Population ageing with an increasingly disabled population has become a major concern in developed and developing countries [1, 2], and the demand for long-term care services is rising [1–3]. Taiwan became a World Health Organization (WHO) defined ageing society in 1993, and the percentage of population aged ≥65 years (an aged population) is predicted to double by 2017 [4]. The impact of rapid population ageing is complex and raises many healthcare issues including the long-term care of disabled people in countries including Taiwan [5].

Home healthcare is one part of a continuum of health care in many countries. In Taiwan, home healthcare services are reimbursed by the National Health Insurance (NHI) program [6]. According to the Home Nursing Care Payment Regulations in Taiwan, home healthcare service reimbursements are limited to medical or nursing institutions that meet the requirements of the Department of Health (DOH). Furthermore, the regulated parameters include the frequency of professional visits including physician visits (one visit every two months) and nursing visits (one visit every two weeks) [7]. In Taiwan, becoming a practice home healthcare nurse requires registered nurses to complete basic training courses including curricula on long-term care, infection control, disabled care, nutritional care, physical examination, terminal care, swallowing and speech care, and maintenance of activities of daily living. Clinical practical internships in home healthcare and in long-term care facilities are also needed [8]. A patient qualified to apply for home healthcare services needs to fulfill the following three criteria: 1) limited ability of self-care (over 50% of the time while awake, the patient is chair-bound or bed-bound), 2) definite medical or nursing care needs, and 3) chronic conditions requiring long-term nursing care, or continual nursing care needs following hospital discharge.

The home healthcare services items reimbursed by NHI in Taiwan include general nursing services, special skilled nursing services, laboratory tests, nurse visits and physician visits [7]. The general nursing care services include physical evaluations, nursing instructions, drug injections and fecal extraction. Special skilled nursing services include the changing of urinary catheters or nasogastric tubes, or tube tracheostomy, nephrostomy or cystostomy catheters; changing the dressing of stage III and IV pressure sores; intravenous fluid injection and ostomy nursing [7]. The NHI reimburses home nursing visits with fixed rates according to resource utilization groups (RUGs) graded 1-4 as follows: RUG-1 are patients who need general nursing care services only; RUG-2 patients need a single additional kind of special skilled nursing care service besides general nursing care; RUG-3 patients need two additional kinds of special skilled nursing care services; and RUG-4 patients need an additional three kinds of special nursing care service [7]. The NHI also reimburses physician visits in a fixed payment, not according to the RUG classification of patients as for nursing visits [7].

More information concerning home healthcare service utilization is needed to meet the needs of a rapidly aging population in Taiwan. Presently, a nationwide study of health insurance data was undertaken to examine utilization and delivery patterns, including diagnostic indications, for home healthcare services used by seniors in Taiwan.

Considering the total home healthcare visits, individuals aged 75-84 years accounted for the greatest proportion of total visits (47.0%), while those ≥85 years of age represented the lowest proportion of visits (24.4%). On average, those aged 65-74, 75-84 and ≥85 years of age had 6.9 ± 4.8, 6.5 ± 4.8 and 6.3 ± 4.8 home healthcare visits, respectively (Table 1). The number of home healthcare visits per patient during 2004 was further arranged into five categories (1-3, 4-6, 7-9, 10-12 and ≥13 visits). Females were more likely to receive home healthcare visits than males in every category (Figure 1).

According to the ICD-9-CM coding systems, the five major diagnoses for patients receiving home healthcare visits were cerebrovascular diseases (n = 64,789, 50.7%), dementias (n = 14,432, 11.3%), diabetes mellitus (n = 7,523, 5.9%), other diseases of the lung (n = 3,755, 2.9%) and Parkinson's disease (n = 3,482, 2.7%).

Among all home healthcare visits to beneficiaries ≥65 years of age in 2004, community-based home nursing institutions were responsible for providing the majority of visits (52.6%), followed by metropolitan (18.4%) and local (17.3%) hospitals, academic center-affiliated nursing institutions (9.8%) and community health centers (0.9%).

Population ageing and its impact on healthcare systems are important issues worldwide [1, 2, 5]. Aging and disabled populations need continual care delivered in the home or community healthcare institutions [3, 14]. In Taiwan, home healthcare is reimbursed by the NHI system, a social health insurance that covers almost all of the country's citizens. The present nationwide survey revealed that 19,483 beneficiaries over 65 years of age received home healthcare services in 2004. However, the estimated number of older people who were disabled and in need of home personal or health care was 40,000-100,000 in 1993 [14], and is expected to grow to 118,000-240,000 by the end of 2010 [14, 15], indicating that the patient number receiving home healthcare in 2004 under the NHI was much lower than the estimated disabled older population. There are several possible reasons which may account for this discrepancy. First, in Taiwan, home healthcare services are reimbursed by the NHI, which defines clear criteria of the application for home healthcare services [7]. However, the estimation of the disabled population was made according to the disability level evaluation by activities of daily living, or instrumental activities of daily living. Secondly, the study did not include the older population who needed living support such as personal care, home help, living care, or meal services. Lastly, the study did not include patients who received long-term care in long-term care facilities or in nursing homes.

Several studies have demonstrated the gender differences in healthcare utilization [16–19]. Women take more responsibility and have greater concern for their health conditions, visit their physician more often and utilize primary care services more than do males [18, 19]. In this study, similar gender differences in the prevalence and utilization of home healthcare services were noted; females were more likely to use home healthcare services and receive more visits than males, even after adjustment for age. This may reflect the fact that there were more disabled females than males in these aged populations [15].

Community home nursing care institutions are one kind of nursing institution in Taiwan supplying home healthcare visits and services [20], and are regularly inspected by the national DOH. In this study, half of home healthcare services, as well as professional visits, were provided by these institutions. However, the quality of home healthcare provided by different healthcare institutes, and the outcome of patients who receive home healthcare from these different institutes, deserves further evaluation.

Physician-based comprehensive home visitation is effective in preventing functional decline, nursing home admission, and death in elderly people [21–23], and also is associated with good satisfaction among patients and their family members [24]. Taiwan NHI regulations limit physician home healthcare visits to one every two months [7]. To improve the outcomes of patients receiving home healthcare and the quality of home healthcare, a physician-based comprehensive and integrated home visit program seems to be necessary [25].

Taiwan's NHI pays for home nursing visits at a fixed rate based on resource utilization group classifications of patients, which is dependent on skilled nursing services. This payment system might contribute to the high rate of tube placement in home healthcare receivers and the potentially inappropriate intubation of these patients is possible. In this study, RUG-2 contributed to nearly 60% of all nursing visits. Previous studies revealed that the prevalence of indwelling urinary catheters or nasogastric tube insertion among long-term care facility residents in Taiwan is higher than that in the United States and European countries [26–29]. Long-term placement of urinary catheters or enteral feeding through nasogastric tubes can cause patient discomfort and lead to complications such as tube dislodgement, mucosal injury, infection and pressure ulcers, resulting in a decreased quality of life [26, 30]. The rate of tube replacement of home healthcare patients in Taiwan deserves more attention.

The strengths of this study include its large sample size and the use of a complete nationwide computerized database representing the current practice pattern over a year. Although the study was a nationwide claims-based study, it also had some limitations. First, the one-year cross-sectional survey could not provide information about trends in home healthcare use. Second, the claims data did not provide detailed demographic and socio-economic data, or medical backgrounds of the beneficiaries, which precluded analysis of possible contributing factors such as education level, economic background, caregiver status, family composition, polypharmacy and inappropriate prescription for home healthcare utilization.

The NHI program provides available, accessible and accountable home healthcare services for disabled older patients in Taiwan. However, only a limited number of disabled older patients apply for these services. Among these patients, individuals aged 75-84 years old account for the greatest proportion of total visits, and females used these services more than males, mainly for treatment in connection with cerebrovascular diseases. Most of the home healthcare services are provided by home nursing care institutions and the majority of home skilled nursing services involve tube replacement. Further research is needed to clarify the rate of tube replacements in home healthcare services in the elderly population in Taiwan.