregivers.