Monday 2 March 2015

What's needed for home care to work

As the country gears itself up to care for more people in the comfort of their own homes, Janice Tai and Priscilla Goy take stock of home-care efforts and look at whether they can be ramped up successfully
The Sunday Times, 1 Mar 2015

Jenny (not her real name) was months old when her father walked out on the family. Her mother, who was in and out of prison for drug offences, was mostly absent too.

She had her first taste of family life only when a foster family took her in. She was cared for by three such families in her first nine years. Otherwise, she would have been placed in a children's home.

Jenny, now 19, said: "You get to realise the joy of being loved by a family. Though it felt strange at first, it felt right to call them 'mum' and 'dad' as we became closer."

Receiving care at home is more beneficial than being in institutions because people feel more comfortable in a familiar setting.

Home care also frees resources in institutions for people in greater need - Singapore's limited land and burgeoning population mean that it cannot keep building new ones.

So it is following a global trend in shifting the care of more vulnerable people - abused or abandoned children, the frail elderly or the disabled - from institutions to homes.

Two-thirds of these children grow up in children's homes and a third live with foster families - a ratio the Ministry of Social and Family Development hopes to reverse in the next five years. To do so, it wants to double the number of foster parents to 500 and will start an $8 million, three-year pilot to set up agencies that better support them.

It also started a pilot initiative last year to provide the disabled with services such as therapy and personal hygiene in their homes.

While baby steps are being taken towards home care for children and the disabled, significant strides are being made in this area for seniors.

From the early 2000s, the Ministry of Health (MOH) has been investing heavily in expanding home-care services by public hospitals and voluntary groups.

Since then, all public hospitals have started home-care programmes for some of their patients.

In five years' time, MOH expects home-care providers, mostly voluntary groups and private players, to be able to serve some 10,000 seniors with home-based health-care and 7,500 of them with home-based personal care each year, up from 6,500 and 1,250 now, respectively.

The progress so far

Public hospitals' home-care programmes have worked in improving care of sickly people, especially the elderly, such that they are being re-admitted less often, or not at all.

For instance, in such a programme for elderly patients who make multiple visits to Alexandra Hospital's emergency department, health workers visit them after their discharge and help with aspects such as wound dressing and home modifications to prevent falls.

Patients get treatment without going to hospital, and the close monitoring prevents complications that require re-admission.

From April 2013 to March last year, 90 per cent of them did not go to the emergency department at all within a month of their discharge.

National University Hospital (NUH) and Singapore General Hospital (SGH) have halved the number of re-admissions and the length of stay.

Khoo Teck Puat Hospital found that giving 800 patients home care saved about 60 beds, or close to two wards of space, over six months.

Home care has also led to saved funds for the state and individual.

In 2008, the Agency for Integrated Care launched a project to form hospital teams to help older patients transit from hospital to home via regular visits and phone calls.

In a 2010 review, it found that running the project for six months cost about $1.94 million, mainly for the workers who went to the homes of 4,000 patients. Yet, $5.3 million was saved from not hospitalising those patients, resulting in net savings of $3.4 million.

Associate Professor Lee Kheng Hock, head of the family medicine and continuing care department at SGH, said: "The average total bill size of C Class admissions is more than $1,000, so a prevented admission saves a lot of money."

Home care for the disabled is nascent, but also looks promising.

In a 2010 pilot, a few intellectually disabled people became more independent after living in a cluster of HDB flats instead of welfare homes. The Government said in 2012 that it intends to expand this.

Singapore lacks data on its fostering scheme, started in 1956, unlike other countries with research comparing foster and institutional care.

Challenges ahead

While the progress is encouraging, there is still room for improvement.

Hospital re-admission rates remain high even though home-care services have helped lower them.

Almost one in five public hospital patients aged 65 and older is re-admitted within a month - comparable with that of the United States but higher than that of Britain.

This suggests that many people cannot care for themselves properly at home, stakeholders said.

One key reason is the lack of home-care professionals.

While the number of clients at Touch Home Care grew by 40 per cent in 2013 to 2,265 last year, it could add only 22 more employees to its lean staff count of 52.

NTUC Health faces a similar problem. It served 1,700 clients last year, up from 1,000 clients in 2013, and it plans to double its current staff strength of 226 this year.

To ease manpower woes, operators here are tapping new labour sources such as back-to-work mothers, housewives and graduates of the Institute of Technical Education, which began offering community care courses in recent years.

But more has to be done to draw people to join the home-care sector as career progression is limited, said Associate Professor Corinne Ghoh of the social work department at the National University of Singapore (NUS).

The second obstacle is a lack of support and training for caregivers.

Some children move from foster families to welfare homes as foster parents cannot cope with them.

For instance, Jenny stayed with two foster families for only a year. She moved to a children's home in 2005 and has been there since.

Some foster parents did not know how to handle her emotional outbursts. She also considered her foster siblings as "frenemies".

She said: "They behave as friends towards you as their new companion. But as soon as they realise that there is more competition for their parents' love, they feel jealous."

The Haven superintendent Peter Khoo said foster parents and their own children need to be trained in how to relate to, and live with, the new entrants to the family.

Mr Cayden Woo, a team leader at Chen Su Lan Methodist Children's Home, said: "After we train the foster parents, we would know which child-foster parent pair would make a good match and foster parents may also need our guidance along the way."

Caregivers of the elderly, many of whom struggle with burnout, could also do with more support.

A study by Duke-NUS Graduate Medical School revealed that nearly half of all 1,190 caregivers surveyed have jobs. Yet they spend 38 hours every week on caregiving, and are more likely to experience higher caregiver stress and depression.

Another challenge is coordinating the myriad of offerings well.

Senior Minister of State for Health Amy Khor had noted a lack of coordination between separate home-care providers - "not ideal as an individual's health and personal care needs are closely intertwined".

MOH has asked providers to offer a wider range of services, so clients can meet their medical and personal care needs at one go, and no longer need to get nursing from one provider, therapy from another and housekeeping from a third.

This can be advanced by putting an anchor operator in charge of all services within a region, giving providers economies of scale, said operators. Last year, the Government started such a system for senior activity centres and group homes.

MOH is also looking into funding home-care providers on a per- client instead of a per-visit basis, to encourage them to coordinate various services for patients.

Winning hearts, minds

These problems are "transitional challenges that can be overcome", said Dr Kang Soon Hock, head of the social science core at SIM University. "Getting awareness and buy-in are the most challenging."

Stakeholders say the biggest hurdles are creating awareness on home-based services and changing mindsets on the viability of home care as a career and way of life.

While most people here wish to live and die at home, their loved ones may prefer to leave them in institutions for their peace of mind.

Dr Ng Shu Ee, associate consultant at NUH, said the belief that institutions give more care and "more is always better" needs to change.

To attract workers, providers will have to raise pay and come up with career progression paths.

Recruiting foster parents has been an uphill task too as the culture here has yet to accept fostering. Only 30 per cent of vulnerable children here are in foster care, fewer than the 80 per cent in the US.

While home care is becoming important, it "should not be seen as a panacea for all the problems of our system", Prof Lee warned.

Institutions have a role in caring for high-needs and complex cases, Minister for Social and Family Development Chan Chun Sing said repeatedly last year.

A balance needs to be struck between both forms of care, experts said. Hearts and minds need to be won to boost home care.





Health checks that come with some friendly chat
By Janice Tai, The Sunday Times, 1 Mar 2015

Before her husband died five years ago, Madam Yiew Poh Lieng, 87, led an independent and active life.

She would do the grocery shopping, whip up her husband's favourite dishes and then go on to mop and clean their three-room flat. The only lull was when she caught up with her drama serials at night.

But things took a drastic turn when her husband had a heart attack and died. Shortly after, Madam Yiew suffered a stroke.

Her brother-in-law found her a place in a nursing home, concerned that the widow would not be able to care for herself alone at home. She said: "I was very 'pek chek' (Hokkien for frustrated) and kept asking to go home."

She did not like being housed with 10 other senior citizens in a ward and recalled the stench that accompanied some of those who had incontinence.

"I would get breathless walking to the breakfast area as it was a distance from the bed and I had to sign so many documents whenever my sister-in-law took me out to see the doctor," she said.

Most of all, Madam Yiew missed the freedom that came with having a place of her own.

The former odd-job worker said: "At home, I can sit where I like and watch whichever TV channel I want."

So she was over the moon when her brother-in-law agreed to take her out of the nursing home last year.

But he still felt uneasy about leaving her alone at home as she has a host of medical problems, from lung disease to arthritis in the knees.

He hired a domestic worker and Madam Yiew was also referred to the Hua Mei mobile clinic, run by the Tsao Foundation, for home care services.

Staff nurse Chua Yah Li, 36, recently visited Madam Yiew after learning that she had had a fall at home. Madam Yiew has had three falls in the previous two months.

Ms Chua asked: "How did you roll over from the bed and fall down?"

"I don't know," Madam Yiew replied. "Maybe I was dreaming."

Ms Chua checked the bump on her head and gave her cream to massage her legs with. The nurse then made her walk to the kitchen to assess her gait, and checked with the team if it was possible to install a side rail on her bed.

Ms Chua and a team of doctors and social workers have been making home visits once a month to check on Madam Yiew. Besides monitoring her vital signs, they also make sure that she keeps track of the various checkups that she has to go for.

A doctor's visit costs between $35 and $167, and a nurse's visit, about $16 to $77, after subsidies. The foundation will help those who cannot afford these charges.

"I am thankful that they not only check on my health but also talk to me," said Madam Yiew, who has lived in her Tanjong Pagar flat for the past 40 years. "It's good that I will be able to die here."





A place to call their own, within the community
By Priscilla Goy, The Sunday Times, 1 Mar 2015

At first glance, the three-room flat looks like any other Housing Board unit: The living room has a TV set, a sofa and a dining table with a few chairs. The bedrooms are small and generally neat, except for a corner where some phones and tablet devices are being charged.

But take a closer look, and one would notice some oddities.

The three male residents are not brothers and there is no family photo anywhere. An A4-size poster listing a few rules is pasted on a wall.

This is a mock-up flat, on the premises of the Movement for the Intellectually Disabled of Singapore (MINDS) in Lorong Napiri.

The residents lived here as part of their training before moving into Singapore's first community group home for the intellectually disabled, an actual four-room HDB flat in Bedok.

The MINDS project, piloted in 2010, aims to allow the intellectually disabled with little family support to live independently within the community, instead of in hostels or welfare homes.

In both flats - the mock-up and the real - the men do household chores, head out for meals and grocery shopping together, and spend their free time as they choose.

Mr Tham Kar Soon, 31, whose parents and brother are dead, prefers living in the mock-up flat to the MINDS hostel - just one floor below - where he spent eight years.

"The hostel could sometimes be more noisy," said the McDonald's service crew leader.

The hostel typically has eight beds in a room, common toilets, and just one TV for more than 20 people. Residents pay up to $50 a month, after subsidies.

The group home project is funded by the Tote Board and Ministry of Social and Family Development. Residents need not pay, but should have lived in the hostel for at least a year, and shown their potential to be independent. For instance, they need to have an allowance of at least $600 a month, whether from their jobs or families.

The lease of the Bedok flat expired, so Mr Tham and his housemates moved back into the mock-up flat in 2013. But he looks forward to moving to Bukit Merah, where MINDS recently secured three HDB flats - for him, his housemates and four women. They are slated to move in soon.

Mr Tham said: "Of course I prefer living outside... I can interact with the community."

Mr Ling Chong Beng, head of the hostel/group home at MINDS, hopes more people would be willing to let their disabled family members live in group homes.

"This group home arrangement is not something that's cast in stone. It's not as if they can't move out once they're in. It's just like letting your child study overseas and learn to live on his own."

Last year, MINDS and the Asian Women's Welfare Association piloted a scheme in which the disabled get home-based care services such as therapy and help with bathing. This is for those who do not need centre-based services, are unsuitable for such centres because their disabilities are too severe, or those who cannot travel to the centres.

Mr Philip Choo, 40, has received home-based care such as therapy and help with personal hygiene since last October. His mother, Madam Loong Swee King, 73, said he looks forward to days when the MINDS staff come and help him with stretching exercises.





Fostering love and safety
By Janice Tai, The Sunday Times, 1 Mar 2015

As he scooped some chicken curry onto his foster sister Aliah's plate, Jeff said: "Don't just have the potatoes. Here's some ayam (chicken in Malay) for you."

"My foster parents have shown me what love is, and so, I'm able to love my foster siblings, too," said Jeff.

His foster parents - Madam Norli Fargi, 51, and her husband, Mr Jafri Mohd Yusoff, 51 - have two daughters, Nur Hidayah, 11; and Nur Khairunnisa, 18.

Besides Jeff, 14, and Aliah, 10, they also care for Jeff's biological siblings Sarah, 15, and Jason, 12. All the foster children are Malay/Muslim, but their names have been changed as their identities are protected by law.

Love transcends blood ties in this family. Nur Hidayah has a stronger bond with her foster brothers than her own sister because she spends more time with them.

And Madam Norli took Jason and Aliah under her wing, even though they have special needs. The former shipping clerk said: "I read about the fostering scheme in the newspaper in 2003 and I wanted to give those abandoned children my love, care and a home."

Foster families such as Madam Norli's provide shelter, stability and love to children who have been abandoned, neglected or ill-treated, or when their birth parents cannot look after them due to physical or mental illness, incarceration or other social issues.

The fostering scheme by the Ministry of Social and Family Development has 278 foster parents and 339 children on its register now. The ministry matches the race and religion of the child to those of the foster family as closely as possible.

Over the past 11 years, Madam Norli and her security officer husband have fostered eight children, including the current four. Some stay for weeks, others for years.

Though it has not been easy to part with the children when they return to their families, Madam Norli said she continues to take in foster children because she has seen the benefits of a home environment.

Jeff, for example, came to her with a stammer 11 years ago because of self-esteem issues.

Madam Norli encouraged him to confide in her and to play big brother to the rest and build up his confidence, such as by fetching Aliah from her school. Today, his stammer is gone.

Sarah used to hoard sweets and chocolates, refusing to share them with others. Over the years, she learnt to open up to others and share.

Jason recalled: "She and the rest took out toys and snacks to make me feel welcome on the first day."

The children, who all sleep in the same room, said there is no jealousy between them because they know their parents are fair.

"If there's a quarrel, all of them get scolded," said Madam Norli with a laugh.

Nur Hidayah also stands up for her foster siblings. She said: "When my friends ask why they look different from me, I always say they are like my real siblings."

Madam Norli's first foster child, who was adopted by another family 11 years ago, still visits the family every Hari Raya.

Sarah said: "We may also have to leave some day, but I try not to think about it. My life is complete now."

To find out more about fostering, call 6354-8799 or go to www.msf.gov.sg/fostering.


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