Primary Care Doctors - How primary Chinese health Beliefs and Chinese Culture affect health and Illness?.
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Traditional Chinese health beliefs adopt a holistic view emphasizing the significance of environmental factors in increasing risk of disease. Agreeing to Quah (1985), these factors work on the equilibrium of body's harmony, yin and yang. These are two opposite but complementary troops and, together with qi (vital energy), they operate the universe and by comparison the association between citizen and their surroundings. Imbalance in these two forces, or in the qi, results in illness.
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In order to restore the balance, primary restorative practices may be needed. For example, excess `hot' power can be counterbalanced by cooling herbal teas, and vice versa. These beliefs are deeply ingrained among the Chinese, and have been found to be unchanged following migration to Singapore.
Lee, et. Al. (2004), found that patients with exact continuing diseases, namely arthritis, musculoskeletal diseases and stroke, were more likely to use primary Chinese rehabilitation (Tcm). This was strongly considered by the 'chronic disease triad', perceived pleasure with care and cultural health beliefs.
Hence the use of Tcm is not connected with the capability of doctor-patient interaction. Astin (1998) also agreed that it was seen as being more compatible with the patients' values, spiritual and religious philosophy, or beliefs with regard to the nature and meaning of health and illness.
In primary Chinese culture, taking medication is idea to be aversive, hence medications tend to be taken only until symptoms are relieved and then discontinued; if symptoms are not obvious, medications will probably never be taken.
Apart from parental cultural beliefs, minor side effects of sure antibiotics such as stomach upset may lead to the poor adherence of medication. The use of "leftover", "shared" antibiotics and over-the-counter buy of antibiotics by parents are tasteless situations in the community.
They think that their children suffer from the same illnesses judging by the similar symptoms, so they would give the "leftover" or "shared" antibiotics to their children and only bring them to their doctors if there is no correction (Chang & Tang, 2006). This may cause their conditions to deteriorate and may necessitate aggressive treatments later which may have unnecessary side effects.
However, there are small groups of Chinese who also blamed ill-health or misfortunes on supernatural forces, or on divine retribution, or on the malevolence of a 'witch' or 'sorcerer' (Helman, 1994). Such groups will normally seek cures from their religions.
In Singapore, the Ministry of health has drawn up the Tcm Practitioners' Ethical Code and Ethical Guidelines to preclude any unscrupulous practitioners from preying on their patients and taking advantage of their beliefs, for example, molesting ignorant patients.
The degree of acculturation has been evidenced in the following case. An old man was brought into our hospital with a week-long history of malaise, nausea and vomiting, and sudden jaundice. He was diagnosed to have an obstructive mass in the liver.
A biopsy revealed hepatocellular carcinoma. The serological test recommend continuing active hepatitis B. When the news broke to his son that his father had cancer, he requested not to disclose that to his father.
When we discussed end of life issues such as hospice care and "do-not-resuscitate" (Dnr) orders, the son tried to divert the argument to other issues such as when his father could go home.
Cultural Issues that may be complicated in this case are:
The Chinese tend to protect the elderly from bad news.
Believing in karma - the older folk believe that discussing illnesses or death/dying is bad luck. They think that talking about something bad will cause it to come true.
There is an increased incidence of liver cancer resulting from Hepatitis B due to delayed rehabilitation in the elderly, as it may take a long time for them to accept the preliminary diagnosis.
Reference:
Astin Ja. (1998). Why patients use alternative medicine. J Am Med Assoc 1998; 279: 1548-1553.
Chan, G. C. & Tang, S. F. (2006) Parental knowledge, attitudes and antibiotic use for acute upper respiratory tract infection in children attending a primary healthcare clinic in Malaysia. Singapore medical Journal, 47(4):266
Helman, C. G. (1990) Culture, health and Illness. Wright, London.
Quah, S. R. (1985) The health belief Model and preventive health behaviour in Singapore. Social Science and Medicine, 21, 351-363.
Lee Gbw, Charn Tc, Chew Zh and Ng Tp. (2004). Complementary and alternative rehabilitation use in patients with continuing diseases in primary care is connected with perceived capability of care and cultural beliefs. Family Practice, 21(6): 654-660.
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Primary Care Providers - 2010 Largest Assisted Living Providers
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While stormy economic conditions buffeted the business last year, indicators now point to smoother sailing ahead. As businesses in nearly every U.S. Sector struggled to stay afloat last year, assisted living was the buoy in the choppy waters. Steady query for ability services helped keep associates stable-even if accompanied by a hiatus from major mergers and acquisitions.
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As businesses in nearly every U.S. Sector struggled to stay afloat last year, assisted living was the buoy in the choppy waters. Steady query for ability services helped keep associates stable-even if accompanied by a hiatus from major mergers and acquisitions.
Now, as economic forecasters allude to the end of the "Great Recession," associates like this year's Largest Providers are poised for growth, some of which is already underway. Forty-two of those associates (60%) that made the 2010 list description increases in licensed assisted living resident capacity-though much of that growth was in single-digit percentages. Other 16 of the top 70 associates maintained their size, while just 12 reported losses.
Here's a look at Assisted Living Executive's 2010 Largest Providers, and the business environment, transactions, and trends that landed each business a spot.
Top Players Hold Steady
In 2009, no assisted living providers merged nor acquired any other complete company. However, while most deals were small, the year did yield a few large briefcase acquisitions and vital reshuffling. The biggest gains and losses were among the biggest players and occurred through easy sales and acquisitions.
For the first time since Assisted Living menagerial began compiling this yearly Largest Providers list, Sunrise Senior Living, based in McLean, Virginia, no longer sits at No. 1. The company, now No. 2, had no new construction starts and sold off about 9 percent of its assisted living capacity (about 2,896 units) last year. Its biggest transaction was a briefcase of 21 communities in 11 states to Milwaukee, Wisconsin-based Brookdale Senior Living for 4 million, but Sunrise also sold smaller portfolios to regional providers, such as Baltimore-based Brightview Senior Living (The protection Group), which purchased two of Sunrise's New Jersey communities.
The Sunrise downsize has made Seattle-based Emeritus Senior Living the nation's largest assisted living provider. Emeritus acquired 2,221 new licensed assisted living units and grew by 7 percent in the past year, and it's very likely that Emeritus will not only profess the top spot next year, but advance significantly in 2011. The company's partner, Blackstone Real Estate Advisors, is pursuing the buy of 134 communities operated by Sunwest Management, which is in part 11 bankruptcy. Under a preliminary agreement, Emeritus would administrate the properties with the option to invest up to 10 percent of the equity in a joint speculation with Blackstone and Columbia Pacific Management, an entity controlled by Dan Baty, Emeritus chairman and co-Ceo.
Brookdale Senior Living maintained its No. 3 ranking, but also grew by 3,808 residents, or 15 percent, in 2009. Sunwest Management, last year's No. 4 company, comes in at No. 7 this year with 9,186 assisted living residents, a 43 percent drop. The business will disappear fully from the 2011 list if Blackstone or Other entity receives court approval to buy the remainder of Sunwest's portfolio.
In terms of ration growth, the clear winner is Solana Beach, California-based Senior reserved supply Group, Other beneficiary of Sunwest's financial woes. The business picked up administration contracts for 41 properties in 11 states, under the name LaVida Communities, when institutional investor Lone Star Funds of Dallas acquired the properties in the first big deal of 2009. Senior reserved supply Group catapults from No. 55 to No. 11, having grown its assisted living resident capacity more than 500 percent, to 4,897.
Big Movers
For the next Largest Providers ration spike, look to Crl Senior Living Communities, which enters the list at No. 57, thanks to more than doubling its assisted living capacity from 502 to 1,019. Also on the growth path, Frontier administration extensive by 64 percent, from 828 to 1,358 licensed assisted living units, thanks to seven new administration contracts and two new buildings. Frontier administration jumps 15 spots from No. 57 to No. 42. Watch this Western regional provider to grow added next year as several more new buildings open.
The fourth-largest list jumper is Carmichael, California-based Eskaton Senior Residences and Services, rising 12 spots to No. 56. The business reports 1,036 licensed assisted living units (up from 732 last year) due to either expansions or applications for added assisted living licensing.
Only seven other providers description gains of 20 percent or more in the past year, and among them is Bradley, Illinois- based Bma Management. Because of its focus on the affordable market, the business continues to benefit from accessible financing sources not available to former providers. Bma Management's assisted living resident capacity jumped 27 percent in the past year as the business opened six new communities. In 2010, the business moves up the list by three spots, coming in at No. 21.
Other associates that increased their licensed assisted living capacity comprise Capital Senior Living Corporation (No. 20), which grew by 25 percent, and Bonaventure Senior Living (No. 23), whose assisted living capacity surged by 21 percent to 2,595. Assisted living capacity for Carlsbad, California-based Integral Senior Living (No. 24) rose 24 percent. Benedictine condition ideas (No. 41) grew by 20 percent, and Brightview Senior Living (No. 52, up from No. 62 last year) extensive by 29 percent, thanks to the Sunrise deal, which added 240 residents. Other chart-jumper was free time Living Management, which vaulted nine places from No. 58 in 2009 to No. 49 this year simply by adding 200 residents (22 percent).
The vast majority of addition providers, however, had gains of less than 10 percent. But a tiny growth can go a long way when nearly 60 percent of associates on the Largest Providers list have fewer than 2,000 assisted living residents.
In Other indication of assisted living growth, Independent Healthcare Properties, the smallest business on the list at No. 70, only kept its 2009 rank thanks to an 18 percent capacity gain from 706 to 833. Most of the 2009-ranked associates that did not make this year's list either maintained capacity or had very small gains. Other intuit for higher numbers at the lowest of the list is attributed to data from five providers not previously listed-Spectrum relinquishment Communities (No. 28), Mountain View relinquishment (No. 50), Crl Senior Living Communities (No. 57), Welcome Home administration business (No. 64), and Elder Care Alliance (No. 66).
Other than Sunwest, the business with the most dramatic drop in licensed assisted living capacity was Northstar Senior Living, which shed 1,068 residents, or 55 percent of its 2009 capacity, falling from No. 28 to No. 67. Again, because of modest ample numbers, decreases were most renowned toward the lowest of the top 70 list. Grace administration saw a 30 percent decline from 1,399 to 979 and dropped from No. 37 in 2009 to No. 61 this year. Carillon Assisted Living, No. 49 in 2009, decreased its capacity by 24 percent from 1,024 to 775, removing it from the list altogether.
Several associates that didn't make this year's list but may show up in 2011 comprise Trinity Lifestyles Management, which nearly doubled in size to 480 assisted living residents after picking up three Atlanta-area EdenCare properties, formerly operated by Sunrise Senior Living. Wichita, Kansas-based Legend Senior Living has been raising its assisted living component steadily with new construction, addition Other 18 percent to 692 in 2010. And finally, AdCare condition Systems, based in Springfield, Ohio, remains a smaller provider at 231, but that reflects a 38 percent growth over the prior year, and the business recently announced raising .5 million to fund acquisitions.
More carport Times Ahead
"The fact that we'll be able to point to this time period-the worst economic downturn in our lifetimes-and say that our manufactures weathered it pretty well and even prolonged to grow is significant," says Granger Cobb, president and co- Ceo of Emeritus Senior Living.
The past two recessions hit assisted living hard, and many providers at the start of 2009 were implicated that the stalled housing market, depleted stock store earnings, and high unemployment among the adult children of inherent residents could cause occupancy rates to plummet. Instead, after modest 2008 rate declines and a rent growth slowdown to 2 percent from 2.9 percent in 2008 and 4 percent in 2007, the needs-based component of assisted living seemed to trump economic concerns. Move-ins could be postponed but only for so long.
By second quarter 2009, signs of stabilization began to emerge, followed by a slow but upward trend, says Robert G. Kramer, president of the Annapolis, Maryland-based National speculation center for the Seniors Housing & Care manufactures (Nic). While national unemployment still hovered at a troubling 10 percent in January, Kramer says he's cautiously optimistic about the future, especially since the manufactures saw its largest absorption rate in the third quarter of 2009 since the first quarter of 2006- 1,400 assisted living units in the top 30 urban markets and slightly stronger in the top 100 markets.
Those statistics suggest that the ample photo is much rosier for assisted living than for other real estate sectors, including multifamily, hotels, and offices, Kramer notes. "Basically, we are seeing operators keeping the line with regard to rates," he adds. "We de facto are seeing more concessions out there, but at the same time, those concessions tend to be very much market-specific, property-specific, or even unit-specific."
Still, move-in delays due to economic factors have amplified a trend already developing pre-recession-residents tend to be older and frailer, says Jim Moore, president of Moore Diversified Services and author of "Strategic Forecast," published in Assisted Living Executive's January/February 2010 issue. The succeed is heightened occasion in dementia care, which is even more needs-based than assisted living, he adds. Indeed, a whole of top 70 operators reported having converted independent units to assisted living or assisted living to memory care.
As for new construction, buildings already in the pipeline prolonged to open, but few associates launched new developments, and by January 2010, the whole of new construction starts had fallen to the lowest point since Nic started tracking senior housing trends. No associates went public in 2009.
Forecast for 2010
Access to capital will remain the former challenge for improvement in 2010, although new properties financed before the retreat will continue to open through the third quarter of 2010. But the lack of new properties isn't necessarily bad news for assisted living.
"We're going to go through a duration of very tiny new stock coming online, but if that coincides with pent-up query and a rescue in the economy, all should bode well for occupancies and rent growth in assisted living," Kramer says. "Outside of external economic factors that we don't have any operate over, the greatest risk to assisted living is overbuilding."
Fannie Mae and Freddie Mac will continue to be trustworthy sources of permanent 10-year financing, but when it comes to construction loans, developers have few options. Some very tiny Hud 232 financing will be available, but more likely, the few projects that embark on will do so because of relationships with local lenders.
Indeed, The Arbor Company, based in Atlanta, lacks the cash to fabricate properties on its own, but thanks to a partnership with Formation Capital, Arbor will administrate two new properties scheduled to break ground this fall, says Coo Judd Harper. "We feel much stronger and more optimistic about the assisted living occupancies in today's gently recovering economy, but are optimistic about independent living's rebound in the future," he adds. "As people get jobs, they no longer are going to be able to care for a parent at home."
A challenging spot in the acquisitions arena, secret equity entities are starting to eye assisted living as a desirable sector again, and the major Reits in senior housing are well-positioned to invest again, Kramer notes. Emeritus will be a business to watch thanks to the Blackstone deal, and while it only plans one new construction in 2010, the business actively will be seeing for other acquisition opportunities at challenging prices.
"If a business has liquidity, cash flow, and a reasonably salutary balance sheet, it will be in a great position because there are opportunities right now," Cobb says. That benefit isn't just for big associates like Emeritus, but also for regional and even small mom-and-pop players with targeted expansion plans, he adds, noting that "interest rates have not changed that much over the last combine of years, but the whole of equity and coverage ratios you have to have in place has come to be more stringent, as well as the underwriting."
Fanwood, New Jersey-based Chelsea Senior Living leveraged a strong relationship with a local lender to buy a former Sunwest asset in New Jersey last fall and is actively seeing for more deals, says Roger Bernier, president and Coo. "Some people are likely to see their debt maturing and be unable to refinance," he forecasts. "Ultimately we'd like to grow by two communities per year, but it has to be the right deal for us to take a look."
Much of the acquisitions performance in 2010 is likely to remain with distressed properties, however, and no one expects lots of high-end properties to come on the store this year, says Steve Monroe of Senior Care Investor. "High-performing properties are only going to sell if owners can get a good price, although that may start to convert later in 2010."
Still, wise operators should not be blinded by challenging price tags so much that they forget to consider how well the acquisition fits into their existing briefcase and evolving demands of seniors and their families, Moore cautions. "Senior psychographics are changing," he adds. "It's not so much the World War Ii homemaker widow as 80-year-olds who have been in the pro workforce."
Another area of occasion in 2010 may be new administration contracts for owners and lenders who may be unhappy with their current management, Moore suggests. And for many companies, the wisest move in 2010 may be just to sharpen internal operations, he says.
Although Greensboro, North Carolina- based Bell Senior Living is open to the right deal within the mid-Atlantic states in which it already operates, the latter strategy will be the company's prime priority this year, says President Steve Morton. "I'd say it's a time to focus on operations, improve operating results including administration and revenue streams, and put together the vital tools to maximize and run communities in the most productive manner possible," he says. "This is something we can do because we don't have five acquisitions or improvement deals."
Finally, unstable financial markets still make it unlikely that any business will go public in 2010, but if conditions improve, Moore says, the two associates to watch continue to be Atria Senior Living Group (No. 4) and Hcr ManorCare (No. 10).
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