Integration of medical and social services in long-term care needed: Lien Foundation/KPMG study

Consider elderly patients' social needs too, docs urged

Study says a holistic view of care should be adopted

By Priscilla Goy, The Straits Times, 22 May 2013

DOCTORS treating the elderly need to be more aware of their patients' social and psychological needs, a new report has found.

They should take a holistic view - instead of drawing a distinction between medical and social care - said the study commissioned by the Lien Foundation and developed by consultancy firm KPMG.

Released yesterday, the research aims to draw ideas from other countries on how they have addressed their challenges. It is based on interviews with 46 eldercare experts in 14 nations. Four were from Singapore while others came from countries including Japan and the United States.

Dr Gerald Koh, a National University of Singapore associate professor and one of those interviewed for the report, said: "We're very good at building hardware and infrastructure, and that's not a bad thing, but we could do more in the 'heartware' area.

"Traditionally, doctors focus more on cures and treatment. I think we're training them to be more patient-centred, to be aware of the patient's social and psychological needs. But we could move beyond awareness and get them to take these needs into consideration when planning the management of the patient."

Doctors should work more closely with social workers and therapists in an "interdisciplinary team", added Dr Koh, from the university's Saw Swee Hock School of Public Health.

And there should not be "a sharp demarcation between the different roles". For example, in the United States, multidisciplinary teams provide services ranging from medical care to occupational therapy and diet monitoring - all at an adult day health centre.

The report - An Uncertain Age: Reimagining Long-term Care In The 21st Century - recommended providing more training and support to informal caregivers, and introducing more sustainable funding models. For instance, one pool of money could be used to fund institutional care and home-based or community-based services. This would avoid having two separate budgets.

Ageing Asia managing director Janice Chia said health-care facilities had been integrated to some extent, but more could be done to help the elderly age within the community.

"There have been collaborations between hospitals and nursing homes, but these focus more on medical care...

"We should have more activities in the area of preventive care, such as strength training and mental training, or other communal activities to draw them out from these homes and prevent them from being socially isolated."

And Singaporeans are likely to expect more, said Lien Foundation chief executive Lee Poh Wah. He added: "Is our current system more geared towards serving the poor, versus the middle- and upper-income groups?

"Having visited some nursing homes in Asia, most of our nursing homes today resemble Class C hospital wards that lack the homely feel. That's why few people would welcome the thought of spending old age in such an environment."

Innovative practices overseas

- Rewarding volunteers with "time credits"

Non-profit organisations can give people rewards based on how much time they spend helping one another.

In Japan's Hureai Kippu scheme - which was created in the 1990s and is translated literally as "caring relationship tickets" - those who help the elderly earn "time credits".

They can use these credits to claim assistance for themselves when they fall ill, or use them for another person of their choice.

Non-monetary rewards like these could attract more people to volunteer in their communities.

- Giving the elderly a "village" to lean on

Pioneered by Beacon Hill Village in the United States in 2001, this approach involves recruiting elderly residents and other volunteers who live in an existing community to help one another with basic services such as transportation, household tasks and health care.

Although many of these "villages" rely almost exclusively on volunteer help, some also include paid staff or contracted service providers.

Having one team to offer all-inclusive care

Developed in 1973, participants in the Programme of All-Inclusive Care for the Elderly in the US attend an adult day health centre, where they receive services that are provided by a multi-disciplinary care team.

These services include speciality medical care, therapy, transportation and help in making minor modifications to their houses to make them handicapped-friendly.

Coordinating services in this way reduces costs by delaying nursing home care for the elderly, as well as shortening hospital stays.

Last year, the US state of Wisconsin piloted a "virtual" version of this scheme, which offers more flexibility over where the care is provided.

Health Ministry on track to meet needs of elderly
By Vimita Mohandas, Channel NewsAsia, 22 May 2013

The Ministry of Health (MOH) has said it is on track to meet the needs of the elderly under its Healthcare 2020 Masterplan.

Minister of State for Health Amy Khor gave this update a day after a study was published by the Lien Foundation on areas of concern in Singapore's long-term eldercare system.

Among the issues raised are better integration of medical and social care, and a relook at the current financing model.

Dr Khor said the current healthcare financing model is already undergoing a major review, and the ministry is also working to expand capacity and enhance capabilities.

She stressed that no one will be denied the care they need, adding that steps are being taken to ensure there is an integrated care model for the elderly.

Dr Khor said: "Recently we have integrated the policy as well as the service delivery functions related to the social and healthcare aspects of aged care within the Ministry of Health and the Agency for Integrated Care (AIC).

"Previously some of the social support and care needs of the elderly were taken care of by the Centre of Enabled Living (CEL). This has been transferred under the purview of AIC and that is to integrate care for the elderly -- not just the healthcare (aspects) but (also the) social aspects.

"We have also enhanced the various care options for the elderly in terms of bringing care for the elderly nearer into the community, so we've expanded day rehab services within the community through the development of senior care centres."

Integrating care for seniors a priority
When it comes to seniors' care and medical needs, the medical and social care professionals may be working at cross-purposes. Together with ordinary citizens, all need to get their act together to decide on new eldercare models that also provide for 'good ageing'.

By Loke Wai Chiong, Published The Straits Times, 24 May 2013

THE fact that Singapore has one of the world's fastest ageing populations is no big secret. By 2030, elderly people in the country are expected to number 870,000.

If the total fertility rate remains low, Singaporeans aged 65 and older could constitute one in every three citizens and permanent residents by 2050. Over this period, the median age of its resident population will also have gone up from 39 years old in 2012 to 55 years old in 2050.

Seven working adults in Singapore supported one retiree over the age of 65 in 2011. By 2030, this ratio is expected to drop to just 2.3 working adults to a retiree.

This imbalance suggests that the costs of long-term care in Singapore will be increasingly funded by an ever smaller working proportion of the population.

An ageing population will inevitably need greater investment in eldercare. Yet, the capacity of Singapore society and families to provide or pay for formal care is also threatened by changing demographics.

A worrying trend of falling birth rates, rising divorce rates and more children choosing to live farther from their parents are compounding the situation. This breakdown of traditional family structures is pointing the way to a future where elderly people are becoming far less likely to receive care from their families.

Integration of care lacking

IN PREPARING a recently launched KPMG eldercare report commissioned by the Lien Foundation, we had the opportunity to interview more than 45 eldercare practitioners from all over the world.

A recurrent theme from these discussions is that many leading eldercare practitioners believe that current long-term eldercare practices are focused on the wrong areas. Despite the best of intentions, long-term care today is often based on a health-care provider's systems and procedures.

Long-term care should be focused instead on delivering a patient-centred outcome. Along with promoting positive outcomes from medical treatment, care should be centred on addressing a patient's needs and preserving his or her dignity.

We often see a lack of coordination between medical and social care for the elderly sick. Doctors are trained to cure illnesses and heal injuries. Symptom relief is a secondary priority. Many doctors therefore end up failing to address the emotional, spiritual and psychological sufferings which accompany many treatments.

In contrast, social care professionals are often only concerned with comfort, pain relief and the ability of the patient to live with dignity.

These two components need to be better coordinated. Otherwise, the elderly patient becomes a victim.

In some cases, the patient may end up enduring aggressive, demoralising and expensive medical procedures, when he or she would have been better off convalescing at home, or in a nursing facility.

Nowhere is this more important than in end-of-life care, where a person could suffer unnecessarily and incur great expenses without advance care planning or an Advance Medical Directive.

Holistic approach needed

SO FAR, long-term care has attracted relatively little attention and investment from governments. Yet there is an urgent need for action.

The aged care specialists interviewed for the Lien-KPMG report pointed to the need for governments to go beyond building more and bigger senior care facilities to tackle the ageing crisis.

A holistic approach towards eldercare is needed. This involves developing policies that integrate, rather than differentiate between housing, urban planning, transport, health, social care and other areas.

Australia and Japan are possible role models for a comprehensive eldercare system.

In April last year, the Australian government announced an aged care reform package with the objective of building a fairer and more sustainable aged care system.

This package provided A$3.7 billion (S$4.6 billion) over five years to encourage health-care providers to create a seamless system that would allow elderly Australians more options and easier access to a full range of services.

Greater priority will also be given to providing better access to residential care, and more assistance for those with dementia.

In Japan, the government has established a regional care system for senior citizens who need long-term care and want to remain in their homes.

As a first step towards this goal, the Japanese government created home help services and housing with care services. The importance of preventing health conditions and improving wellness is also being promoted, with the aim of controlling health-care costs.

Conversation on eldercare

IN THIS year's Budget, the Ministry of Health (MOH) committed itself to enhancing the quality of aged care.

New measures include developing more options for home and community-based care, and providing Medisave top-ups for the elderly.

The MOH is also setting up a Geriatric Education and Research Institute modelled on similar institutions in the United States. This new institute aims to increase the proficiency of health-care workers. It also hopes to educate health-care professionals about the special needs and clinical management of elderly patients.

Hopefully, all doctors and caregivers will gain the right skills to ensure that a patient's social, emotional and psychological elements are also taken into consideration.

In the long run, I believe that care facilities will expand and overcome their current fragmented state by merging into more efficient networks.

Health-care providers will also improve how they deliver services and ensure that these are effectively supported. Matters such as end-of-life care, providing conditions for a "good death" acknowledging the wishes of a patient will become increasingly significant issues.

At the same time, policies will need to be developed to encourage quality long-term care programmes which challenge existing perceptions of old age.

Platforms such as the ongoing series of Our Singapore Conversations represent ideal opportunities for citizens to come together and engage in deeper conversations around issues such as what constitutes "good ageing", who should pay for long-term care and which new eldercare models should be supported.

The writer is director, Global Healthcare Practice, KPMG in Singapore. KPMG is a network of professional services firm.