Written by  2015-03-20

Community Holistic Onsite Inclusive Care of the Elderly

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            As patient ages and become more dependent from natural processes of aging or secondary to diseases or organ failures, the need for external help increases. Care for the daily living of a dependent elderly traditionally comes from the daughter or the daughter in law. With fragmentation of family units and smaller families, more of the dependent elderly are either admitted into care institutions like nursing homes or in Singapore context, getting a fulltime paid care giver which is usually untrained into homes of the elderly for 24/7 hours care.

            For those into aged care and policies will be familiar with the PACES model in the United States of America started by the On Lok group in San Francisco Bay in 1971. It encompass all the elements in care of a nursing home type patient in the community, namely, preventive, primary care, acute care and long term care services.  The provider is responsible for a holistic care of the dependent elderly in the community.  The provider has more freedom in the use of the funds with capitated payment arrangements. 

            Patient selection for such programs will be crucial, and although it should not be age sensitive, for majority of the policy makers, it would be easier to justify for such program if directed mainly to the aged dependent sick population. For PACE model, it is regional and patients must be 55 and above, certified to be requiring a nursing home care to be included. In Singapore context, it will translate to category 3 or 4 in our local Barthel score.

            In Singapore, we have advantageous policies that allow employment of a stay in full time care giver from neighbouring states. Most of these full time carers are not trained in eldercare. Hence, policies have been implemented to train these newly engaged carers by nurses in a funded program. However, caring of a dependent elderly is a full time 24/7 job and some of these carers may suffer from burn outs and work stress. They are sometimes unable to take leave urgently if their own family member back home is sick or dying. Most of these carers do not get a day off as well as there will not be anyone caring for the patient in their absence. Care sometimes will be compromised and patients get repeated admissions into the restructured hospital as a result.

            Many families will admit their dependent elderly into nursing facilities for long term as a result if they are unable to source for a dependent carer. To support the running of nursing homes, it will likely be more costly in the long run due to added expenditures of administrative manpower and facilities management. Most elderly will also prefer to age and pass on eventually at home where  they are familiar and comfortable with. Nursing home placements are usually the last and for some, the only option due to the local funding system in place. The past 2 years has seen home and community care being boosted by the government with more funding on the services and consumables.

            I am proposing a Singaporean model of care, Community Holistic Onsite Inclusive Care of the Elderly or CHOICE. It will be similar to PACES in the capitated funding aspect and it will also take advantage of our local manpower policies and current funding model for patients taken care at home.

            Under CHOICE model, provider will be the “Healthcare Home” for dependent elderly which are more than 55 years of age and with a Barthel score of 2 to 4. Like the PACE model, it will be of a capitated payment arrangement.  The care arrangements can then be organised with many permutations depending on the needs and support. Each patient is funded as if he or she has been admitted into a nursing home. The provider will be paid in terms of “length of stay” in the service, with no funding during the period if patient is admitted into restructure hospital, community hospital or nursing home.

          Services provided will be multi-disciplinary including physicians, nurse practitioners, nurses, pharmacists,  social workers, therapists, case managers, stay-in senior care staff, drivers and anyone else required. For example, funding can even include services to remove bed bug infested bed and buy a new bed for the patient to prevent recurrent skin infections. Funding can also organise day recreational trips to places such as Gardens by the Bay and Singapore Changi Airport, giving both the carer and the elderly more exposure to Singaporean places of interest. 

       Instead of getting only one full time carer with high risk of carer fatigue and no other reserve to support, CHOICE will provide carers for the homes instead, supported by nurse, therapist, social workers, psychologist and lead by an experience home and long term care physician. There can be various permutation of care:

1.     24/7 stay in carer,  provided by CHOICE institutions as a care team member supported by other healthcare professional and led by an experience home and long term care physician.

2.     Day services only from 7 am to 7 pm daily either in their own homes or at CHOICE day eldercare centers  with transfer provided for the less dependent.

3.     Night services only from 7 pm to morning 7 am either in their own homes or at CHOICE day eldercare centres with transfer provided for the less dependent.

4.     Senior Home Care service for 3 hours per session for those taken care by family members and only requiring intermittent respite support.

5.     24/7 Interim Care service if the usual family carer require a respite from the care giving.

6.     Given enough patients in a certain area, a unit from the same block can also be rented and converted into a day care or night care service center for nearby elderly requiring such supportive care.

7.     Given enough patients in a certain area, a unit from one of the elderly can be selected to be the designated care unit, and fees for this elderly providing the unit can be reduced by 50% or more. It will also foster “Kampung spirit” . This unit can only be serving only as day care units.

8.     Any other proposal from the family will be taken into consideration.

       As interim care services, senior home care, home medical/nursing/therapy services are already established, this model will seek to further improve our effectiveness of service and provide a nursing home at home solution for the benefit of our dependent elderly. This is will an aging-in-place model for the near future.

       Remotely operated information technology will be utilised for proper documentation of the elderly clinical and functional progress. On cloud electronic systems such as Lotus ElderMemories system will enable the patient to be properly monitored and managed at home. As the carer is now part of the care organisation, daily vitals can be recorded and input into an application in the smart phone which will consolidate all the data.

           CHOICE model will allow operations to get creative on the possible permutation of services in the community.

 

 

Drafted by Dr Tan Jit Seng

Senior Home Care Physician

Lotus Eldercare

 

 

Read 4721 times Last modified on Saturday, 21 March 2015 08:38

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