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Debate on Quantity of Care versus Quality of Care

What is your opinion on single bed rooms for nursing home care? Read the comments here
How can we sustainably fund high quality long term care for our elderly? 
Read the comments here

Q2 3 Aug

" Having read the Straits Times articles it seems as though the biggest hurdle you face is Government legislation being very restrictive. We have that too, but not as restrictive. Providers in Australia can pretty much build to whatever configuration they like and the residents frailty, acuity and complex care needs are what dictates the funding from Government.
 "

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

" One can set up a studio or suite - similar setting in a private hospital room to allow more privacy with easy access to medical attention. " 

Anonymous, Hong Kong SAR

" The Government first need to acknowledge the market demand of a more conducive & enticing facility for seniors. Hospital brings along the negativity to seniors. The Government also needs to roll out new legislations to encourage private sector as well as NFP organisations to invest in aged care products that serve the needs of the market, particularly the middle to the upper end of the markets. " 

 

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

" The solution is actually simple, budget-driven with far-reaching multilateral outcomes for the healthcare sector at large in Asia. In countries reaching demographic tipping points in terms of support ratios (China, Singapore, Thailand, Myanmar and Vietnam), there’s nearly a continuous elder segment overrepresentation in the acute care sector, especially hospital emergency units, an unacceptable mix for the following reasons:

  • An imbalanced acute sector mix compromises medical tourism strategies in some South-East Asian countries
  • Albeit amalgamated under the same healthcare sector, acute and elder care are incompatible disciplines
  • An acute care bed costs in average 8 to 12 times more than a high-care residential eldercare bed

Reallocating a fraction of the acute sector budget (for example 10%) toward residential eldercare and home care services would free up precious and expensive capabilities in the acute sector (arguably up to 40% or more) while contributing to the building from the ground up of an entirely new and efficient eldercare industry in Asia. "

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

" For elderly, it is very difficult to treat their disease. Almost all of their diseases are chronic, multiple, complicated, and easy to recurrent. Thus, it is more important to support their lives with diseases (or disorders) than to treat them. We should allow them to live their life to the fullest, with dignity and gracefulness. "

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

" We have to adopt a more comprehensive and total care model, i.e. let long-term care home not only focus on elder institution, but it can also refers to being at home with the support of ample community care. "

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

" There are a few steps that can be work towards long term care: 

Step one – recognise that “Age is not a Disease”, and that at every stage of all our lives what we strive for is “Quality of Life” – this remains the case for aged persons as much as for teenagers and young adults. Inside every 80 year old is trapped a 30 year old – just ask them.  

Step two – having come to terms with step one – accept that Medical and Nursing Care contribute only a very small part to that Quality of Life – choice, security, independence, support and respect are far more important.

Step three – Aged Care is NOT about Medicine and Health Care – meaningful aged care models must put Medicine and Healthcare in their rightful place and that is NOT at the center; doctors and nurses are not the experts in what it means to be old.  The elderly, what they want and how they want it should be at the center of the system – medicine and healthcare providers play a minor support role.  In my professional experience about 90% of what we pay highly trained nurses to do can just as capably be done by other far less qualified (and less costly) staff – or daughters and sons for that matter.  Pay nurses well for the expertise they have, not for the things others can do just as well.

Step four – plan care and support services in collaboration with each elderly person those services are being provided too – ask what assistance they want, how and when they want it and actively encourage them to do all they can manage to do for themselves – that’s respect, that’s choice, that’s independence (however limited it may be).  The experts in aged care are the elderly – we need to stop being so paternalistic/maternalistic – that’s disrespectful. 

Step five – employ technology as a key mechanism to monitor and manage much of the medical/chronic disease components of health care for the individuals – in collaboration with Doctors and Healthcare professionals.  This will improve outcomes, reduce hospitalization/admission rates, hospital lengths of stay and significantly reduce costs on the aged and healthcare systems across the board.

Support elderly people in their choices and we’ll find most want to stay at home – so provide a “home-like environment”.  That means providing service into the home for as long as possible, then when the person is no longer capable of living in their home, build “home-like” care facilities (communities) supported by in-home/quality of life care models. 

Aged Care, focused on “Quality of Life” can be delivered in any location, you don’t need a sub-acute hospital type model, which is what nursing homes are (they are unnecessarily expensive and were established for the convenience of the system – doctors and nusres). 

Independent living, low care support, high care, complex and many clinical care services (including palliative care) can and should in fact, be provided in the location and environment of choice – the elder persons choice.  For the most part, such models are considerably less expensive both for the individual and for governments and provide much better outcomes for the individual, the system and staff alike. To not pursue a Quality of Life, elderly person centric approach to aged care is quiet simply “lazy politics and lazy, inept care”.

Get some young people involved with the elderly – the creative and the wise. "

Mr Nick Loudon, Chief Executive Officer, Seasons Living Australia Pty Ltd, Australia

" Understanding that the person living has medical diagnosis and not a digital medical diagnosis itself. "

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

" As our population ages rapidly, there is insufficient fewer younger generations to support the elderly. Hence we should create more retirement villages or elderly day care centers to support the elderly. "

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

" 'Patient, Client, Service User or Resident?' - putting personal care needs first!

As with most advanced healthcare systems across the world, many find themselves in the position of having to adjust rapidly to changing demands either through fundamental demographic changes and shifting population growth, or both. In these circumstances we are talking about the increase in the size of the population aged not only 60-65 plus, but 85 plus, brought about through increased longevity and increased healthy life expectancy, i.e. people are not only living longer but are increasingly looking to health and care providers (whether state or insurance lead programmes) to adapt in such a way that will help them maintain their long term health and care needs. This means healthcare systems need to be 'flexible' and 'responsive' to individual health and care needs, offering 'plurality' in provision, and wherever possible 'choice' in that provision - as the somewhat over used expression 'one size fits all' will simply not do! However, in accepting the case for plurality of provision in health and care services, governments and/or state providers must ensure that 'core standards', in the services to be delivered, are of a high quality and effective.

With this in mind, and by way of comparison, the UK models of 'home care' provision - covering England and the 3 devolved administrations - have a long history as part of the ongoing development of the wider 'whole healthcare system', which is 'co-lead' by the NHS, (essentially primary, secondary and community healthcare); Local Authorities, (including social care, rehabilitation, home care, and therapies in the community (in England); and a developing independent care sector.

In order to grasp how the 'whole healthcare system' operates in England, requires an understanding of how each component part of that healthcare system is defined - and is in the process of being 're-defined', as demands on the system increase.  For the purpose of this article, the key issues to be considered are as follows: where does acute hospital care provision begin and end for older people? What do we mean by 'intermediate care & reablement?' and when we speak of 'nursing home care' are we talking about 'assisted living' or long term 'residential health and care'? Defining the above, and understanding their differences will be crucial for any national government commissioner (or major insurance provider) of integrated healthcare.

In the late 1990's the UK recognised that the prevailing model of acute hospital care was unsuited to patients with complex long term conditions, and that a strategic shift in resources and the scope of the services provided would be required if the healthcare needs of older people, primarily those aged 65 plus were to be met.  The Care Standards Act 2000 lead the way, which was followed by the introduction of rigorous Care Homes Regulations in 2001, both of which provided the background and context to the publication of a series of 'national minimum standards' for the provision of services to older people in care homes, (enacted June 2003). A key 'standard', that was fundamental to the 'new approach' to care for older people was the need for 'privacy & dignity' in provision - a place where 'service users feel they are treated with respect and their right to privacy is upheld', (Standard 10). 

There are 7 sections which form the basis of the national minimum standards, these include:

  • Choice of home
  • Health and personal care
  • Daily life and social activities
  • Complaints and protection
  • Environment
  • Staffing
  • Management and administration

Standard 23, in the section on 'environment', gives details regarding 'Individual Accommodation & Space Requirements', and states that: a) Service users’ own rooms must suit their needs; b) Where rooms are shared, they are occupied by no more than two service users who have made a positive choice to share with each other. In 2016, shared provision is now the exception - with single room accommodation the most common form provision for older people in care homes in England. This approach has been further strengthened in acute hospital care (and mental health care) settings with the focus on ensuring that 'privacy and dignity' is maintained through increased provision of single rooms with adjacent single-sex toilet and washing facilities, (preferably en-suite).

This direction of travel was strengthened further by the introduction of the 'National Service Framework for Older People in 2001, which set out 4 key themes regarding the provision of healthcare for older people, namely:

  • Respecting the individual
  • Intermediate care
  • Providing evidence-based specialist care
  • Promoting an active, healthy life

Whilst the theme of 'respecting the individual' lends support to the requirements set out in the national minimum standards (2003) above, the recommendations concerning the development of 'intermediate care' services are critical to understanding the UK's attempts to reduce dependency on acute hospital care and the re-modelling of long term care in the community for older people. Responsibility and negotiations at local level in England between NHS (Healthcare) and Local Authority (Social Care) commissioners persist to this day, as to 'who' is responsible for the resourcing of 'intermediate care or reablement' services - on the grounds of 'where does healthcare service provision (medical & nursing - funded) end and social care (personal & therapeutic - chargeable) provision take over?'  However, both commissioners are convinced of the benefits that intermediate care and reablement services can provide, namely, that they can:

  • help to avoid unnecessary admission to hospital
  • encourage the person to be as independent as possible after a hospital stay or illness
  • help to avoid someone moving permanently into a care home before they need to do so.

In 2009, the Department of Health in England widened its definition to include aspects of organisational structure (integration) and again emphasised the outcome of maximising independent living. Intermediate care was thereafter defined as including:

  • a range of integrated services to promote faster recovery from illness
  • prevent unnecessary acute hospital admission and premature admission
  • to long-term residential care
  • support timely discharge from hospital and maximise independent living

Looking at the UK evidence and examples above, the key issue for Asia would seem to be the need to determine the role that 'intermediate care' services might play in helping health and care systems across the region to re-define what is understood by the term 'acute hospital care' (i.e. where it begins and ends) and re-model acute services within an effective integrated health and care system for long term care.

Whilst provision of adequate levels of funding and resources will be required to achieve (in some cases) this 'turning of the tanker' approach, a shift in government policy and a commitment to more 'person centred care' will be necessary in re-shaping the planning and development of future long term care across Asia. Diversity in the provision of that care should be welcomed, with new service providers, bringing new ideas and new technology, to be encouraged and nurtured. However, in so doing governments will need to ensure that robust systems of regulation and control, and effective patient safeguards are in place to guarantee the provision of high quality health and care services in the community. "

Mr Kush Sankla, Director, Solutions 4 Health, The United Kingdom


Japan e-card 3 Aug 

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