Analysis on Long-Term Care and Influencing Factors of Empty-Nest Differently Abled Elderly People in China —Based on the Data from the Chinese Longitudinal Healthy Longevity Survey

Purpose: This study aimed to understand the actual needs of empty-nest differently abled elderly people and analyze their long-term care status including the factors affecting choice of care mode so adequate resources can be allocated to meet their healthcare needs. Methods: An empty-nest group was compared with a non-empty-nest group based on data from the 2014 Chinese Longitudinal Healthy Longevity Survey. Individual characteristics, family characteristics, and sociological factors were considered as independent variables, and long-term care model was the dependent variable in the three binary logistic regression method. Results: Age, gender, marriage, and disability were the most important factors influencing the choice of long-term care mode, including the willingness of the differently abled elderly. Family care can no longer meet the needs of the severely disabled elderly. Long-term care for such elderly people should be undertaken by professional and specialized social institutions. Conclusion: Multi-level services should be provided according to the elderly peoples’ needs, and the skill and expertise of professional personnel of care institutions should be strengthened. The government should deploy fund-raising initiatives, actively use the power of non-governmental organizations, and strive to resolve the financial issues faced by the emp-ty-nested elderly people with disability.


Study Sample
According to the screening criteria, at least one of the ADL indicators was conducted for the elderly people with disability (PWD) who needed partial help or depended entirely on others; missing values were eliminated to obtain a total of 1702 samples. Among 1702 samples, we obtained a sample of 497 empty-nest elderly PWD, which included both couples and single persons, and 1205 elderly PWD in the non-empty-nest group. There were 259 males (52.1%) in the empty-nest group. Their ages ranged from 66 years to 116 years, with an average of 87.44 years.

Measures
In this study, personal characteristics, family characteristics, and sociological factors of elderly PWD were determined as independent variables combined with CLHLS data. Demographic characteristics included age, sex, marriage, disability, and self-rated health status. Family characteristics included the number of surviving children, self-assessment of economic status, and main sources of livelihood, among others. Sociological factors included current medical insurance and the willingness of the elderly to live. For categorized covariates, variable coding with a small assignment was used as the reference group.
The dependent variable was the LTC model. According to the responses of the CLHLS questionnaire to "who is the primary caregiver when you need help in six daily activities" and "who will take care of you when you are sick," care modes were divided into three types: first, family pension provided by direct relatives such as spouses and children; second, home-based care provided by nannies and communities; third, care provided by old-age institutions. The latter two were paid services. Furthermore, according to Su Qun's (2015) classification of the LTC model, the second and third types are collectively referred to as socialized care. Family care was assigned a value of 0 and social care was assigned a value of 1.

Data Analysis
SPSS 22.0 software was used to describe and analyze the basic situation and LTC status of empty-nest elderly PWD, and the influencing factors of LTC model were analyzed by the binary logistic regression method.

Degree of Disability in the Elderly with
Different Socioeconomic Characteristics Table 1 shows the degree of disability in the elderly with different socio-economic characteristics. The proportion of male elderly PWD in the empty-nest group was significantly higher (P < 0.001) than that in the non-empty-nest group. In terms of marital status, the proportion of elderly PWD without spouses in the empty-nest group was significantly higher (P < 0.001) than the second. In the empty-nest group, the proportion with mild disability was 56.7%, followed by severe disability at 24.3%, and that of the elderly with moderate disability was 18.9%. The proportion of elderly PWD who received pension or government relief in the empty-nest group was higher than the other; in contrast, the proportion of family support in the empty-nest group was significantly lower (P < 0.001).  Table 2 shows that among the six basic activities, the elderly PWD had the worst self-care ability in bathing; more than 90% of the elderly PWD needed help. The elderly in the empty-nest group also had the highest degree of disability in bathing and had the most urgent need for bathing care. The proportion of elderly PWD in empty-nest who needed help with dressing, toilet, indoor walking and eating was lower than that of the non-empty nest, and the difference was statistically significant (P < 0.05).

LTC Status of Empty-Nest Disabled Elderly
Upon comparing the disabled elderly's demand for LTC services between the two groups, it could be seen that the elderly PWD in the empty-nest group had a higher demand for various services than those in the non-empty-nest group, except for doctor visits and delivery of medicine. The demand for daily living care service was 1.90 times more among the elderly PWD in the empty-nest group than those in the other. In terms of spiritual consolation services, the elderly's need to engage in conversation and legal assistance services was significantly higher (P < 0.05) in the empty-nest group than in the non-empty-nest group (Table 3).
One-third of the long-term caregivers of the elderly PWD in the empty-nest group were spouses. Besides, social service volunteers/groups (6.1%) were also the main caregivers for the elderly PWD in this group. Incapacitated husbands were mainly cared for by their wives, while LTC for females was mainly obtained from children and social support. The difference between the two groups was statistically significant (P < 0.001). In comparison, the elderly PWD in the non-empty-nest group had lower demand for social services or nursing care, because their adult children were around and their caregivers were their sons, daughters-in-law, or daughters (Table 4).
Three quarters of the elderly in the empty-nest group chose the family care model with spouse as the main caregiver, but 30% chose the social care model with home-based nursing service or nursing home as the long-term caregiver.

Influencing Factors of LTC Model Choice for Empty-Nest Disabled Elderly
This study used the binary logistic regression model to analyze the influencing factors of the LTC model for empty-nest elderly PWD. In the regression analysis, demographic characteristic variables, family characteristics, and sociological was much improved after adding sociological factors (pseudo R 2 = 0.316). The explanatory power of the three models gradually increased (Table 5). people, and the elderly with a spouse was more likely to choose family care.
The probability of the elderly with moderate/severe disability choosing social care was significantly higher than that of those with mild disability, and the incidence ratio was 2.16 times higher than that of the elderly with mild disability. Moreover, the empty-nest elderly PWD who thought they were in poor health were more willing to choose family care. The choice of the LTC model for empty-nest elderly PWD was affected by many factors, especially health status, disability degree, and economic condition. Therefore, these factors should be fully and reasonably considered when providing care services for them.

Strengths and Limitations
The data in this study uses the CLHLS cross-sectional data (2014), which was This study analyzes the quality of health care and health outcomes for empty nest differently abled elderly people in China to understand their long-term care status, and the factors affecting the choice of care mode so that adequate re-sources can be allocated to ensure their health care needs are taken care of. This study makes a new perspective for models of geriatric nurse, quality improvement, for improving the life conditions of the lesser-privileged section of the society, through sustainable solutions including evaluation of the situation, upskilling the institution care personnel, and robust government initiatives. In Japan, LTC assessment was carried out for the elderly and infirm over 65 years old using a care identification questionnaire. The questionnaire used as the national unified standard is objective, rational, and scientific in nature. When evaluating the elderly's abilities, it can be used not only for assessing daily activities and cognitive abilities, but also for medical evaluation. This can be helpful in providing daily life care and medical care at the same time [7].

Interpretation within the Context of the Wider Literature
Research shows that case-based management and care service greatly improves the life condition of the elderly and reduces the number of the elderly living in nursing homes [8]. In China the need for socialized care has increased with the growing prevalence of disability in the elderly. Because the daily activities of the severely disabled elderly basically depend on the care of others, and the task of care is heavy, simple basic living care services are inadequate. According to CLHLS data, about 29% of the elderly PWD are empty nesters, which is estimated to be around 12 million in China. Therefore, with limited government financial expenditure on old-age security, professional evaluators should give priority to comprehensive health assessment of empty-nest elderly PWD, assess their degree of disability, and then determine the content of hierarchical care services most suitable. Through the model of hierarchical care of family, community, and institution, the rational allocation of endowment and medical resources can be realized to meet the multi-level care demands of elderly PWD [9].

Implications for Policy, Practice and Research
Excellent care institutions and high-quality nursing staff can provide high-quality care services for the empty-nest elderly PWD. To ensure that the elderly can access a higher quality of service, developed countries have formed a relatively mature mechanism in the training and assessment of service personnel. For example, German and Japanese caregivers have to pass the professional skills ex- This study has shown that economic capacity largely limits the need for professional LTC for empty-nest elderly. Besides, fund guarantee is also the key to effectively implementing various systems [12]. The Organization for Economic Co-operation and Development (OECD) estimates that spending on LTC for the elderly will increase rapidly, from 1.2% of GDP in 2005 to 2.3% by 2050. The out-of-pocket cost of LTC for elderly PWD in the US comes from medical insurance, medical assistance, and pricing per person. LTC financing in the UK consists of national and/or local taxes and user self-payment. China's support for LTC is mainly realized indirectly through pension, old-age insurance, or low insurance expenditure, but most of the cost of care is borne by the state, which results in heavy financial burden [13]. Therefore, the government should learn from international experience, broaden the channels of raising funds for LTC services, and allow full play to the advantages of non-governmental organizations [14].
• The government should establish a sustained and stable financial input mechanism to incorporate the LTC service fund projects into the government public budget and ensure that the financial input and expenditure on LTC services form a fixed proportion [15]. Under the guarantee of sufficient funds, the existing basic service facilities will be further improved to ensure the sustainability of the LTC service and welfare institutions. • It is necessary to build a policy-oriented LTC insurance system and incorporate it into the social insurance system, to establish a system paid jointly by the elderly individual, the unit where they belong, the family, and the gov-Open Journal of Preventive Medicine ernment. This will help in forming a subsidy system for LTC services, in addition to the government finances, ensuring that the elderly PWD and families with financial difficulties obtain prompt LTC services and benefit from the welfare scheme [16].
• The government can enrich the service content of LTC for empty-nest elderly PWD by purchasing services, helped by a variety of social service sectors, mapped to the needs of the empty-nest elderly PWD, thus providing diverse and specialized services. Finally, by implementing preferential policies such as tax relief and low-interest loans, the government can relax the market access mechanism, encourage social organizations to invest in LTC services for the disabled elderly, and continuously expand the field of services for the elderly. Industrialization, standardization, and institutionalization of the empty-nest elderly PWD LTC services can prove to be beneficial. Further, active trials of LTC insurance and establishment of a nationwide LTC insurance system can be carried out as soon as possible to reduce the financial burden on the elderly PWD.