Yan Ming-kit knew she had to seek outside help when her mother suffered a fourth stroke eight years ago. Tam Kam-chue had been a livewire when she was younger, but at the age of 79, arthritis, high blood pressure and diabetes were taking a toll on her health. The confusing changes she was experiencing as dementia set in also left Tam feeling suicidal, so the family decided to act.
'She used to live with me and my three daughters. I woke up at 6am every day, fed and bathed her before going to work,' says Yan, then an insurance agent. 'We delayed institutionalisation for as long as possible. After the fourth stroke, we placed her in a day-care centre and I picked her up after work every day.
'But social workers told us that tending to my mother would become overwhelming. In the end I took their advice and applied for a place at a government-subsidised nursing home.'
It was an excruciating four-year wait before there was a place at the Quan Chuen Home for the Elderly in Aberdeen. Tam's condition deteriorated rapidly, and her dementia induced incontinence and insomnia. Nonetheless, 57-year-old Yan found it a wrench to place her mother in a nursing home.
'We were always close and when we lived together, I often went shopping with her. She loved visiting jewellery shops,' she says. 'I didn't want to part with her. But with her worsening condition, it is in her best interest to let professional health-care workers take care of her.'
Yan's mother is relatively fortunate. As the city marks Senior Citizens Day today, families and care services are coming under huge pressure in Hong Kong's rapidly ageing society. Census officials estimate that the proportion of people aged 65 and above will rise from the current 13 per cent to 28 per cent by 2039.
Inevitably, increasing numbers of seniors will require special attention. But gerontology experts say skewed policies are leading to a greater rate of institutionalisation in Hong Kong while driving many families to place their elderly in third-rate private nursing homes because better-run subsidised centres are bursting at the seams.
About 6 per cent of the more than one million people in Hong Kong over the age of 60 live in nursing homes - well above the 2 per cent to 3 per cent rate of elderly institutionalisation in countries where more resources are devoted to community care. But it doesn't have to be this way, says Chan Chi-yuk, a member of the Elderly Commission and vice-chairman of the Elderly Services Association of Hong Kong.
The frenetic work culture and crowded living conditions in the city mean many families can't afford to have their elderly live with them. As independent life becomes more difficult for the old folks, families struggle to place them in properly run care centres.
Social Welfare Department figures for September show there were 27,707 seniors queuing for places in subsidised homes, which are mainly run by charities and are better quality. Applicants have to wait an average 29 months for a spot and 5,000 die each year before they can get in. The long wait has forced many elderly to turn to private nursing homes, often of dubious quality, says Chou Kee Lee, an associate professor in gerontology at the University of Hong Kong.
'While the 26,000 subsidised places are all full, there is a 30 per cent vacancy among the 52,000 slots in [about 600] private nursing homes. Government-subsidised homes typically occupy entire blocks and are staffed by large teams of health-care workers. In contrast, private homes occupy sites of former restaurants and nearly all their residents are assistance.'
Insiders in elderly services argue that the government approach of subsidising only seniors without family support discourages people from taking care of aged parents and call for a comprehensive policy revamp. At present, families must cover nursing home fees either with the subsidy of about HK$5,000 or entirely out of their own pocket.
'Such a policy means that many families can only enrol in homes that charge within that amount. Paying the full bill of more HK$10,000 each month at a better home is beyond their means,' Chan says. Chou adds: 'When you enrol your parent in a private nursing home, the first thing staff ask you to do is to apply for welfare assistance. This is so the home gets steady revenue from the government.
'But to qualify for assistance, you must sign a declaration that you will stop supporting the parent and leave them to their own devices.
'Instead, the government should introduce a co-payment mechanism, where it will match any contribution made by offspring towards nursing home fees. This will not only encourage people to care for their parents but also enhance the standard of nursing homes.'
Private care homes vary but the organisation Against Elderly Abuse of Hong Kong is receiving increasing complaints about their operations, says its assistant executive director Roy Lam Man-chiu. Last year, the group registered 1,767 cases of abuse in private nursing homes, a 53 per cent rise from the 1,154 cases in 2008. Complaints often involve poor nutrition and sanitation, psychological and physical abuse, and asset appropriation.
Lam reckons the Residential Care Homes (Elderly Persons) Ordinance introduced in 1996 is too lax in its requirements of staff ratio, standard care procedures and the like. 'The spot-check regime is not strong enough to deter abuse,' he says.
A significant part of the problem is private homes don't organise residents in terms of level of care, Lam says.
'To remain open, homes take in even severely ill patients who need 24-hour care, although they know they are not set up to do so. Unlike government-subsidised centres, where the sprightly are separated from the bedridden, everyone is under one roof in private homes, regardless of health condition.'
Noting that money spent on nursing homes far exceeds funds for community care, Chan says more resources should be channelled into boosting rehabilitation, day-care and temporary residential services. This would reduce the need for institutional care.
'It is assumed that once an elderly resident enters a nursing home, he will stay there until he dies. Currently, no one would leave a subsidised home as they have to queue for years to get a place again. Yet over 90 per cent of old folk do not like living in care centres.'
Elderly people can lose the ability to care for themselves due to conditions including renal problems, stroke, bone and joint ailments and frequent falls induced by osteoporosis.
But even those who are paralysed can stay at home if there is sufficient family support, says Dr Kong Ming-hei, a consultant in geriatric medicine at Pamela Youde Nethersole Eastern Hospital.
'Given support and love by families, even the severely ill elderly can recover. Good emotional health also slows their decline.'
The key is whether family members are willing to learn how to look after them, for instance, mastering ways to move and bathe the bedridden, administer medication and prevent bedsores. At the same time, Kong says there must be a comprehensive community care system to help family members.
'They need to know what kinds of resources are available to them and who to call when problems come up. The 14 days after discharge from hospital are critical,' Kong says. Adopting schemes from the West, the government recently launched a pilot project to identify the high-risk elderly, who would be given transitional care after their discharge from hospitals.
NGOs involved would be informed of the release date to make sure they receive rehabilitation or have basic needs taken care of when they go home, while hospital case managers would visit or call to monitor their progress.
But demand for community care far outstrips the government's ability to supply it, says Cheng Ching-fat, secretary of the Community Care and Nursing Home Workers General Union.
'In districts with rapidly ageing population like Wong Tai Sin, you have to wait for 19 months after hospital discharge to get a community worker to deliver meals for you. There are also long queues for other services like help with bathing, washing wounds and shopping. A minimum four-month wait for a place in a day-care centre is the norm. In the intervening period, no one knows how the elderly person is doing.'
Tight work schedules mean community workers can only tend to the elderly's basic need, he adds. 'A group of about eight workers have to visit 60 households, so there's little we can do beyond delivering the food.'
Cheng suggests learning from Japan, where community care is provided by social enterprises. They mobilise retirees and housewives to serve as nannies, pairing each with two seniors. 'Happy and healthy ageing can only be achieved in a close-knit community,' he says.
But for those with severe conditions, Chan says families should put in extra time and effort to lessen the shock and pain of inevitable institutionalisation.
'The elderly will feel frightened and abandoned after being relocated to a nursing home. It takes time to get used to group living, like having fixed schedules. Families should pay frequent visits to help them make the transition,' he says.
Yan Ming-kit goes the extra mile, making a long commute daily to visit her mother in Quan Chuen.
'She loves dolling up. She used to put on perfume, nail polish and wore all kinds of accessories, so I do all of that with her on my visit. We also stroll outside, window-shop and visit Chinese restaurants. I don't want her life to change just because she's moved to a nursing home.'