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Debate on Quantity of Care versus Quality of Care

How can Asia move away from the hospital approach towards long term care? Read the comments here
How can we sustainably fund high quality long term care for our elderly? Read the comments here

Q1 27 Jul

" Overall, the recent study in Singapore is commendable as it looks into the economy and cost side of things. There are however a few key elements that needs more distillation, deliberation and discussion:

Costing: While the additional cost on nursing and operational support are reasonable (for the new model), there is a under costing on the land/space element. The use of the current TOL subvention will not be able to show the true impact on total costing; let alone inflation land cost over time. A fairer way is to reflect land to be costed at least at the market rate for land/rental. The reason is that the private sector single bed nursing home basic charges are over $5000 per month. So the current costing done now appears very conservative.

Evidence based: Yes there are studies that show positive outcome under this model. However it is not those type of evidence  like “specific antibiotics for a special bacteria infection”. The evidences are generally correlations; and there are many other variables and varying sensitivity and specificity are not scientifically validated at the same time. There is a overloading or emphasis on “dedicated, home like,” infrastructure and mixed up with patient centre care and independent. Furthermore, there seems to be over zealous focus that this should be “gold standard” for all nursing home and all types of patients. So the question will be if we are given dollar (or even lesser), can we provide similar good outcome by focusing on other elements like good rehab, patient centre care, plenty of social recreations and activities... more day activity spaces etc

Theory: There are in fact studies that focus on loneliness/ depression track. For a given nursing/rehab care, the singular most important factor is how to prevent any elderly of feeling lonely... if this factor is not prevented, it will lead to detachment and depression and then all forms of care plan will fail. This lonely effect can occur regardless whether the elderly is in a dormitory or in a dedicated single room.

Comparative: Many of the benchmark countries have two key facts that differ from Singapore; land and use of caregiver (foreign maid). Since land is plenty in these countries, they can have all the space. For these countries, foreign domestic maids are not common, so they will definitely need a service provider to employ the caregiver. For Singapore land is scarce so the issue of opportunity cost and finite land must be considered. In Singapore, even the lower income family can afford a maid (with subsidy) 

Dedicated space and home-like: I agree that if an elderly do need this for good outcome, then there must be an economical way to support them. The answer is simple “stay at home”. For the $106 dollar a day, it is more than adequate for the elderly to have caregiver (maid, trained in Caregiver skills) and then go to the local day care/social care on a daily basis. They can have all the privacy, dedicated space, all the memories and yet have the dedicated care and also the social activities. These provision will cover literally all the middle income group and even the lower income.

Gap: So the gap are really the “elderly living alone or poor or those living in rented flats”. Even the highlighted group like dementia care, if the “dedicated personal space is so important”, they should really stay at their current home. For those who are living in rented flats, they too can stay put... it is a matter of working out an arrangement between HDB and MOH to have some service provider to set up assisted living shop within the rental block of elderly. 

We support MOH direction to build up capacity in the community like the new Active Aging Hub and more senior care centre. So that more elderly (even the less independent) can remain in the community. Increasingly the NH (because it is land and manpower intensive) should only cater for those who are frail elderly, higher Cat 3 and 4. There can also be merit however to have specialised type of NH or wards for the psychiatric or more complex type of dementia  cases. But the notion to have all remaining NH beds based on these consultancy model remains a big question mark. " 

Dr Ow Chee Chung, CEO, Kwong Wai Shiu Hospital, Singapore

" The demand on single room for elderly is in high these days due to their behavior change as well as more privacy is needed. I have visited some new properties (Eden in Johor ) are using the cabinet to divide the beds. These are not ideal to protect the privacy of one's daily life. In addition, The ceiling lighting, snoring noise from next bed and activities around the nursing station may not be the ideal setting for retired elderly who plans for long stay in the Hospital ward-like environment. Our retirement project in Hong Kong only provides one unit/ residence per senior +  spouse or sibling in the same gender of the immediately family members. "

Anonymous, Hong Kong SAR

" Alzheimer’s Australia NSW has done a lot of consulting work with providers of residential aged care and we have found that high levels of care, satisfaction, wellbeing can be achieved in rooms with 2-3 residents. Our market is driven to deliver 1 bed rooms as this is primarily what family members want for their loved one for privacy and dignity reasons. This is fair and reasonable, but overlooks the value of social connections, increased foot traffic in multi-bed rooms, higher visitor numbers, and higher frequency of interaction with staff. We have also done some work with an organisation called Group Homes Australia who are using suburban houses of up to 8 bedrooms to run a very homelike service. They are not Government funded, unlike the traditional residential aged care providers with facilities up to 200 beds. Our debate doesn’t really focus on the room configuration, but more as you say on the quality of care. This is influenced by the number of staff, the attitudes and qualities of the staff, and the qualification they possess. Our consulting work also highlights the critical importance of leadership of a facility in influencing the quality of care that takes place. "

Mr Brendan Moore, General Manager, Policy, Research and Information, Alzheimer's Australia NSW

" As a nation like Singapore becomes more affluent, the middle and upper income group of seniors demand for better facility in which they can afford with or without government subsidies. This had proven by the evolution process of the more advanced western nations whereby some 60 years ago or more, they had started with multi-beds rooms to what is now the private single bed room. It had been proven that dignity & lifestyle of seniors were enhanced in this environment. Clinical outcome was not compromised , rather it was better. However, multi-beds rooms are still applicable to the lower end of the market to make it affordable for the seniors and the Government alike. In short, the market needs both the single bed and the multi-bed rooms. One must always respond to market needs at all times. "

Mr Tan Choe Lam, Founder & Managing Director, Jeta Gardens Group, Australia and Malaysia

" When we discuss the future eldercare landscape it has to start with - Do what seniors want and What do our seniors want? Seniors want to LIVE! Not to be cared for!

Can we live, when we are in a nursing home? Don’t get me wrong. Nursing homes are doing a good job, keeping us breathing and our heart beating. But are we alive?  What does it mean to live, to be alive? I am alive when I have a reason to wake up for, when I may do things to feel the rush of adrenaline. What is there to look forward to? What purpose is there for me to live one more day?

Let’s start with a change in our approach to care. We need a culture of choice and self-control for seniors so that seniors get rehabilitated quickly, to be well enough to go home or be assisted by home help. When in a nursing home, seniors should be able to live. Today architects are told to pack beds into nursing homes. We provide too little social space. Where can family or friends chat with the seniors, other than his bedside? Nursing home should not be design like a hospital as this is where our seniors are supposed to live (nursing home) for an extended period of time.

If our nursing home is going to be the HOME to our seniors, it has to be beyond “home-like” environment, beyond just single beds. It has to be a home where our seniors have a choice and control over their food, activities, social interaction, moments of quiet, sleep, what they wish to wear and even how they wish to do up their hair. Like home, they should be able to do things with their family and friends. Our seniors should also be able to take a stroll in the neighbourhood!

Lastly, seniors of the future will be better educated and knowledgeable, used to independence and want to live life!Homes should be the first choice for seniors to be in, followed by day centres and their last choice should be institutions like old age homes or nursing homes. Wherever they are, we should strive to give seniors a sense of purpose, empower and support them to live independently as much as possible with ample opportunities to interact with other people, including family and friends. "

Ms Lim Sia Hoe, Executive Director, Centre for Seniors, Singapore

" Only a small percentage of patients can or willing to pay for single bed rooms nursing care homes. Do in the ratio of 20% single bed rooms and 80% 4-6 bed rooms. "

Dr John Heng, Co-Founder, Director, SynPhNe Pte. Ltd., Singapore

" It would be a mistake to relate the question of single vs multi-beds rooms to purely economic, efficiently and sustainability considerations. We should take into account of the elderly’s preferences rather than that of their younger contacts/relatives. Misconceptions (driven by generationally-based cultural and social differences) and misalignments in care quality often derive from projecting relatives’ wishes or perception of what quality of care is over the elderly’s wishes and preferences.

Many older generations (typically but not exclusively pre-WWII) might actually feel happier in a multi-beds room context than they would be in an isolated single bed room. The notion that a single-bed room is of a higher quality is a modern perception which might be misaligned with the elderly’s perception, and might become a requirement only decades from now for elderly belonging for example to the “baby boomer” generation, more attuned to topics such as privacy and self-social-isolation.

Thorough pre-admission assessment and consultation with the elderly are essential to determine a best individual setup to maximise well-being. While important, sustainability and economic matters are secondary aspects respect to the elderly’s well-being goal. The fact that a multi-bed might be more sustainable than a single bed is a collateral rather than a primary benefit. "

Mr Giovanni Di Noto, Chairman & CTO, cloudyBoss Pty Ltd, Thailand

" I think to live in single bed room is an essential right for every people. It helps to improve the elderly's quality of live and it helps caregivers in caring for people with dementia or in the end-of-life stage. However, the cost performance of the single room care will be much higher than multi-bed room care. "

Dr Jun Sasaki, Founder & Chairman, Yushoukai Medical Corporation, Japan

" I think we have to respect and respond to the particular needs of individual elder who either can or cannot afford for single room. Indeed, having group room would encourage socialisation and networking, whilst single room can respond to those who are used to having a private life. "

Mr Timothy Ma, Executive Director of Project Flame, City University of Hong Kong, Hong Kong SAR

" It should be an option provided by the public system with tiered subsidy. Market demand is there and a basic human need for long term stay context. "

Mr Isaiah Chng, Director, ProAge, Singapore

" Preferably for those with difficult personality and affecting other persons. " 

Mdm Low Mui Lang, Executive Director, The Salvation Army Peacehaven Nursing Home, Singapore

" What is the experience of living with dementia? Does it make you less of a person than you are now? Will it change what is “right” for you as a person if you develop dementia? Until we grapple with the fundamental paradigm of what it is to live with dementia, we will always struggle to set an agreed standard of high quality care with evidence based outcomes in environments that enable, enhance and sustain wellbeing and personhood. The debate if having 4 or 5 strangers share a bedroom with you as it is a cheaper option is one that a developed society in the 21st century should not be needing to have. The ageing of our populations, the increased prevalence of dementia and the necessary responses by Government and society should not be a shock or a surprise. We have known this reality was coming for decades, yet have done little to prepare for it. We should not now be offering sub-standard living environments because we have failed to be ready for this growing need.

If you need to ask if shared bedrooms are ok consider how you would respond to the following scenario: You arrive to check into the hotel that you have booked for a vacation. The lady on the reception desk tells you that due to demand they are having to put extra beds into the hotel rooms and that you will now be sharing that bedroom and bathroom with 2 complete strangers. What would your response be? Why do you think your response would be any different if you had developed a cognitive impairment? How about if the vacation wasn’t for two weeks but the rest of your life? We need to find viable and sustainable funding models to support our older generation, especially those with dementia, but should never accept poor long term care environments to be an acceptable answer to societies failure to adequately plan for the care needs of older people now and into the future. Evidence shows that a lack of control and decision making, boredom and loneliness are key concerns of the general public when considering the option of long term care homes, this has created stigma and fear of what the future might bring as you age or develop dementia. Developing homes where people have privacy, control of their front door and are welcoming of the community to maintain relationships should be the goal, after all isn’t that how we choose to live our lives in the 60 previous years of adulthood? "

Mr Jason Burton, General Manager, Education, Research & Consultancy Department, Alzheimer's Australia 


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