Wednesday, 6 January 2016

Would you want to grow old in today's nursing homes?

If the answer is 'No', it's time to talk about the changes needed to move away from institutionalised care for the elderly, to care that is centred on small group homes with individual rooms.
By Gerald Koh and Philip Yap, Published The Straits Times, 5 Jan 2016

Imagine waking up one day and, for the rest of your life, not knowing what the date or time of day is, and not recognising your closest relations or your own bedroom.

Imagine that your bedroom has eight identical beds and you struggle to tell which is yours, and there are seven other strangers laying claim to the one bed you are convinced is yours.

Welcome to the world of a person with dementia, living in a dormitory-like, long-term care facility - the nursing home.

The Straits Times reported on Dec 21 (Shelved: Plans for different model of nursing home) that plans for Jade Circle had been put on hold. Jade Circle is a pioneering model of care for dementia patients that proposes to house them in single or twin rooms, instead of the usual six- to eight-bed dormitories.

The Ministry of Health (MOH) told the group developing the Jade Circle home last month that it could not provide subsidies to residents staying in such rooms.

Its reason: "It will be difficult for MOH to provide ongoing subsidies for patients staying in wards that are designed to proxy private or A-class ward configurations, such as single or double-bedded rooms only. Such parameters will be hard to scale or be financially sustainable, if applied to the rest of the aged care sector."

This raises the issue of whether lower patient-to-bed ratio residential facilities are medically justifiable or a luxury.

In developed nations, such as the United States, Britain and Japan, single and twin rooms are the norm. In Singapore, all subsidised beds in hospitals and nursing homes are in six- to eight-bed dormitories.

The only instance where a subsidised patient is housed in a single room in Singapore is for infection-control purposes (that is, when the patient has an infectious disease, or is immuno-compromised and susceptible to infections which would be life-threatening).


While the need for patients to be housed in single rooms in infectious diseases cases is obvious to most, the need for single rooms for residents with dementia may be less apparent.

A systematic review of several papers in 2010 by a leading expert in dementia-friendly environments, Professor Richard Fleming from Dementia Collaborative Research Centres in Australia, found evidence that residents with dementia in nursing homes with individual rooms and more opportunities for personalisation of their living space exhibited less anxiety, irritability and aggression, and had better sleeping patterns.

In clinical practice, dementia patients with agitation and aggressive behaviours are often suppressed with anti-psychotic medications, which are associated with increased risk of falls and fractures, strokes, cardiovascular events and even sudden cardiac death.

Conducive living spaces may reduce the need for potentially harmful anti-psychotic medications and form part of what is considered appropriate care of residents with dementia.

Furthermore, unlike highly contagious diseases which are short-lived and only require isolation rooms until the infection has run its course, dementia is a slow, progressive and debilitative illness till death, with a high toll on caregivers.

Good care practices and enabling environments have not only reported better clinical outcomes in nursing home residents, but also improved staff satisfaction, retention and higher return on investment.

One such example is the Green House Project model, where small houses are home to six to 12 residents who have private rooms and bathrooms that open onto a central living area. A nurse is available 24 hours a day and care is provided by consistent self-directed staff.

Beyond people with dementia, Singaporeans also need to decide what kind of nursing, or retirement home, they would like for themselves in the future, or to place their loved ones in.

While most people would like to age at home, the reality is that many elderly will be cared for in group or institutional settings outside their own homes. The number of physically and cognitively frail seniors is rising sharply as the population ages, and fewer family members are available to provide care as many are holding full-time jobs. The number of singles is increasing, with more seniors staying on their own, too.

A simulation study published by Duke-NUS Graduate Medical School researchers predicted that the number and proportion of people in Singapore with severe dementia will increase significantly between now and 2050, and the concurrent decline in family size with limited caregiving capability will result in fewer individuals with dementia living at home.


How many Singaporeans will choose to stay in the nursing homes of today, where dormitory living and regimented routines are the norm?

The current institutional model of nursing home care can threaten the autonomy and personhood of seniors, and is not synonymous with patient-centred care. Nursing homes in Singapore evolved as extensions of hospital-based care, with centralised decision-making and rotation of medical personnel.

Residents have little control over their daily routines, including meals, bathing and sleep. There is minimal privacy as they share common toilets, bathrooms and sleeping spaces, and have only a small bedside drawer to keep their personal belongings.

Relationship-building between staff and residents is not prioritised and the regimented care eventually leads to depersonalisation, loneliness and diminished quality of life. The drawback of a culture that prioritises safety above autonomy can be seen in patients with mild- to moderate-stage dementia, who are physically restrained to prevent them from falling when they attempt to walk.

These patients are drawn into a vicious spiral of decline as they physically deteriorate, with diminished opportunities to walk around and eventually become dependent, chair- and bed-bound.


Patient- or person-centred care, on the other hand, centres on valuing a person's experiences and making the person the focus of care delivery (that is, the Very Important Person or VIP).

Four core themes, with the acronym VIPS, of person-centred care have been described as: (V)aluing the person or care recipient, and those who care for them; treating people as unique (I)ndividuals and, hence, the need to individualise care; looking from the (P)erspective of the person in care delivery; and creating a positive (S)ocial environment in which the person can experience relative well-being and thrive, not merely survive.

Thus, a person-centred culture would entail staff fostering relationships with residents, emphasising individual needs and personal preferences, and empowering them in decision-making to create a sense of belonging and "home".

This can benefit residents' well-being and reduce depression, which is associated with worse clinical outcomes, impaired role and social functioning, and increased hospitalisation.

Concretely, this can be expressed by clustering residents into a shared living space, the size of a four-room Housing Board unit, for example, while maintaining privacy with single or twin bedrooms.

Each unit should be self-sufficient, with living and dining rooms, toilets as well as a kitchen. Even seniors with dementia can be encouraged to use their residual abilities in housekeeping and making simple meals, thereby maintaining their independence which would, in turn, reduce medical manpower needs.

There is potential for relationships to flourish, as seniors living in the same unit can help each other and continue to grow as persons. Although the memory of a person with dementia may be declining, their ability to emotionally connect is often retained till late in the disease process. Similarly, consistent assignment of staff to the residents is important to promote bonding.

Nursing homes in Singapore should adapt to the more sophisticated requirements of increasingly well-educated seniors by looking beyond our current medical and institution-based model, and towards a holistic and humanistic approach grounded in residents' emotional and socio-psychological needs.

Locally, nursing homes have, for a long time, been stigmatised and associated with negative stereotypes. In 2012, Nightingale Nursing Home employees were filmed mistreating an elderly resident, while the construction of nursing homes in Bishan aroused displeasure among neighbours, evoking the not-in-my-backyard (NIMBY) syndrome and highlighting the lack of societal support and acceptance of nursing homes.

Perhaps if nursing homes can evolve from crammed institutions to real homes with private spaces, they will be seen in a more positive light and NIMBY syndromes can be overcome. It seems likely that many more Singaporeans will stay in long-term care facilities in the years to come.

Ultimately, we must decide what we want for ourselves, and the curtailed Jade Circle nursing home model of single resident rooms is a timely call for such conversations.

Gerald Koh is an Associate Professor in Saw Swee Hock School of Public Health of the National University of Singapore and Philip Yap is a Senior Consultant Geriatrician in a public hospital.

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Unwise to subsidise premium nursing care

If the Government were to provide subsidies for premium nursing homes, anything provided by the state would be considered a right by the people and invariably lead to more being demanded at the expense of taxpayers ("Shelved: Plans for different model of nursing home"; Monday and "Room to test models of care"; Tuesday).

The issue raises three questions:

First, what costs should be the responsibility of nursing home residents?

Second, what subsidising mechanisms should be used for people who cannot afford to pay for nursing-home care?

Third, what mechanisms are in place to ensure that people have the adequate income to pay for their own nursing-home care?

The approach to answering these questions will result in the creation of different experiences.

For example, people who can afford to stay in premium nursing homes should pay the full cost of their nursing-home care.

To do so, families of the elderly must be prepared to change their spending habits by putting aside some money to pay for such luxuries; they cannot rely on the state for subsidies.

Those who do not have sufficient income to pay for premium nursing services should choose standard homes, and the state should offer them subsidies to enable poorer citizens to pay for such care.

Public funding of the healthcare component of nursing-home care should be based on the principles of shared risk, which must recognise nursing homes as not accommodations of choice, but as a source of necessary healthcare support for many older adults with chronic illnesses and disabilities.

Should differences in nursing-home accommodation costs be tolerated in a needs-based healthcare system?

Subsidising premium nursing homes would induce other no-frills nursing homes to upgrade their facilities to enjoy the subsidies, which may lead to uncontrolled competition and fewer beds to cater for lower-income patients.

Francis Cheng
ST Forum, 25 Dec 2015

Boost dementia-friendly landscape in nursing homes

Associate Professor Gerald Koh and Dr Philip Yap rightly highlighted the need for nursing homes to move away from the current institutional model to a person-centred care approach ("Would you want to grow old in today's nursing homes?"; Tuesday).

They also cited various research studies to make the case for the provision of single rooms for nursing home residents with dementia.

Indeed, almost all of the more than 20 well-run nursing homes in Canada, Britain, Ireland and the Netherlands I have visited have single rooms. This runs counter to the current notion that single rooms are a luxury item in our public healthcare landscape.

But is this too idealistic, as some have argued ("Unwise to subsidise premium nursing care" by Mr Francis Cheng; Dec 25, 2015 and "Shelved: Plans for different model of nursing home"; Dec 21, 2015)?

Most current evidence comes from the West.

While some evidence may be transferable, variations in socio-cultural, financial and organisational systems mean that generalisation must not be assumed.

One has to be mindful of a few issues too: Some residents in single rooms may complain of feeling isolated. More sociable residents may actually enjoy the company of fellow residents in their shared bedroom, as some studies have found.

Reduced line of sight by care staff can be an issue for residents with behavioural issues. The current shortage of care staff will be compounded.

Land scarcity and cost are also issues that need to be dealt with.

Our hot and humid climate may also pose some challenges in terms of ventilation.

That said, we should still work towards a better dementia-friendly environment in our nursing homes.

Perhaps the number of beds per cubicle can be reduced to no more than four. The bed area can be personalised through clever design to facilitate orientation and familiarity.

The dementia ward can have a few single rooms available on an as-needed basis; for example, when residents become agitated or when there are residents who have a need for more privacy.

Or, a pilot ward with a small number of single rooms can be tested out to gain the necessary local experience.

Beyond bed configurations, other dementia-friendly features in nursing homes should include support for engagement and activities, provision for being alone or with others, appropriate levels of useful stimulation and gardens or wandering paths.

This combination of dementia-friendly features ("hardware") and person-centred care model ("software") will transform our nursing home landscape for those with dementia, leading to better quality of life for the residents.

Joshua Kua Hai Kiat (Dr)
ST Forum, 7 Jan 2016

Balancing various needs, concerns

I understand the concerns of Associate Professor Gerald Koh and Dr Philip Yap ("Would you want to grow old in today's nursing homes?"; Tuesday) and the Ministry of Health ("Shelved: Plans for different model of nursing home"; Dec 21, 2015).

Such dilemmas are not uncommon, especially in an ageing society such as Singapore.

While it may seem vital to provide ample care and support for the elderly, the Government also has to take into consideration the viability of spending such a large amount of public funds on a special group of people ("Unwise to subsidise premium nursing care" by Mr Francis Cheng; Dec 25, 2015).

What I propose is to have rooms which are larger but still able to accommodate six to eight residents and include retractable doors to separate them. By doing so, residents can be given their privacy if needed and desired, but can also be in a room with other residents, where social interactions will help in their recovery.

Furthermore, it does not clash with the Health Ministry's funding strategies for subsidised residents.

It would be a waste to have a nursing home put on hold just because of a clash of ideals, and negatively affect those who truly require help, care and support.

Cheryl Chua Xing Jun (Miss)
ST Forum, 7 Jan 2016

Person-centric care must be sustainable

I agree with Associate Professor Gerald Koh and Dr Philip Yap on the need for a holistic and person-centric dementia care philosophy in our nursing homes, focusing on respect for the residents' dignity, value and personhood ("Would you want to grow old in today's nursing homes?"; Jan 5).

But it is equally important to recognise that greater space and single- or twin-room designs are but one of many enablers.

There are alternative ways to provide dignified person-centric care, without the inevitable increase in demands on space and manpower.

In Singapore, where space is at a premium, and shortage in healthcare manpower a perennial problem, such considerations are critical.

The challenges of single- or twin-room models, in terms of space, social isolation, safety surveillance and demands on manpower, cannot be ignored and have been highlighted by other experts ("Boost dementia-friendly landscape in nursing homes" by Dr Joshua Kua Hai Kiat; Jan 7).

The harsh reality is that dementia is no longer a rare disease.

In Singapore, with our fast-ageing population, the estimated number of people with dementia is expected to grow from 45,000 last year to 103,000 in 2030.

Therefore, a more pragmatic and balanced approach may be to strive for person-centric yet sustainable solutions ("Balancing various needs, concerns" by Miss Cheryl Chua Xing Jun; Jan 7).

For instance, instead of looking at single- or twin-room wards, we can consider innovative designs that provide more privacy for residents using the same amount of space per bed.

We can also strive to foster personal identity, while encouraging our patients to interact more meaningfully with other residents.

We are also seeking better care models with improved facilities for rehabilitation and continuum of care.

Our journey of care for dementia patients is evolving. Dialogue among the Ministry of Health, care providers and innovators is dynamic and healthy.

Together, we can co-design person-centred care models that are sustainable and scalable within our limited healthcare resources.

Philip Choo Wee Jin (Dr)
ST Forum, 15 Jan 2016

Long-term geriatric care both science and art

Associate Professor Gerald Koh and Dr Philip Yap's commentary ("Would you want to grow old in today's nursing homes?"; Jan 5) offers insights into the potential benefits of an enabling environment and a person-centred care approach in nursing homes, particularly for people with dementia.

Those with dementia can become increasingly disorientated as their attention span and ability to register, retain and retrieve new information become more impaired.

Clear distinctions in personal and common spaces, with proactive routine setting by support staff skilled in listening, engaging and encouraging, can significantly reduce the quantity of care (and the quantity of medication) needed to contain behavioural and psychological symptoms of dementia.

Opinion editor Chua Mui Hoong, in turn, recognises the immense challenges facing our regulators today, and reflects on the current paradigm of subsidy entitlements ("If a new player disrupts the rules, maybe it's the rules that need to change"; Sunday).

The Government has injected significant funds in response to the increasing demand for nursing home beds. The current discourse raises concerns about sustainability.

There seems to be the assumption that single or twin-shared rooms are more expensive to operate and should not be subsidised unnecessarily by the Government.

We do need a test bed for whole system redesign and learning, including exploring the many alternatives to dormitory and custodial living, particularly in the care of people with dementia.

Innovations may disrupt current norms, but we also need to discover new ways of delivering care that is better, cheaper and more meaningful.

Long-term care is both science and art. Across the world, the walls of acute institutional hospitals and specialist consultation clinics are increasingly being broken down in recognition that truly effective healthcare requires an interconnected network that stretches into the community and the home.

This conversation is really not just about the single room, but it does make us think about the purpose of long-term care, and how it is resourced.

Much of this ground remains uncharted in Singapore. Experiments, improvisation and learning from our mistakes are key ingredients for creating the model we need.

Our profession has a lot to learn, too, and is ever ready to support the Ministry of Health with our skills and understanding, as we collectively seek to serve the best interest of our ageing population.

Christopher Lien (Dr)
Chapter of Geriatricians
College of Physicians
Academy of Medicine, Singapore
ST Forum, 15 Jan 2016

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