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Outcomes and Costs of Residential Services for Adults with Intellectual Disabilities in Taiwan: A Comparative Evaluation

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Title: Outcomes and Costs of Residential Services for Adults with Intellectual Disabilities in Taiwan: A Comparative Evaluation
Language: English
Authors: Chou, Yueh-Ching, Lin, Li-Chan, Pu, Cheng-Yun, Lee, Wan-Ping, Chang, Shu-Chuan
Source: Journal of Applied Research in Intellectual Disabilities. Mar 2008 21(2):114-125.
Availability: Blackwell Publishing. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8599; Fax: 781-388-8232; e-mail: customerservices@blackwellpublishing.com; Web site: http://www.blackwellpublishing.com/jnl_default.asp
Peer Reviewed: Y
Page Count: 12
Publication Date: 2008
Document Type: Journal Articles
Reports - Evaluative
Descriptors: Costs, Residential Institutions, Group Homes, Mental Retardation, Adults, Comparative Analysis, Residential Care, Interviews, Normalization (Disabilities), Quality of Life, Foreign Countries
Geographic Terms: Taiwan
DOI: 10.1111/j.1468-3148.2007.00373.x
ISSN: 1360-2322
Abstract: Background: The disability policy in Taiwan has traditionally emphasized residential care in large institutions and, more recently, medium-sized group homes. This paper compares the relative costs, services provided and outcomes between the traditional institutions, medium-sized group homes and new small-scale community living units that were launched in 2004 in Taiwan. Materials and Methods: Cross-sectional analysis was used to investigate the three current residential service models. A total of 248 participants with intellectual disabilities were interviewed, including all residents from the existing 25 small residential units and purposively sampled respondents from the other two residential models. Results: Outcomes for the Taiwanese participants were consistent with the existing literature on deinstitutionalization from Western societies. Small homes provided better subjective and objective quality of life than both medium-sized community-based units and traditional institutions. Conclusion: Participants living in small residential homes experienced better outcomes at lower cost than persons living in medium-sized group homes or institutions.
Abstractor: As Provided
Entry Date: 2009
Accession Number: EJ835094
Database: ERIC
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  Value: <anid>AN0028794132;e0301mar.08;2019Jun04.08:08;v2.2.500</anid> <title id="AN0028794132-1">Outcomes and Costs of Residential Services for Adults with Intellectual Disabilities in Taiwan: A Comparative Evaluation. </title> <p>Background  The disability policy in Taiwan has traditionally emphasized residential care in large institutions and, more recently, medium‐sized group homes. This paper compares the relative costs, services provided and outcomes between the traditional institutions, medium‐sized group homes and new small‐scale community living units that were launched in 2004 in Taiwan. Materials and Methods  Cross‐sectional analysis was used to investigate the three current residential service models. A total of 248 participants with intellectual disabilities were interviewed, including all residents from the existing 25 small residential units and purposively sampled respondents from the other two residential models. Results  Outcomes for the Taiwanese participants were consistent with the existing literature on deinstitutionalization from Western societies. Small homes provided better subjective and objective quality of life than both medium‐sized community‐based units and traditional institutions. Conclusion  Participants living in small residential homes experienced better outcomes at lower cost than persons living in medium‐sized group homes or institutions.</p> <p>Keywords: outcomes; intellectual disability; cost; residential services; Taiwan; community living</p> <p>Current research is focusing on the impact of deinstitutionalization on adults with an intellectual disability. Presently, differences are reported in both costs and outcomes across different studies in the UK ([<reflink idref="bib1" id="ref1">1</reflink>]; [<reflink idref="bib16" id="ref2">16</reflink>]; [<reflink idref="bib2" id="ref3">2</reflink>]; [<reflink idref="bib13" id="ref4">13</reflink>]; [<reflink idref="bib10" id="ref5">10</reflink>]; [<reflink idref="bib15" id="ref6">15</reflink>]) and in the USA ([<reflink idref="bib22" id="ref7">22</reflink>]; [<reflink idref="bib6" id="ref8">6</reflink>]; [<reflink idref="bib18" id="ref9">18</reflink>]; [<reflink idref="bib31" id="ref10">31</reflink>]). The closure of institutions for people with an intellectual disability in some developed countries has been completed or is almost complete. Furthermore, supporting these people to live in their own homes in the community has become a mainstream policy in these developed countries. However, institutional services in some countries still remains the main public policy ([<reflink idref="bib3" id="ref11">3</reflink>]), as is the case in Taiwan.</p> <p>Deinstitutionalization in Taiwan is continuously under debate, but the current government policy still values large facilities. However, medium‐sized group homes have existed since the beginning of the 1990s and in the past 5 years, there has been an action group movement that has been advocating and developing residential services in units smaller than six residents ([<reflink idref="bib4" id="ref12">4</reflink>]). Instead of moving to an institution, in these new smaller units people with an intellectual disability can receive residential services and still live near their families.</p> <p>It is generally assumed that smaller sized residential facilities have more positive outcomes as depersonalizing practices are more frequently found in larger facilities ([<reflink idref="bib22" id="ref13">22</reflink>]; [<reflink idref="bib24" id="ref14">24</reflink>]). [<reflink idref="bib25" id="ref15">25</reflink>], [<reflink idref="bib11" id="ref16">11</reflink>] and [<reflink idref="bib12" id="ref17">12</reflink>] have pointed out several important factors that influence the outcomes of residents' quality of life (QOL). These indicators include size, architectural design, location, furnishing, staff ratio and performance of the residential services. However, small size alone does not guarantee quality, nor does community location, building design or high staffing ([<reflink idref="bib11" id="ref18">11</reflink>]).</p> <p>Available research that has compared the outcomes between individuals living in small‐scale community‐based units and in institutions suggests better outcomes for small‐scale alternatives. This is shown by a number of indicators such as QOL, choice making, community inclusion, activity engagement, family contact, staff assistance, interaction between staff and residents ([<reflink idref="bib20" id="ref19">20</reflink>];[<reflink idref="bib16" id="ref20">16</reflink>]; [<reflink idref="bib29" id="ref21">29</reflink>], [<reflink idref="bib30" id="ref22">30</reflink>]; [<reflink idref="bib18" id="ref23">18</reflink>]; [<reflink idref="bib14" id="ref24">14</reflink>]). In addition, some studies have focused on the impact on the residents who have moved from an institution to the community or to a small‐scale home, measuring impact by adaptive behaviour, challenging behaviour, independent community living skills, client satisfaction, engagement in activities, use of community facilities, contact with family and friends, choice, etc. ([<reflink idref="bib9" id="ref25">9</reflink>]; [<reflink idref="bib31" id="ref26">31</reflink>]; [<reflink idref="bib7" id="ref27">7</reflink>]).</p> <p>Other investigators have examined the costs and effectiveness of institutional and community services and have come up with inconsistent findings for different types of residential settings. For instance, [<reflink idref="bib13" id="ref28">13</reflink>] found higher staffing costs in small residential homes and explained this by the residents' severe disabilities that required more intensive staffing. On the other hand, this intensive staffing produced better quality of care when the residents' level of functioning was controlled. However, in their study [<reflink idref="bib17" id="ref29">17</reflink>] found no connection between the used resources (costs or staff ratios) and any indicator of service quality.</p> <p>The present study was conducted as an outcome evaluation for the new small‐scale community living scheme granted by the Ministry of Interior. This study aims to examine and report relative costs and outcomes of the different types of residential models for people with intellectual disabilities in Taiwan. In addition, the personal characteristics and environmental variables that are significantly associated with the outcomes for the individuals are explored.</p> <hd id="AN0028794132-2">Materials and Methods</hd> <p></p> <hd id="AN0028794132-3">Variables definition</hd> <p>In Taiwan, three different residential models are present: the institution (larger than 50 beds), the group or community home (<50 beds), and community living (six and less beds). In this study, the institution is defined as a unit providing residential services for over 100 residents; they are usually located in suburbia or the countryside and are segregated from local community. The group/community home has fewer than 50 residents and has been available in Taiwan since 1990 ([<reflink idref="bib4" id="ref30">4</reflink>]); they vary from 11 to 39 users per unit and are located within the community. The majority of group/community homes are houses with three to four floors; some might form a unit on the ground floor of public housing and share three or four flats. 'Community Living' was launched towards the end of 2004 and was sponsored by the central government (12 homes) or funded by the non‐governmental organizations after 2000 (13 homes); it provides accommodation for six or fewer residents with an intellectual disability or mental illness, who then live in ordinary homes or houses in the community. The majority of residents need to share a bedroom in the house or flat, which is rented or purchased by the service providers. In this study, we focus our analysis on the different sized units that make up the three models mentioned above. Three dependent variables were analysed in this study: (<reflink idref="bib1" id="ref31">1</reflink>) personal outcomes that involved, the resident's QOL, the availability to make choices by the residents, community inclusion, frequency of contact with family, satisfaction with the accommodation and satisfaction with roommates/housemates; (<reflink idref="bib2" id="ref32">2</reflink>) the support services provided, that involved the physical environment, staffing, and any scheduled activities; and (<reflink idref="bib3" id="ref33">3</reflink>) the monthly cost of the service per resident (the cost figure was based on staffing costs as well as the package of services provided).</p> <hd id="AN0028794132-4">Participants</hd> <p>Residents with an intellectual disability from various small residential homes (25 settings), the group homes/community homes (35 settings) and governmental/non‐governmental institutions (20 settings) were invited to participate in the present cross‐sectional study. The questions posed to assess their QOL, choices making, community inclusion, family contact and satisfaction with the accommodation were self‐responded by the residents or, if necessary, with the assistance of their main care workers1. Front line practitioners and residential managers (or administrators) were invited to take part in self‐administered interviews on such questions as the adult's characteristics and adaptive behaviour, services provided and costs. The sampling frame of the survey was based on the lists of the users of the three residential models provided by the providers All the residents (<reflink idref="bib113" id="ref34">113</reflink>) of 25 small residential homes in Taiwan were invited to participate in the study and these have been matched with 113 residents from group homes/community homes and 113 residents from institutions; this purposive sampling was based on the resident's disability level, age and gender. Out of the original total sample, four service providers and 89 residents, representing all three residential models, could not be contacted. The reasons for this included that either the residential setting or the parents/guardian of the person with an intellectual disability had declined participation in the study, that the residents had gone back to live with their original families or that the residents were unable to participate because of illness.</p> <p>In the end, 248 participants completed this study (103 from small residential homes, 69 from group homes and 76 from institutions) and they came from 77 settings (25 small residential homes run by 18 providers, 33 group homes run by 8 providers and 19 institutions managed by 19 providers). As shown by the descriptive data in Table 1, among the 103 participants from small residential homes, the majority were male, aged in their 20s and 30s, with moderate intellectual disability. Statistical comparison revealed no significant differences between the three groups based on the three sampling criteria (i. e. residents' level of disability, age and gender). However, there were significant differences between the groups in terms of adaptive functioning, maladaptive behaviour and daily activity involvement (<emph>P </emph><<emph> </emph>0.001).</p> <p>1  Personal characteristics of participants</p> <p> <ephtml> <table><thead valign="bottom"><tr><th>Characteristics</th><th>Small residential home (<italic>n</italic> = <italic>103)</italic></th><th>Group/ community home (<italic>n</italic> = <italic>69)</italic></th><th> Institution (<italic>n</italic> = <italic>76)</italic></th><th><italic>F</italic> or χ<sup>2</sup> (<italic>post hoc</italic><italic>test)</italic></th></tr></thead><tbody valign="top"><tr><td><italic>Age</italic></td></tr><tr><td> Mean</td><td>28.6</td><td>30.5</td><td>29.5</td><td valign="top">1.05</td></tr><tr><td> SD</td><td>7.6</td><td>8.9</td><td>8.0</td></tr><tr><td>Gender (%)</td></tr><tr><td> Male</td><td>77.7</td><td>60.9</td><td>72.4</td><td valign="top">0.15</td></tr><tr><td> Female</td><td>22.3</td><td>39.1</td><td>27.6</td></tr><tr><td><italic>Level of disability (%)</italic></td></tr><tr><td> Profound</td><td>9.7</td><td>7.3</td><td>7.9</td><td valign="top">0.08</td></tr><tr><td> Severe</td><td>32.0</td><td>33.3</td><td>32.9</td></tr><tr><td> Moderate</td><td>41.8</td><td>50.7</td><td>46.1</td></tr><tr><td> Mild</td><td>16.5</td><td>8.7</td><td>13.2</td></tr><tr><td><italic>Adaptive behaviour</italic></td></tr><tr><td> Mean</td><td>241.1</td><td>257.0</td><td>133.2</td><td valign="top">9.56** (1 > 3*; 2 > 3*)</td></tr><tr><td> SD</td><td>207.2</td><td>210.4</td><td>137.4</td></tr><tr><td><italic>Maladaptive behaviour</italic></td></tr><tr><td> Mean</td><td>91.7</td><td>94.9</td><td>126.7</td><td valign="top">12.37** (1 < 3**; 2 < 3*)</td></tr><tr><td> SD</td><td>48.8</td><td>52.6</td><td>46.7</td></tr></tbody></table> </ephtml> </p> <p>1 *<emph>P </emph><<emph> </emph>0.01; **<emph>P </emph><<emph> </emph>0.001.</p> <p>The 25 small residential homes were all operated by non‐governmental organizations and commenced operation since 2001. Thirty (90.9%) group/community homes were managed by the NGOs and 21 (63.6%) were established between 1990 and 2000. Three of the five public institutions were operated by the central government and 11 (57.9%) institutions had been created before 1990. Nearly 50% of the institutions were located in rural areas and 72.0% of the small homes were flats. Only 26% of the residents in small home residential services were female, while women made 51.2% and 40.8% of the users living in group/community homes and institutions respectively. The average unit size of small homes was 4.7 residents (ranged between one and six), group/community home 11.4 (ranged between 11 and 39) and institution 220 (ranged between 104 and 447). Staff ratios for small home, group/community home and institution were 1.8, 1.0 and 0.5 resident per staff respectively (Table 2).</p> <p>2  Characteristics of 45 providers in three residential service models</p> <p> <ephtml> <table><thead valign="bottom"><tr><th>Variables</th><th>Items</th><th>Small home (<italic>N</italic> = <italic>18)</italic>, <italic>N (</italic>%<italic>)</italic></th><th>Group/community home (<italic>N</italic> = <italic>8)</italic>, <italic>N (</italic>%<italic>)</italic></th><th>Institution (<italic>N</italic> = <italic>19)</italic>, <italic>N (</italic>%<italic>)</italic></th></tr></thead><tbody valign="top"><tr><td valign="top">Public or voluntary </td><td>Statutory</td><td>0 (0)</td><td>2 (25)</td><td>5 (26.3)</td></tr><tr><td>NGO</td><td>18</td><td>5 (62.5)</td><td>13 (68.4)</td></tr><tr><td>Public Contract</td><td>0 (0)</td><td>1 (12.5)</td><td>1 (5.3)</td></tr><tr><td valign="top">Year of start</td><td>Before 1990</td><td>0 (0)</td><td>2 (25.0)</td><td>11 (57.9)</td></tr><tr><td>1991–2000 </td><td>2 (0)</td><td>4 (50.0)</td><td>7 (36.8)</td></tr><tr><td>Post‐2001</td><td>16 (100)</td><td>2 (25.0)</td><td>1 (5.3)</td></tr><tr><td valign="top">Location</td><td>Urban</td><td>14 (77.8)</td><td>5 (62.5)</td><td>10 (52.6)</td></tr><tr><td>Rural</td><td>4 (22.2)</td><td>3 (37.5)</td><td>9 (47.4)</td></tr><tr><td valign="top">Type of housing</td><td>Flat</td><td>9 (45.5)</td><td>0 (37.5)</td><td>0 (0)</td></tr><tr><td>House</td><td>9 (54.5)</td><td>6 (37.5)</td><td>0 (0)</td></tr><tr><td>Institution</td><td>0 (0)</td><td>0 (0)</td><td>19 (100)</td></tr><tr><td>Other</td><td>0 (0)</td><td>2 (25.0)</td><td>0 (0)</td></tr><tr><td valign="top">Gender of residents</td><td>Male</td><td>89 (74)</td><td>166 (48.8)</td><td>2403 (59.2)</td></tr><tr><td>Female</td><td>27 (26)</td><td>174 (51.2)</td><td>1658 (40.8)</td></tr><tr><td>Average unit size (range)</td><td> 4.7 (1–6)</td><td> 11.4 (11–39)</td><td>220 (104–447)</td></tr><tr><td>Staff : resident ratio/total residents</td><td>1 : 1.77/113</td><td>1 : 0.9/375</td><td>1 : 0.48/4181</td></tr></tbody></table> </ephtml> </p> <hd id="AN0028794132-5">Procedure</hd> <p>Before the selection of the participants was set up, we sent a letter to each provider of the residential services and this included an official document from the sponsor of the present study, Department of Social Affairs of the Ministry of Interior. The letter described the study and asked whether the selected participants and one or more residential staff members who were knowledgeable about the participant's lifestyle would be willing to be interviewed by the research assistant. Next, written informed consent was sought from each potential participant and agreement to participate was obtained from either the participants' parents or their legal guardian. After obtaining consent, the adaptive behaviour scale (ABS) as well as questionnaires on the participants' demographic information and the structure of the residential service (services provided and costs) were mailed to the line managers. Throughout the study a full time research assistant who had graduated from a Department of Social Work was the single interviewer. The database was collected between July and September of 2005 and all interviews were carried out at the participants' residential settings.</p> <hd id="AN0028794132-6">Behavioural measures</hd> <p>The participants' adaptive and maladaptive behaviour were measured using the ABS‐Taiwanese version, which comprises two parts and was developed by [<reflink idref="bib23" id="ref35">23</reflink>] and [<reflink idref="bib28" id="ref36">28</reflink>]. Part I of the ABS focuses on 10 different behaviour domains including independent functioning, communication capability, social skill, domestic activity, community activity, self‐direction, security and sanitary activity, practical knowledge, leisure activity and vocational activity; these reflect the level of adaptive functioning. The assessment consists of 100 items and yields scores that range from 0 to 100 with lower scores indicating lower levels of adaptive behaviour. Part II addresses two domains of maladaptive behaviour related to human relationships and getting along with other people. The assessment consists of 20 items and yields scores that range from 0 to 20 with higher scores indicating higher levels of maladaptive behaviour. The ABS was designed for administration by persons familiar with the individuals to be evaluated. Parts I and II of the ABS (ABS‐I and ABS‐II) that were used in the present study yield Cronbach's alphas of 0.96 and 0.71 respectively.</p> <hd id="AN0028794132-7">Personal outcome measures</hd> <p></p> <hd id="AN0028794132-8">Measures of quality of life</hd> <p>These were obtained using the 1993 version of the Quality of Life Questionnaire (QOLQ) ([<reflink idref="bib27" id="ref37">27</reflink>]). The QOLQ is a 40‐item instrument that uses a three‐point scale to measure self‐perceived QOL. The QOLQ yields four subscale scores for satisfaction, empowerment/independence, competence/productivity and social belonging/community integration. For the purposes of this study, the QOLQ was used as a single scale. The responses available are scored from one (poor QOL) to three (high QOL), thus giving the overall QOL score a theoretical range of 40–120. A check on the internal consistency of the QOLQ was performed for the present study and gave a coefficient alpha of 0.87.</p> <hd id="AN0028794132-9">The resident's choice making</hd> <p>This was measured using the Residence Choice Assessment Scale (RCAS) ([<reflink idref="bib19" id="ref38">19</reflink>]), which measured the extent to which the person was able to exercise choice and control over key aspects of their life. It was scored on a scale from one to seven, with 1–7 (never – always) meaning that the person control over his or her major and minor life choice ranged from no choice available to total freedom of choice. The scale consists of 25 multiple choices questions about specific everyday choices, such as choice of bedtime, mealtime, clothing, bathing, privacy, roommates and participation in domestic activities, recreation and social activities. Total scores on this instrument range from 25 (no choice) to 175 (full choice). In the present study, the internal consistency of the RCAS was considered acceptable with a Cronbach's alpha of 0.84.</p> <hd id="AN0028794132-10">Community inclusion</hd> <p>This was scored using the Use of Community Facilities Scale (UCFS) and measured the variety of community places and activities that the residents used and were engaged in. This scale was a self‐design questionnaire and measured how often the residents visited, used or were engaged in facilities and activities with friends, roommates, support staffs or alone. A list of 18 community facilities, places and activities was provided and these included supermarket, shopping mall and department store shopping, the use of a post‐office and/or bank, the use of a swimming pool or health club, the use of a library, eating at restaurant, visiting a bookstore, using a hairdressing salon, visiting a video shop, using transportation including buses, taxis and the Mass Rail Transport System, Karaoke, visiting an internet café or games room and engaging in activities at a temple or church. Participants indicated the frequency of times/days she/he had used or been engaged in each facility or activity. The frequency of places/activities used or engaged in made up the total score, which ranged from 0 to 54 with higher scores indicating a greater inclusion. The internal consistency of the UCFS was considered acceptable with a Cronbach's alpha of 0.81.</p> <hd id="AN0028794132-11">Contact with family</hd> <p>This indicated the frequency of face‐to‐face visits between the participant and her/his family members. A single item in the questionnaires addressed this with the question: 'How frequently do you visit your family or your family comes to visit you?' This question was put to each resident to gain information concerning the frequency and nature of her/his outings from the residence and the frequency of visits to the residence by her/his family.</p> <hd id="AN0028794132-12">Satisfaction and the identification with the accommodation</hd> <p>These measures were developed by the research team to identify whether the residents thought that the accommodation was 'home' and whether they like the place where they lived including their room/housemates. This also included whether they had been involved in making the decision to move to the accommodation and had choice with respect to their room/housemates.</p> <hd id="AN0028794132-13">Support services measures</hd> <p>This included three areas, namely, the physical environment, the scheduled activities and the staff levels. The information was collected by the single interviewer from the present study from the care staff or the line manager.</p> <hd id="AN0028794132-14">The Physical Environment Index</hd> <p>It was modified from the Arc Minnesota Research and Training Center on Community Living ([<reflink idref="bib26" id="ref39">26</reflink>]) to collect information on aspects of the physical environment. This scale is able to discriminate between the different types of residential facilities for people with an intellectual disability as well as how home‐like and pleasant the setting is. It was completed by the single interviewer from the present study when she interviewed the participants at their accommodation and rated each accommodation in terms of three dimensions: (<reflink idref="bib1" id="ref40">1</reflink>) physical facilities, consisting of 41 items; (<reflink idref="bib2" id="ref41">2</reflink>) the building, consisting of 12 items and (<reflink idref="bib3" id="ref42">3</reflink>) accessibility, consisting of 15 items. The internal consistency of the Physical Environment Index in the present study was considered acceptable with a Cronbach's alpha of 0.79 for the domain of 'physical facilities', a Cronbach's alpha of 0.84 for the 'building' and Cronbach's alpha of 0.73 for 'accessibility'.</p> <hd id="AN0028794132-15">Scheduled activities</hd> <p>They were measured by questions asking whether there were scheduled activities arranged and examining the daily/weekly timetable for scheduled activities. The results included data on the nature and duration of scheduled daily life and group activities and whether personal activities by the residents were permitted.</p> <hd id="AN0028794132-16">Staff levels</hd> <p>It refers to the number of direct‐care staff members on duty at various times recorded. For this study, this was used to calculate the number of staff present overnight and on weekday evenings as well as the average daily support hours during night time and the average weekly support hours during day time. These were selected as representative measures to compare the duty staff levels between the groups.</p> <hd id="AN0028794132-17">Service cost measures</hd> <p>This was the monthly service expenditure per resident embracing staffing, daily utilities, facilities, equipment, rent, water, electricity, gas, telephone, housing modification, health insurance premiums, food, transportation, staff in‐service training and administrative costs. The above service expenditure was funded in three ways, namely by government payments for the residential services, payment or co‐payment by the residents' families and donations from the service providers. Information about these service costs was obtained from the service managers or administrators. The managers or administrators were provided with a detailed written set of guidelines that allowed the creation of a standardized table of expenditure including each of the above categories. All settings or households received provider‐based funding as a whole and not individual funding for individual costs and this funding was based on the number of residents living in the setting or household including day programmes (i.e. day care and vocational services) and residential services. The cost to the provider per month of a single resident (total annual service expenditure divided by 12 months and by the total users in the setting) was used in this study. The costs did not include a component for capital costs, such as the cost of purchasing the housing. All cost data was for the 2004 financial year.</p> <hd id="AN0028794132-18">Data analysis</hd> <p>The data set was analysed using the Statistical Package for the Social Sciences (SPSS) version 14.0 for Windows (SPSS, Chicago, IL, USA). Descriptive analysis was used to characterize the participants' basic information including the residents and the settings. anova and a cross‐table were used to determine whether the residents' personal characteristics, outcomes and services provided varied by the three residential settings. Moreover, for the outcome comparisons of the three models, we used adaptive behaviour and maladaptive behaviour along with other variables as covariates. Costs for the residents who live in these three residential settings were compared using the Kruskal–Wallis one‐way analysis and the Mann–Whitney <emph>U</emph>‐test for the post‐test between the two groups, as cost data are generally not normally distributed regardless of the sample size. To explore what personal characteristics and environmental variables are significant factors of the individuals' outcomes, multiple regression analysis was conducted. The level of statistical significance was set at <emph>P </emph><<emph> </emph>0.01.</p> <hd id="AN0028794132-19">Results</hd> <p></p> <hd id="AN0028794132-20">Personal outcomes between the models</hd> <p>Table 3 indicates the outcome data after adjusting for the participants' adaptive and maladaptive behaviour, and shows that there are significant differences between the groups in terms of resident's QOL, choice‐making, community inclusion and frequency of family contact. <emph>Post hoc</emph> tests showed that small homes have significantly better outcomes than the other two models (<emph>P </emph><<emph> </emph>0.01 and <emph>P </emph><<emph> </emph>0.001). However, small homes and group/community homes did not differ significantly on choice. Table 4 shows that there is a statistically significant difference in the identification of the accommodation as a 'home' (<emph>P </emph><<emph> </emph>0.001), the satisfaction with the accommodation (<emph>P </emph><<emph> </emph>0.01), 'do you like your housemates' (<emph>P ≤ </emph>0.001), the number of roommates (<emph>P ≤ </emph>0.001) and changes in roommates and housemates (<emph>P </emph><<emph> </emph>0.01 and <emph>P </emph><<emph> </emph>0.001) between the models. Again, however, except for relationships with housemates, there were no statistically significant differences between small homes and group/community homes. Participants from both small homes and group/community homes tended to rate their satisfaction higher in terms of the accommodation and the relationships with housemates. However, it is clear that the participants from all three models had very few opportunities to make their own decisions and that almost none of them were involved in the decision to move to a particular unit or in decisions on their housemates.</p> <p>3  Mean personal outcomes by setting (means adjusted for the effects of adaptive and maladaptive behaviour as covariates)</p> <p> <ephtml> <table><thead valign="bottom"><tr><th valign="bottom">Outcomes</th><th>Small residential home (<italic>n</italic> = <italic>103)</italic></th><th>Group/community home (<italic>n</italic> = <italic>69)</italic></th><th>Institution (<italic>n</italic> = <italic>76)</italic></th><th valign="bottom"><italic>F</italic> (<italic>post hoc</italic><italic>test)</italic></th></tr><tr><th>Mean</th><th>SD</th><th>Mean</th><th>SD</th><th>Mean</th><th>SD</th></tr></thead><tbody valign="top"><tr><td>QOL</td><td>84.2</td><td>8.8</td><td>78.1</td><td>10.4</td><td>72.8</td><td>8.8</td><td>8.9** (1 > 2*; 1 > 3**)</td></tr><tr><td>Choice making</td><td>120.9</td><td>18.5</td><td>111.7</td><td>13.5</td><td>84.3</td><td>19.8</td><td>20.9*** (1 > 3**; 2 > 3**)</td></tr><tr><td>Community inclusion</td><td>20.0</td><td>8.8</td><td>14.5</td><td>5.4</td><td>12.6</td><td>8.4</td><td>8.3*** (1 > 2*; 1 > 3**)</td></tr><tr><td>Family contact</td><td>2.5</td><td>0.8</td><td>2.1</td><td>0.9</td><td>1.9</td><td>0.8</td><td>5.1* (1 > 2*; 1 > 3*)</td></tr></tbody></table> </ephtml> </p> <ulist> <item>2 *<emph>P </emph><<emph> </emph>0.01; **<emph>P </emph><<emph> </emph>0.001. QOL, quality of life.</item> <item>4  Home identification and services provided (N = 248)</item> </ulist> <p> <ephtml> <table><thead valign="bottom"><tr><th /><th>Small home</th><th>Group/community home</th><th>Institution</th><th><italic>F</italic><italic>(Scheffè)</italic></th><th>χ<sup>2</sup></th></tr></thead><tbody valign="top"><tr><td>Do you think 'Here' is your home?<sup>1</sup> (%)</td><td>0.83</td><td>0.68</td><td>0.42</td><td /><td>32.07**</td></tr><tr><td>Do you like to live 'Here'?<sup>2</sup> (mean/SD)</td><td>3.51/0.68</td><td>3.42/0.95</td><td>3.04/1.06</td><td> 6.62* (1 > 3*)</td><td> </td></tr><tr><td>Do you like your roommate(s)?<sup>2</sup> (mean/SD)</td><td>2.99/1.54</td><td>3.22/1.12</td><td>2.87/1.12</td><td> 1.31</td><td> </td></tr><tr><td>Do you like your housemates?<sup>2</sup> (mean/SD)</td><td>2.53/1.51</td><td>0.90/1.55</td><td>0</td><td>86.82** (1 > 2**; 1 > 3**; 2 > 3**)</td><td /></tr><tr><td>Was it your decision moving to 'Here'?<sup>1</sup> (%)</td><td>0.11</td><td>0.06</td><td>0.07</td><td /><td>1.66</td></tr><tr><td>Family's decision<sup>1</sup> (%)</td><td>0.48</td><td>0.55</td><td>0.72</td><td /><td>11.17*</td></tr><tr><td>Worker's decision<sup>1</sup> (%)</td><td>0.46</td><td>0.30</td><td>0.18</td><td /><td>14.93*</td></tr><tr><td>Others<sup>1</sup> (%)</td><td>0.01</td><td>0.09</td><td>0.05</td><td /><td> 5.99</td></tr><tr><td>Did you find your roommate(s) yourself?<sup>1</sup> (%)</td><td>0.15</td><td>0.13</td><td>0.04</td><td /><td> 5.54</td></tr><tr><td>How many roommates do you have?<sup>2</sup> (mean/SD)</td><td>1.45/1.37</td><td>2.04/1.34</td><td>4.50/3.30</td><td>46.79** (1 < 3**; 2 < 3**)</td><td> </td></tr><tr><td>Can you change your roommate?<sup>1</sup> (%)</td><td>0.35</td><td>0.57</td><td>0.34</td><td /><td> 9.89*</td></tr><tr><td>Did you find your housemates by yourself?<sup>1</sup> (%)</td><td>0</td><td>0</td><td>0</td><td /><td> </td></tr><tr><td>Can you change your housemates?<sup>1</sup> (%)</td><td>0.25</td><td>0.16</td><td>0</td><td /><td>22.03**</td></tr></tbody></table> </ephtml> </p> <ulist> <item>3 *<emph>P </emph><<emph> </emph>0.01; **<emph>P </emph><<emph> </emph>0.001.</item> <item>4 <sups>1</sups>Percentage of the participants answering 'Yes'.</item> <item>5 <sups>2</sups>4 = very much; 3 = yes; 2 = no; 1 = not at all.</item> </ulist> <hd id="AN0028794132-21">Support services provided between the models</hd> <p>As shown in Table 5, three dimensions of the physical environment including 'physical facilities' and 'building' differed significantly between the groups. 'Building' of the small homes was significantly better than the group homes and the institutions (<emph>P </emph><<emph> </emph>0.001); in contrast, 'accessibility' of the institutions was better than the group homes and the small homes (<emph>P </emph><<emph> </emph>0.001).</p> <p>5  Physical environment</p> <p> <ephtml> <table><thead valign="bottom"><tr><th valign="bottom">Facility</th><th>Small home (<italic>n</italic> = <italic>25)</italic></th><th>Group/community. Home (<italic>n</italic> = <italic>33)</italic></th><th>Institution (<italic>n</italic> = <italic>19)</italic></th><th valign="bottom"><italic>F</italic><italic>(Scheffè)</italic></th></tr><tr><th>Mean</th><th>SD</th><th>Mean</th><th>SD</th><th>Mean</th><th>SD</th></tr></thead><tbody valign="top"><tr><td>Physical facilities</td><td>55.7</td><td>5.6</td><td>55.3</td><td>2.3</td><td>51.9</td><td>4.3</td><td>5.3*</td></tr><tr><td>Building</td><td>75.9</td><td>8.6</td><td>63.8</td><td>10.6</td><td>64.5</td><td>5.5</td><td>14.9** (1 > 2**; 1 > 3**)</td></tr><tr><td>Accessibility</td><td>75.8</td><td>9.1</td><td>76.3</td><td>6.9</td><td>91.2</td><td>7.2</td><td>27.2** (1 < 3**; 2 < 3**)</td></tr></tbody></table> </ephtml> </p> <p>6 *<emph>P </emph><<emph> </emph>0.01; **<emph>P </emph><<emph> </emph>0.001.</p> <p>Residents in small homes had significantly more personal activities permitted and less daily life timetable arranged than residents in the group/community homes and institutions (χ<sups>2</sups> = 33.76, <emph>P </emph><<emph> </emph>0.001; χ<sups>2</sups> = 30.11, <emph>P </emph><0.001). One hundred per cent of group homes, 94.7% of the institutions and 96.0% of small homes who were interviewed in the present study have arranged group activities for residents every day (as shown in Table 6).</p> <p>6  Scheduled activities and staffing</p> <p> <ephtml> <table><thead valign="bottom"><tr><th>Providers</th><th>Small home (<italic>n</italic> = <italic>25)</italic></th><th>Group/community home (<italic>n</italic> = <italic>33)</italic></th><th>Institution (<italic>n</italic> = <italic>19)</italic></th><th><italic>F</italic> or χ<sup>2</sup></th></tr></thead><tbody valign="top"><tr><td>Group activities arranged (%)</td><td>96.0</td><td>100</td><td>94.7</td><td>5.17</td></tr><tr><td>Personal activity permitted (%)</td><td>60.0</td><td>3.0</td><td>5.3</td><td>33.76**</td></tr><tr><td>Daily life timetable arranged (%)</td><td>52.0</td><td>69.7</td><td>94.7</td><td>30.11**</td></tr><tr><td>Night staffing (%)</td><td>88.0</td><td>100</td><td>100</td><td>6.49</td></tr><tr><td>Sleepover night staffing (%)</td><td>84.0</td><td>100</td><td>100</td><td>8.78</td></tr><tr><td>Support staff average daily hours during night time (mean/SD)</td><td>9.2/4.8</td><td>9.2/1.3</td><td>10.1/2.7</td><td>0.60</td></tr><tr><td>Support staff average weekly hours during day time (mean/SD)</td><td>33.6/19.5</td><td>41.7/15.1</td><td>61.4/92.2</td><td>1.89</td></tr></tbody></table> </ephtml> </p> <p>7 *<emph>P </emph><<emph> </emph>0.01; **<emph>P </emph><<emph> </emph>0.001.</p> <p>All the group/community homes and institutions arranged night staffs and sleepover night staffs. The chi‐squared analysis revealed a non‐significant difference in having night staff and sleepover night staff between the groups. anova of the average daily hours during night time and average weekly hours during day time is given in Table 6 and did not show significant differences across service models, although the small homes had the lowest staff hours for both night time and day time.</p> <hd id="AN0028794132-22">Costs between the models</hd> <p>The total costs were greatest in the institutions and were significantly lower in small homes (<emph>P </emph><<emph> </emph>0.01). The average cost per resident per month varied from an average of NTD$17 638 in a small home to NTD$28 067 in an institution. Differences in total costs between small homes and institutions also attained statistical significance (<emph>P </emph><<emph> </emph>0.001). In addition, it is worth noting that there was considerable variation in costs within as well as between the service models and this was particularly true for within the group/community homes with a standard deviation of NTD$14 415 (Table 7).</p> <p>7  Cost (per month) for accommodation and associated care</p> <p> <ephtml> <table><thead valign="bottom"><tr><th valign="bottom">Cost</th><th> Small home (<italic>n</italic> = <italic>18</italic><sup><italic>1</italic></sup>)</th><th>Group/community home (<italic>n</italic> = <italic>8</italic><sup><italic>1</italic></sup>)</th><th> Institution (<italic>n</italic> = <italic>19</italic><sup><italic>1</italic></sup>)</th><th valign="bottom"><italic>P‐</italic><italic>value</italic><sup>2</sup></th><th valign="bottom"><italic>Post hoc</italic><italic>test</italic><sup>3</sup></th></tr><tr><th>Mean</th><th>SD</th><th>Mean</th><th>SD</th><th>Mean</th><th>SD</th></tr></thead><tbody valign="top"><tr><td>Staffing</td><td>9462</td><td>4067</td><td>13 345</td><td>16 654</td><td>15 793</td><td>10 828</td><td>0.02</td><td /></tr><tr><td>Daily utilities</td><td>215</td><td>299</td><td>271</td><td>429</td><td>397</td><td>473</td><td>0.53</td><td /></tr><tr><td>Facilities and equipment</td><td>1671</td><td>2246</td><td>989</td><td>1342</td><td>2255</td><td>5936</td><td>0.78</td><td /></tr><tr><td>Rent</td><td>1378</td><td>1939</td><td>0</td><td>0</td><td>165</td><td>553</td><td>0.06</td><td /></tr><tr><td>Water, electricity and gas</td><td>483</td><td>458</td><td>414</td><td>266</td><td>548</td><td>290</td><td>0.42</td><td /></tr><tr><td>Telephone</td><td>108</td><td>98</td><td>73</td><td>60</td><td>100</td><td>69</td><td>0.71</td><td /></tr><tr><td>Housing repairs</td><td>331</td><td>396</td><td>410</td><td>403.5</td><td>1072.0</td><td>1907</td><td>0.07</td><td /></tr><tr><td>Insurance</td><td>165</td><td>329</td><td>466</td><td>523.6</td><td>368.2</td><td>438</td><td>0.05</td><td /></tr><tr><td>Food</td><td>2317</td><td>2105</td><td>2246</td><td>2187.4</td><td>2254.3</td><td>1706</td><td>0.93</td><td /></tr><tr><td>Transportation</td><td>240</td><td>480</td><td>182.7</td><td>250.0</td><td>152.1</td><td>169</td><td>0.90</td><td /></tr><tr><td>Staff service training</td><td>72</td><td>196</td><td>724</td><td>793</td><td>264</td><td>793</td><td>0.02</td><td>1 < 3*</td></tr><tr><td>Administration</td><td>151</td><td>262</td><td>685</td><td>1436</td><td>464</td><td>989</td><td>0.83</td><td /></tr><tr><td>Other</td><td>751</td><td>1216</td><td>813</td><td>1276</td><td>3835</td><td>4183</td><td>0.01</td><td>1 < 3*</td></tr><tr><td>Total</td><td>17 638 (9919 – 30 556)</td><td>4466</td><td>20 920 (8925 – 54 501)</td><td>14 415</td><td>28 067 (10 334 – 54 501)</td><td>11 340</td><td>0.002</td><td>1 < 3**</td></tr></tbody></table> </ephtml> </p> <ulist> <item>8 Costs (in dollars) were calculated by the providers in Taiwanese dollars at 2004 prices and converted at a rate of USD$1 = NTD$32.</item> <item>9 <sups>1</sups>Providers.</item> <item>10 <sups>2</sups>Based on Kruskal–Wallis one‐way analysis of variance by ranks.</item> <item>11 <sups>3</sups>Based on Mann–Whitney <emph>U</emph>‐test for ranked differences between groups.</item> <item>12 *<emph>P </emph><<emph> </emph>0.01; **<emph>P </emph><<emph> </emph>0.001.</item> </ulist> <hd id="AN0028794132-23">Factors associated with personal outcomes</hd> <p>Stepwise regressions were performed to assess what personal characteristics (the resident's characteristics data, namely, adaptive and maladaptive behaviour, gender, age, level of disability and involvement in daily activities) and environmental variables (model of residential unit and location of residential unit) are significantly associated with the individual outcomes (Table 8). The resident's adaptive behaviour is significantly associated with the individual's QOL, choice making and community inclusion; residents with higher adaptive function had higher QOL, more opportunity to make choices and were more included in the community than residents with lower adaptive function (<emph>P </emph><<emph> </emph>0.01). Residents who were not involved in daily activities had a lower QOL (<emph>P </emph><<emph> </emph>0.001) and a lower score for choice making than those who were involved in daily activities (<emph>P </emph><<emph> </emph>0.01). The type of residential settings was significantly associated with all the dependent variables including the resident's QOL (<emph>P </emph><<emph> </emph>0.01), choice making (<emph>P </emph><<emph> </emph>0.001 and <emph>P </emph><<emph> </emph>0.01), community inclusion (<emph>P </emph><<emph> </emph>0.001) and frequency of family contact (<emph>P </emph><<emph> </emph>0.001 and <emph>P </emph><<emph> </emph>0.01). The location of the residential setting was a significant factor associated with the resident's QOL (<emph>P </emph><<emph> </emph>0.001). The resident's maladaptive behaviour, level of disability, gender and age were not significantly associated in terms of the individuals' QOL, choice making, community inclusion and frequency of family contact.</p> <p>8  Stepwise regression analysis for the variables associated with the residents' quality of life (QOL), choice making, community involvement and family contact (N = 248)</p> <p> <ephtml> <table><thead valign="bottom"><tr><th /><th>Step</th><th>Variables</th><th>Cumulative <italic>R</italic><sup>2</sup></th><th>B</th><th>SEB</th><th>β</th></tr></thead><tbody valign="top"><tr><td>QOL</td><td>1</td><td>Daily activity<sup>1</sup> (not involved)</td><td>0.28</td><td>−7.53</td><td>2.18</td><td>−0.30**</td></tr><tr><td /><td>2</td><td>Location of residential unit (rural)</td><td>0.32</td><td>−4.66</td><td>1.19</td><td>−0.21**</td></tr><tr><td /><td>3</td><td>Adaptive behaviour</td><td>0.34</td><td>0.01</td><td>0.00</td><td>0.15*</td></tr><tr><td /><td>4</td><td>Model of residential unit (group home)</td><td>0.36</td><td>−4.38</td><td>1.42</td><td>−0.18*</td></tr><tr><td>Choice making</td><td>1</td><td>Model of residential unit (institution)</td><td>0.33</td><td>−19.42</td><td>4.55</td><td>−0.38**</td></tr><tr><td /><td>2</td><td>Daily activity (not involved)</td><td>0.36</td><td>−14.55</td><td>4.50</td><td>−0.27*</td></tr><tr><td /><td>3</td><td>Model of residential unit (group home)</td><td>0.38</td><td>8.71</td><td>2.91</td><td>−0.17*</td></tr><tr><td /><td>4</td><td>Adaptive behaviour</td><td>0.40</td><td>0.02</td><td>0.01</td><td>0.14*</td></tr><tr><td>Community inclusion</td><td>1</td><td>Model of residential unit (institution)</td><td>0.10</td><td>−7.14</td><td>1.15</td><td>−0.41**</td></tr><tr><td /><td>2</td><td>Model of residential unit (group home)</td><td>0.16</td><td>−4.74</td><td>1.13</td><td>−0.26**</td></tr><tr><td /><td>3</td><td>Adaptive behaviour</td><td>0.20</td><td>0.01</td><td>0.00</td><td>0.20*</td></tr><tr><td>Family contact</td><td>1</td><td>Model of residential unit (institution)</td><td>0.07</td><td>−1.01</td><td>0.18</td><td>−0.36**</td></tr><tr><td /><td>2</td><td>Model of residential unit (group home)</td><td>0.12</td><td>−0.66</td><td>0.19</td><td>−0.23*</td></tr></tbody></table> </ephtml> </p> <ulist> <item>13 There were a total of eight significant related independent variables including the resident's adaptive behaviour, maladaptive behaviour, gender (male coded as '0' and female coded as '1'), resident's age, resident's level of disability, daily activity involvement (involved employed, vocational services or day care centre coded as '0' and not involved coded as '1'), model of residential unit (small home as the reference group, while group/community home coded as '1', small home and institution coded as '0', while institution coded as '1', small home and group home coded as '0') and location of residential unit (urban coded as '0' and rural coded as '1'). Adaptive behaviour, maladaptive behaviour, age and level of disability are interval/ordinal variables, a higher score indicates better adaptive functioning, higher maladaptive behaviour, older age and higher level of disability. Gender, whether involved daily activity, model of residential unit and location of residential unit are nominal variables.</item> <item>14 <sups>1</sups>Daily activity involvement includes going to a school or day care centre, employed or use of vocational services; daily activity 'not involved' means staying in the accommodation all day.</item> <item>15 *<emph>P </emph>< 0.01; **<emph>P </emph><<emph> </emph>0.001. <emph>SEB</emph> = standard error.</item> </ulist> <hd id="AN0028794132-24">Discussion</hd> <p>In this paper, we examined the outcomes of residential services for adults with intellectual disabilities in Taiwan. Results of the present study are generally similar to those found in the Western literature in that participants in small homes experienced relatively greater choice (but no difference between small homes and group/community homes), better QOL, more extensive community inclusion, had more frequent family contact, showed greater satisfaction with their accommodation, were happier with their housemates and had fewer roommates ([<reflink idref="bib20" id="ref43">20</reflink>]; [<reflink idref="bib1" id="ref44">1</reflink>]; [<reflink idref="bib16" id="ref45">16</reflink>]; [<reflink idref="bib6" id="ref46">6</reflink>]; [<reflink idref="bib9" id="ref47">9</reflink>]; [<reflink idref="bib18" id="ref48">18</reflink>]; [<reflink idref="bib31" id="ref49">31</reflink>]; [<reflink idref="bib32" id="ref50">32</reflink>]). It is worthwhile to note that the majority of the residents across the three models had very little opportunity to make their own choices. Instead, their families and the workers in the unit made decisions for them, including where to live and with whom to live (as shown in Table 4). It seems that the level of self‐determination by these adults in Taiwan is generally of less concern and this is consistent with the findings of [<reflink idref="bib5" id="ref51">5</reflink>].</p> <p>There was a significant difference in the 'physical facilities' and 'buildings' between the models. Surprisingly, the small homes, including the group/community homes, had poorer living environmental accessibility than the institutions (<emph>P </emph><<emph> </emph>0.001). This might be a result of the institutions in Taiwan having access to large grants for the construction of their facilities, particularly accessibility is required by law. Furthermore, the scheme of small homes is still at an early stage and the majority of users were less severely disabled and hence the designs of the small homes are generally not specialized for disabled people. Large group/community homes or institutional care services appeared to allow less personal individual activities (<emph>P </emph><<emph> </emph>0.001) and arrange a more scheduled daily life (<emph>P </emph><<emph> </emph>0.001). However, this study also clearly demonstrates that all three models appeared to lack individualized service that provides support to the residents to allow them to freely engage in group activities and have their own personal life choices within the accommodation (as shown in Table 6). Generally, all the three models required a relatively rigid set of residential activities and these tended to emphasize the medical and therapeutic aspects of care. In addition, the programmes of the group/community homes and the institutions are based on a funding mechanism that requires the application of relatively rigid staff levels. As shown in Table 6, both institutions and group/community homes have full levels of night staff and sleepover night staff (100%) and all three models have high levels of support staff during the night time and day time.</p> <p>Data from the present study (see Table 7) show clearly that institutions are more costly than the other two models. Despite having the highest level of costs, the traditional institution model is neither associated with better personal outcomes nor is the 'preferred' model based on the indicators for support service and the higher level of rigid routine. However, we do not have data on the cost of services provided outside the residential setting and the cost of individual residents. Thus, it should be investigated in future research whether small homes are in fact more cost effective.</p> <p>As shown in Table 8, model of residential unit is obviously an important factor associated with residents' QOL, community inclusion, family contact and choice making, all of which enhance a person's development ([<reflink idref="bib21" id="ref52">21</reflink>]; [<reflink idref="bib8" id="ref53">8</reflink>]). It must be recognized that based on a substantial and remarkably consistent body of research over many years, supporting people to live in small and community‐based facilities is a practical way of increasing their subjective QOL. In the meantime, the findings of the present study suggest strongly that when residents with an intellectual disability are in community‐based small facilities, there is a greater likelihood of access to local facilities as well as greater contact with their families when compared with residents of large size residential units. However, this is part of the debate about deinstitutionalization and the need for community inclusion as well as the quality of day activity programmes arranged for the residents in the institutions.</p> <p>Furthermore, there is a significant correlation between the residents' adaptive behaviour and the residents' QOL, choice making and community inclusion. Based on this study, residents with better adaptive functioning were more likely to live in the small homes. Individuals with an intellectual disability should be given community support to live in small homes if they choose to do this. To date such opportunities have been available rarely in Taiwan. One appropriate policy and service response to our findings would be to increase the provision of small homes particularly for adults with lower level of adaptive behaviour. Additionally, longitudinal studies of people living in the small homes would provide further important information on how the living environments and support arrangements are able to promote better outcomes, and an improved equity compared with the provision of accommodation support to people with an intellectual disability who live in the group/community homes and institutions. Meanwhile, it is necessary to carry out studies to investigate whether staff levels and costs can be reduced in the small homes once the scheme has matured.</p> <p>This study has some shortcomings that necessitate a cautious interpretation. First, the resident's monthly costs were estimated using the average costs of all residents in the residential unit without detailed information on individual costs. As a result, whether higher costs of the institution in the present study were due to having more residents with higher level of disability is uncertain. In addition, we did not have data on service quality, which is closely related to costs. Second, as the small homes scheme has started to receive government sponsorship only recently, the residents of these homes tended to be younger, male and without multiple disabilities, needing relatively less intensive care. As a result, the participants from the group/community homes and institutions were selected purposively among young and male users. Future study is required to investigate whether there would be a similar result for older persons and residents with more severe disabilities across the different models. As the current small home residential model is a new scheme for the providers, the staffing could be backed up by other projects (e.g. day programmes or larger‐scale residential services) and hence these costs may have been left out of the account and causes underestimation of the costs. Third, before the informed consent was delivered, the purposive sampling criteria were based on only residents' age, gender and the level of disability because of limited data that was received from the residential providers. As a result, it was not possible to match the numbers of participants and their adaptive and maladaptive behaviours between the models precisely before the interviews were conducted. Fourth, unlike the Western literature, which has concentrated on the changes in QOL and social inclusion when a resident is relocated from an institution to a community‐based home, using longitudinal data in the analysis, the participants in the present study were a cross‐sectional comparison between the purposive selection of samples from the different residential models. Hence causal effects can not be determined. Fifth, the data on services provided and costs were collected from the service providers and therefore based on their individual interpretations. Additionally, a note of interpretive caution needs to be emphasized concerning the large variation in service outcome and services provided and the large variation in costs both within and between service models.</p> <p>To conclude, the results of the present study indicated that participants living in the new small homes enjoyed a significantly greater QOL and supports than participants living in the group/community homes and institutions. Furthermore, a preliminary analysis indicates that the total cost of providing the small homes was lower than the total cost of the institutions. This however, may be subjected to further investigation controlling for resident's level of disability. In the light of the evidence, traditional policy that upholds large institutions seems highly problematic. It is now the responsibility of policy makers, service managers and parents in Taiwan to change the course of action.</p> <hd id="AN0028794132-25">Acknowledgments</hd> <p>Sincere thanks to the participants and staff that provided the information for this study and to the management of participating residential settings for their assistance and co‐operation. Special thanks to Professor R. L. Schalock for his thoughtful and critical revisions of the manuscript. We would also like to thank Dr Teppo Kröger for his help in the final revision. The study was financed by the Department of Social Affairs, Ministry of Interior, Taiwan, China.</p> <hd id="AN0028794132-26">Correspondence</hd> <p>Any correspondence should be directed to Associate Professor Yueh‐Ching Chou, Institute of Health and Welfare Policy & Research Center for Health & Welfare Policy, National Yang‐Ming University 155, Li‐Nong St., Sec.2, Peitou, Taipei 112, Taiwan (e‐mail: choucyc@ym.edu.tw).</p> <ref id="AN0028794132-27"> <title> Footnotes </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> According to the documented observations of the interviewers: (1) 96.1% of the participants from small homes, 100% from group/community homes and 98.7% from institutions answered the interview questions themselves; the remaining few participants had the interviews answered by their direct care workers; (2) 60.2% of the participants from small homes, 66.7% from group/community homes and 52.6% from institutions understood all the questions on their own directly or after the interviewer's explanation; the rest of the participants were interviewed with the help from their care workers. Still, as mentioned above, almost all of them answered the questions by themselves.</bibtext> </blist> </ref> <ref id="AN0028794132-28"> <title> References </title> <blist> <bibtext> Allen D. & Lowe K. (1995) Providing intensive community support to people with learning disabilities and challenging behaviour: a preliminary analysis of outcomes and costs. Journal of Intellectual Disability Research 39, 67 – 82.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref3" type="bt">2</bibl> <bibtext> Beecham J., Knapp M., McGilloway S., Donnelly M., Kavanagh S., Fenyo A. & Mays N. (1997) The cost‐effectiveness of community care for adults with learning disabilities leaving long‐stay hospital in Northern Ireland. Journal of Intellectual Disability Research 41, 30 – 41.</bibtext> </blist> <blist> <bibl id="bib3" idref="ref11" type="bt">3</bibl> <bibtext> Braddock D., Emerson E., Felce D. & Stancliffe R. J. (2001) Living circumstances of children and adults with mental retardation or developmental disabilities in the United States, Canada, England and Wales, and Australia. Mental Retardation and Developmental Disabilities Research Reviews 7, 115 – 121.</bibtext> </blist> <blist> <bibl id="bib4" idref="ref12" type="bt">4</bibl> <bibtext> Chou Y. C. & Schalock R. L. (2007) Trends in residential policies and services for people with intellectual disabilities in Taiwan. Journal of Intellectual Disability Research 51, 135 – 141.</bibtext> </blist> <blist> <bibl id="bib5" idref="ref51" type="bt">5</bibl> <bibtext> Chou Y. C., Schalock R. L., Tzou P. Y., Chang A. L., Lin L. C., Lee W. P. & Chang S. C. (2007) Quality of Life of Adults with Intellectual Disabilities Who live with Families in Taiwan. Journal of Intellectual Disability Research, in press.</bibtext> </blist> <blist> <bibl id="bib6" idref="ref8" type="bt">6</bibl> <bibtext> Conroy J. W. (1996) The small ICF/MR program: dimensions of quality and cost. Mental Retardation 34, 13 – 26.</bibtext> </blist> <blist> <bibl id="bib7" idref="ref27" type="bt">7</bibl> <bibtext> Cooper B. & Picton C. (2000) The long‐term effects of relocation on people with an intellectual disability: quality of life, behavior, and environment. Research on Social Work Practice 10, 195 – 208.</bibtext> </blist> <blist> <bibl id="bib8" idref="ref53" type="bt">8</bibl> <bibtext> Emerson E. & Hatton C. (1994) Moving Out: the Impact of Relocation from Hospital to Community on the Quality of Life of People with Learning Disabilities. HMSO, London.</bibtext> </blist> <blist> <bibl id="bib9" idref="ref25" type="bt">9</bibl> <bibtext> Emerson E. & Hatton C. (1996) Deinstitutionalization in the UK and Ireland: outcomes for service users. 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Mental Retardation and Developmental Disabilities Research Reviews 7, 75 – 83.</bibtext> </blist> <blist> <bibtext> Felce D., Lowe K., Perry J., Baxter H., Jones E., Hallam A. & Beechman J. (1998) Service support to people in Wales with severe intellectual disability and the most severe challenging behaviours: processes, outcomes and costs. Journal of Intellectual Disability Research 42, 390 – 408.</bibtext> </blist> <blist> <bibtext> Felce D., Bowley C., Baxter H., Jones E., Lowe K. & Emerson E. (2000) The effectiveness of staff support: evaluating active support training using a conditional probability approach. Research in Developmental Disabilities 21, 243 – 255.</bibtext> </blist> <blist> <bibtext> Hallam A., Knapp M., Jarbrink K., Netten A., Emerson E., Robertson J., Gregory N., Hatton C., Kessissoglou S. & Durkan J. (2002) Costs of village community, residential campus and dispersed housing provision for people with intellectual disability. Journal of Intellectual Disability Research 46, 394 – 404.</bibtext> </blist> <blist> <bibtext> Hatton C., Emerson E., Robertson J., Henderson D. & Cooper J. (1995) The quality and costs of residential services for adults with multiple disabilities: a comparative evaluation. Research in Developmental Disabilities 16, 439 – 460.</bibtext> </blist> <blist> <bibtext> Hatton C., Emerson E., Robertson J., Henderson D. & Cooper J. (1996) Factors associated with staff support and resident lifestyle in services for people with multiple disabilities: a path analytic approach. Journal of Intellectual Disabilities Research 40, 466 – 477.</bibtext> </blist> <blist> <bibtext> Howe J., Horner R. H. & Newton J. S. (1998) Comparison of supported living and traditional residential services in the state of Oregon. Mental Retardation 36, 1 – 11.</bibtext> </blist> <blist> <bibtext> Kearney C. A., Durant V. M. & Mindell J. A. (1995) Choice assessment in residential settings. 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AAMR, Washington, DC.</bibtext> </blist> <blist> <bibtext> Molony H. & Taplin J. (1988) Deinstitutionalization of people with developmental disability. Australia and New Zealand Journal of Developmental Disabilities 14, 109 – 122.</bibtext> </blist> <blist> <bibtext> Perry J. & Felce D. (1994) Outcomes of ordinary housing services in Wales: objective indicators. Mental Handicap Research 7, 286 – 311.</bibtext> </blist> <blist> <bibtext> Research and Training Center on Community Living, Institute on Community Integration (UAP), University of Minnesota (2000a) An independent evaluation of the quality of services and system performance of Minnesota's Medicaid Home and Community Based Services for Persons with Mental Retardation and Related Conditions. The College of Education & Human Development, University of Minnesota, Minneapolis, MN</bibtext> </blist> <blist> <bibtext> Schalock R. L. & Keith K. D. (1993) Quality of life questionnaire. IDS Publishing, Worthington, OH.</bibtext> </blist> <blist> <bibtext> Shu S. L. (2004) Handbook of the Adaptive Behaviour Scale – Taiwanese Version. Special Education Center, National Normal University, Taipei.</bibtext> </blist> <blist> <bibtext> Stancliffe R. J. (1995) Assessing opportunities for choice‐making: a comparison of self‐and staff reports. American Journal on Mental Retardation 99, 418 – 429.</bibtext> </blist> <blist> <bibtext> Stancliffe R. J. (1997) Community living –unit size, staff presence, and residents' choice‐making. Mental Retardation 35, 1 – 9.</bibtext> </blist> <blist> <bibtext> Stancliffe R. J. & Lakin K. C. (1998) Analysis of expenditures and outcomes of residential alternatives for persons with developmental disabilities. American Journal on Mental Retardation 102, 552 – 568.</bibtext> </blist> <blist> <bibtext> Young L., Sigafoos J., Suttie J., Ashman A. & Grevell P. (1998) Deinstitutionalization of persons with intellectual disabilities: a review of Australian studies. Journal of Intellectual & Developmental Disabilities 23, 155 – 171.</bibtext> </blist> </ref> <aug> <p>By Yueh‐Ching Chou; Li‐Chan Lin; Cheng‐Yun Pu; Wan‐Ping Lee and Shu‐Chuan Chang</p> <p>Reported by Author; Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib16" firstref="ref2"></nolink> <nolink nlid="nl2" bibid="bib13" firstref="ref4"></nolink> <nolink nlid="nl3" bibid="bib10" firstref="ref5"></nolink> <nolink nlid="nl4" bibid="bib15" firstref="ref6"></nolink> <nolink nlid="nl5" bibid="bib22" firstref="ref7"></nolink> <nolink nlid="nl6" bibid="bib18" firstref="ref9"></nolink> <nolink nlid="nl7" bibid="bib31" firstref="ref10"></nolink> <nolink nlid="nl8" bibid="bib24" firstref="ref14"></nolink> <nolink nlid="nl9" bibid="bib25" firstref="ref15"></nolink> <nolink nlid="nl10" bibid="bib11" firstref="ref16"></nolink> <nolink nlid="nl11" bibid="bib12" firstref="ref17"></nolink> <nolink nlid="nl12" bibid="bib20" firstref="ref19"></nolink> <nolink nlid="nl13" bibid="bib29" firstref="ref21"></nolink> <nolink nlid="nl14" bibid="bib30" firstref="ref22"></nolink> <nolink nlid="nl15" bibid="bib14" firstref="ref24"></nolink> <nolink nlid="nl16" bibid="bib17" firstref="ref29"></nolink> <nolink nlid="nl17" bibid="bib113" firstref="ref34"></nolink> <nolink nlid="nl18" bibid="bib23" firstref="ref35"></nolink> <nolink nlid="nl19" bibid="bib28" firstref="ref36"></nolink> <nolink nlid="nl20" bibid="bib27" firstref="ref37"></nolink> <nolink nlid="nl21" bibid="bib19" firstref="ref38"></nolink> <nolink nlid="nl22" bibid="bib26" firstref="ref39"></nolink> <nolink nlid="nl23" bibid="bib32" firstref="ref50"></nolink> <nolink nlid="nl24" bibid="bib21" firstref="ref52"></nolink>
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  Group: Ti
  Data: Outcomes and Costs of Residential Services for Adults with Intellectual Disabilities in Taiwan: A Comparative Evaluation
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Chou%2C+Yueh-Ching%22">Chou, Yueh-Ching</searchLink><br /><searchLink fieldCode="AR" term="%22Lin%2C+Li-Chan%22">Lin, Li-Chan</searchLink><br /><searchLink fieldCode="AR" term="%22Pu%2C+Cheng-Yun%22">Pu, Cheng-Yun</searchLink><br /><searchLink fieldCode="AR" term="%22Lee%2C+Wan-Ping%22">Lee, Wan-Ping</searchLink><br /><searchLink fieldCode="AR" term="%22Chang%2C+Shu-Chuan%22">Chang, Shu-Chuan</searchLink>
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  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Journal+of+Applied+Research+in+Intellectual+Disabilities%22"><i>Journal of Applied Research in Intellectual Disabilities</i></searchLink>. Mar 2008 21(2):114-125.
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  Label: Availability
  Group: Avail
  Data: Blackwell Publishing. 350 Main Street, Malden, MA 02148. Tel: 800-835-6770; Tel: 781-388-8599; Fax: 781-388-8232; e-mail: customerservices@blackwellpublishing.com; Web site: http://www.blackwellpublishing.com/jnl_default.asp
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  Label: Peer Reviewed
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  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 12
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2008
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Evaluative
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Costs%22">Costs</searchLink><br /><searchLink fieldCode="DE" term="%22Residential+Institutions%22">Residential Institutions</searchLink><br /><searchLink fieldCode="DE" term="%22Group+Homes%22">Group Homes</searchLink><br /><searchLink fieldCode="DE" term="%22Mental+Retardation%22">Mental Retardation</searchLink><br /><searchLink fieldCode="DE" term="%22Adults%22">Adults</searchLink><br /><searchLink fieldCode="DE" term="%22Comparative+Analysis%22">Comparative Analysis</searchLink><br /><searchLink fieldCode="DE" term="%22Residential+Care%22">Residential Care</searchLink><br /><searchLink fieldCode="DE" term="%22Interviews%22">Interviews</searchLink><br /><searchLink fieldCode="DE" term="%22Normalization+%28Disabilities%29%22">Normalization (Disabilities)</searchLink><br /><searchLink fieldCode="DE" term="%22Quality+of+Life%22">Quality of Life</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Taiwan%22">Taiwan</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1111/j.1468-3148.2007.00373.x
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1360-2322
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Background: The disability policy in Taiwan has traditionally emphasized residential care in large institutions and, more recently, medium-sized group homes. This paper compares the relative costs, services provided and outcomes between the traditional institutions, medium-sized group homes and new small-scale community living units that were launched in 2004 in Taiwan. Materials and Methods: Cross-sectional analysis was used to investigate the three current residential service models. A total of 248 participants with intellectual disabilities were interviewed, including all residents from the existing 25 small residential units and purposively sampled respondents from the other two residential models. Results: Outcomes for the Taiwanese participants were consistent with the existing literature on deinstitutionalization from Western societies. Small homes provided better subjective and objective quality of life than both medium-sized community-based units and traditional institutions. Conclusion: Participants living in small residential homes experienced better outcomes at lower cost than persons living in medium-sized group homes or institutions.
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  Data: 2009
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  Label: Accession Number
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  Data: EJ835094
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      – Type: doi
        Value: 10.1111/j.1468-3148.2007.00373.x
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      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 12
        StartPage: 114
    Subjects:
      – SubjectFull: Costs
        Type: general
      – SubjectFull: Residential Institutions
        Type: general
      – SubjectFull: Group Homes
        Type: general
      – SubjectFull: Mental Retardation
        Type: general
      – SubjectFull: Adults
        Type: general
      – SubjectFull: Comparative Analysis
        Type: general
      – SubjectFull: Residential Care
        Type: general
      – SubjectFull: Interviews
        Type: general
      – SubjectFull: Normalization (Disabilities)
        Type: general
      – SubjectFull: Quality of Life
        Type: general
      – SubjectFull: Foreign Countries
        Type: general
      – SubjectFull: Taiwan
        Type: general
    Titles:
      – TitleFull: Outcomes and Costs of Residential Services for Adults with Intellectual Disabilities in Taiwan: A Comparative Evaluation
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            NameFull: Lin, Li-Chan
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            NameFull: Pu, Cheng-Yun
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            NameFull: Lee, Wan-Ping
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            NameFull: Chang, Shu-Chuan
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            – TitleFull: Journal of Applied Research in Intellectual Disabilities
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