Home as Sickroom, Community as Clinic

The Road to Home Healthcare

2018 / September

Lynn Su /photos courtesy of Lin Min-hsuan /tr. by Scott Williams

A 30-year-old Japanese film called The Ballad of Nara­yama depicts the probably apocryphal rural Japanese practice of uba­sute, a harrowing type of senicide. In the film, the residents of a poor village abandon individuals over the age of 70 on a mountainside, leaving them to die as a means of conserving scarce resources.

In Taiwan, the rapid aging of our society has us projected to become a “super-aged society” by 2025. Meeting the healthcare needs of elderly people in such circumstances is a thorny problem. Japan’s system of home healthcare presents us with a potential means of addressing the prospect of becoming what is known as a “death-burdened society”one in which there is a large increase in the number of elderly deaths.


The tall smokestacks of a sugar mill visible from Provincial Highway 11 in Tai­tung’s ­­Donghe Township let us know that we’ve arrived in Du­lan. This sleepy village nestled between Mt. Du­lan and the Pacific Ocean is home to Home Clinic Du­lan, Taiwan’s first primary-care medical office structured around the provision of home healthcare.

We accompany Dr. Yu Sang-ju, the ­clinic’s director, and Lin Lan­fang, its nurse, as they pack up a medical bag and first-aid kit for a trip into the mountains to check on and treat locals who can’t get around on their own. The journey presents us with a perspective on everyday life in a small rural village rarely offered to outsiders.

Managing chronic conditions

We stop in front of the Fu’an Temple to find the elderly Qing­quan (not his real name) dozing in the shade of a banyan tree.

Working in perfect synchrony, Yu and Lin unpack their equipment, check their patient’s vital signs, and evaluate his condition.

The 95-year-old Qing­quan suffers from many of the ailments common in old age, including high blood pressure, skin allergies, and osteoarthritis. He nonetheless remains active, still waking at five o’clock every morning to make his way to the temple in his wheelchair and tend to the vegetables he grows on an open piece of land.

But his circumstances were very different just a few months ago. Then untreated for several conditions, he suffered from itchy skin that prevented him from sleeping soundly and arthritis that made it difficult to walk, as well as having systolic blood pressure of over 180 mm Hg.

The remote location of his home and his family’s lack of a car made it very difficult for him to receive medical care. Yu didn’t begin treating Qing­quan until a home services worker with a social welfare organization turned the case over to him. The regular medical care he has received since then has greatly improved his quality of life.

“Take these!” says Qing­quan, bustling to his garden to cut sweet-potato leaves that he then stuffs into the doctor’s trunk.

Communicating with family members


Lin spends the drive to the next patient on the phone with a physical therapist, confirming that the therapist will be at the patient’s home at the same time as the doctor.

Zhenfa (not his real name) has been bedridden for a long time. In fact, when Yu visited him for the first time several months ago, his family swore that he was incapable of getting out of bed.

Fearing that this lack of activity would result in muscle loss and eventually sarco­penia, Yu found a physical therapist to help Zhenfa work on his leg strength.

“But if he walks around, he could fall down,” worried his son. Yu responded that at the very least they could help make Zhenfa strong enough to stand on his own.

The physical therapist subsequently recom­mended that Zhenfa practice standing three times a day for five minutes at a time.

Yu also suggested that the physical therapist explain the treatment to the nurse, so that she would be able to help Zhenfa practice each time she visited.

A local support network

With the day’s visits done and the sun setting, a still ener­getic Yu asks, “How about going out for some douhua?”

In no time at all, we’re sitting at the round table in front of the display window of Du­lan’s independent bookstore, enjoying the shop’s brown sugar douhua.

For Yu and Lin, it was just another day at the Home Clinic Dulan.

When visiting his patient’s homes, Yu enters like a next-door neighbor, sometimes just chatting with seniors for a moment about this and that. But when he hears that someone isn’t feeling well, he immediately makes an appointment to see them. Such attentive in-home care not only earns the gratitude of family members, but also helps community members begin to grasp what “home healthcare” means.

Dulan is a small community loved by surfers and cycl­ists. Yu is helpng make it a great place for its elderly citizens to age in place, too.

What is “home healthcare”?

“Home healthcare” is a new model for medical care that delivers services in a flexible fashion. It has its roots in the desire to support patients spending their last years in their own homes.

A changing population

With our birthrate declining and our population aging, Taiwan is on the verge of becoming a “super­-aged society,” that is, one in which more than 20% of the population is over the age of 65. To address the impact of this societal change and ease the burden on both the healthcare system and family caregivers, Taiwan has begun experimenting with home healthcare, a system in which doctors go to patients.

In the past, many elderly citizens who needed healthcare had to call for an ambulance to take them to the emergency room for treatment. Having medical teams visit seniors in their homes and enabling patients to communicate with their doctors as needed means that elderly citizens no longer need to tire themselves out with travel and that family members no longer need to take time off from work to accompany them to the hospital. This greatly reduces the costs in time and travel of these patients’ care, and helps mitigate the impact on our national productivity of Taiwan’s transformation into a super-aged society.

Patient autonomy

The hospital system exists to treat illness and extend patients’ lives. But its approach to treating the elderly, which can cycle through first aid, in­tub­ation, intensive care and back again, often lacks respect for differences between individuals and the larger course of life. This is especially evident when one considers that the majority of senior citizens face irreversible age-related loss of capabilities and chronic illness.

Home healthcare takes a different approach, focusing instead on patients’ agency and wishes. Doctors utilizing this approach no longer have absolute authority, and instead take on a role akin to that of a guide, making suggestions on how patients can get to where they want to go.

Multidisciplinary connections


The approach also involves multidisciplinary medical teams. Having team members willing to cooperate with professionals in other fields is crucial to enabling patients to spend their last years in their own homes.

A doctor with a clear understanding of the patient’s condition leads the care group. Other team members have their own specialized roles, and rely on communication and mutual understanding to jointly implement the doctor’s strategy and care for the patient.

End of life issues affect everyone


Advocates for home healthcare and aging in place are working to build community consensus in support of these ideas. When Susu Guesthouse, an independent Tai­tung bookshop, organized Taiwan’s first “home salon” with that objective in mind, it started something of a trend. Since then, over 60 community spaces have hosted such gatherings.

Everyone will someday face the question of how to spend the last years of their life. Home salons encourage each of us to work with our social networks to seek a better old age.

Rescuing marginal communities


In Japan the term gen­kai shu­raku (“marginal village”) refers to communities in danger of depopulation because more than half of the residents are over the age of 65. Elderly citizens tend to be concentrated in rural villages that lack the medical care systems they need to live. With the population in general getting older, many of these rural communities are facing extinction.

Yu, who has chosen to root himself in a rural community, explains: “In effect, what we are doing is community reconstruction. Home healthcare is just the method.”

Home Clinic Dulan provides healthcare services to the community. Its doctor is a community member who drops by the local bookshop for a bowl of dou­hua and a breather. Clinic volunteers help out in Our LivingRoom, a community space, then spend their evenings in a neighborhood guesthouse. This closely woven symbiotic network is revitalizing the village, encouraging residents to remain.

Home healthcare really does help to invigorate local communities.

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