Recently, I have been approached by start-ups, governmental, private agencies, tech coy on this topic of Uberising of health services. 

Well, first things first, go for the more traditional source of uber, somebody or anybody please do a Uber for ambulances to transport bed ridden patients or for special vehicles transporting patients in wheelchairs. There, I said it. The last I have heard, there have been discussion on such efforts being planned so it is good.

On to health services: As a active player for home and remote health services, there is definitely a role in uberising emergent health services. Those routine, long term relationship kind of services will need such supplementation for the coverage to be complete and functional. So what are the scope and the forms of these uberising there is? 

I do home based services and uberising of emergent care is possible, but the services should be properly scoped and clients should have an agreement and understanding of the limitations for such services. Funding will definitely be of issue such these form of services are probably all private right now and will not be covered under any insurance. It will be out of pocket expenses. For a MEANS tested and MEDIFUNDED patient, it will be free for them to go back to acute hospital for any emergent situation, even for just a emergency NGT change!

So who will use this form of health services and why?

Let us start with the most basic care giver services. Most commonly, (in fact just today), one of my patient’s family was asking me where to find a nanny service for the grandma, just for perhaps 2 to 3 hours to allow the usual caregiver (domestic helper) to go off duty. Care for this patient is really simple, just transferring her, routine hygiene care and perhaps companionship. She is eating orally with mince diet, which can be prepared before hand.  There are such services known as senior home help, run by charities, social enterprise and private provider. Right now, I would ask family to go to the private providers to ask for help, but as demand for this sort of services are high and such private services are really being handicapped by MOM restrictions, the request for urgent elder sitting might not be successful frequently. Uberisation of such services can help, either pool in all the providers to see who have spare capacity that day and that hour, or engage another group of caregivers totally out of this pool which sign up with this Uber App.  My patient’s daughter can then receive the services promptly.

The issue of getting Uberised care giver is perhaps 2 fold. On the provider or Uber side, how are they proposing to justify the standards for their care workers? Are they properly trained and by who, for example tube feeding techniques, transfer procedures and hygiene management. On the other site, can Uberised care giver service protect their own caregivers? Who are these clients, are they dangerous for a petite lady carer to go into the home? Is the client violent from psychotic depression or having paranoial symptoms of dementia?

Then we come to the charges, is it standardised for the entire services or each caregiver signing up charges differently based on their skills and experiences?

There are such caregiving courses, run by various charity organisations in Singapore. Perhaps, that can be the certification ground and also the source of manpower for this kind of app. Unfortunately, Lotus Eldercare Academy graduate will not be directly available here in Singapore.

Going higher up, nursing and therapy services. Therapy services are not likely to be required urgently so the market for Uberisation of therapist might not be practical. But for the completeness of the APP, there is no harm perhaps including such services.

Urgent nursing services are plainly procedure based and can be scoped rather easily. Why would family require an urgent nurse visit? Either one of the tubes (nasogastric, urinary catheter, PEG) dislodge or gotten pulled out by agitated patients; to review newly onset wounds or do wound dressings; and perhaps other more specialised procedures not being mentioned.  The certification part is easy, but skill level and comfort zone of each nurse differs. I was suggesting a refresher course for nurses doing home care for procedures to perhaps boost their confident and competency levels before they are being hired if they have not been keeping current with some of the procedures.

Similarly, to enlarge the pool, the Uber app should engage all the charity organisations, social enterprises and private nursing agencies providing such services to increase the total numbers if possible. Dangers are same as for caregivers; work place safety is still a question mark when nurse visits the family. I did have an agitated caregiver once going psychotic and took out a knife to try and stab my nurse many years back.

Lastly, urgent medical support. To me, there are only 2 things for anyone to need urgent home care consults. Urgent home care and Housecall is slightly different. Housecalls can be made to ambulant and rich persons who just want the services of GP coming to the home for treatment instead of going to the nearby GP for treatment. Issues which with a MC rest will solve usually. Urgent home medical visit involves bed or house bound patients with are very dependent and frail. Most of the time it either involves

1.     Signing of Certificate of Cause of Death

2.     Urgent medical consult for infections (which may or may not be life threatening), delirium like agitation or food refusal, worsening of organ failures like congestive cardiac failures or hepatic encephalopathies, emergent medical conditions like ischemic foot with gangrene, myocardial infarctions, strokes and seizures.

Point 1 is commonly the cause requiring urgent medical review. Point 2 can be a simple flu virus to life-threatening conditions.  Depending on the medical services provided, it is often a decision for end of life care at home or more active treatment back in acute hospital for more serious conditions. It also depends on how much resource the doctor can provide, from labs service to intravenous antibiotics to hospital-like services to the home. It is very difficult to scope as different doctors have different capacity and resources.  It will be difficult for any organisation to anticipate the requirements and scope for the services. A medical director should be in place to scope out all the medical service if such an uberisation of urgent medical care is to be done. There is no end for medical service and perhaps even an ICU level of care can be provided at home if there are such resources from the willing family. In fact, a tele-medical services should be inline with such uberisation of medical service to screen and advise. That will be more cost effective and for the very near future!

IFA 2016 held in Brisbane, Australia was indeed an eye opening experience for me in all things ageing. Being a doctor and frequently attending conference, it is refreshing to be in a conference with minimal medically inclined topics, rather, more on the overall social-economical-controversial-overall topics for the seniors. All the keynote speakers were fantastic, giving the insight of ageing policies and on-goings in various countries and the ground issues encountered. Taking a look at the conference program and you will be impressed with the scope and the fascinating number of topics being discussed! Some of the more controversial ones might never make it to Singaporean shores I say!

I presented a simple papers on my findings on the causes of disabilities in our seniors. I have met old friends and many more new friends in this conference, and heard interesting sharings from many different countries, including one from Jamaica! There are far too many lectures I heard throughout the 3 day event but it really expose me to many new ideas and practices. I would be very much interested to attend the next one in Toronto, Canada in 2 years time!

This page is a bookmark more for myself than for you, my readers.

In the past weeks and for the next few weeks, I have been tasked by a few governmental agencies to talk about the topics on Caregivers. In all these seminars and conferences that I have the privilege to be involved, I will share some of my thoughts and things learnt from other experts.

We are all either being the carer at one stage of our lives or have been cared for, when we are young, when we are sick, and when we grow old and frail one day.

Caregiver can be formal (paid and as a full time work) or informal (spouses, children, relatives, friends and even neighbours). The work of caregiving has been increasingly important and perhaps I would say it should be of National Issue! But why?

With ageing population, number of chronic sick patients is ever raising in the current modern healthcare era. Singapore's efficient and fast tertiary healthcare support system have been ever so effective in saving and prolonging life. With the number of dependent patient raising, families are stressed to have the responsibility of caring for their dependent loved ones. Without properly trained and empowered caregivers, these group of dependent elderly may have repeated admissions into the hospital, stressing our already sardine packed restructured hospitals and increasing healthcare expenditure from a mere SGD $4 Billion just a few years back to $13 Billion on 2016. Not only the governmental health care system is stressed, the families are also being stretched, both emotionally and financially. If every and each of us stay home and care for us dependent family members, with smaller family units now and even so in future, we might not be contributing in Singapore economy! The country might fail as such!

I have been called upon to talk about various topic in caregiving; namely, Role and Skills a caregiver should acquire, Perspective of a Singaporean Caregiver, and Future possibilities of caregiver. To me, the simplest topic will be the role and skills of a caregiver. Caregiver training and care plans are part of my daily work and I can rattle off lots of details anytime. Having written a book on skills for caregiver (which NUS press deemed it was too difficult for a normal reader), I feel that caregiver skills are not too difficult to learn and master (That is for me to say of course!). I am currently giving an outline of the caregiver skills for public audience as a MSF Family 365 programme: Families for Life. https://www.familiesforlife.sg/unite-at-an-event/Pages/FamilyTimePreciousTimeEV.aspx

Experiences from each and every caregiver differs greatly. Depending on the culture, religious belief, financial status, patient's profile on physical and mental disability, care giver's profile, solutions for each and every family differs, as well as the needs and support. The challenges every caregiver faces is very different, some stresses on patient's care, for example, a demented and agitated elderly refusing to bath or to dress even, to external stress from relatives telling caregiver to give up and "let go" of the chronic sick, bed bound, tube fed elderly. As a supporting crew, I see many and supported many in these caregiving journeys. 

There are too many permutations and I find it easier to share experiences with the families, often than not, reassure the family of their decisions and others had similar decisions made and the outcome. We are not alone in this world and fortunately, these problems are not solely being "bestowed" to certain families, others had faced similar or worse! Some caregivers are truly commendable in every sense, inspiring and brave in the face of many adversities imaginable in a caregiver journey. These are the people that actually are the most pleasant, down-to-earth and practical. I myself have learnt much from all the carers I come to know and respect.

The future of caregivers will depend a whole lot on governmental policies, sometimes, not only ours, but also policies of our neighbouring countries providing us with the caregiver workforce. I was requested in one of these caregiver sharing sessions to talk about some of my recommendations on the future of caregivers. Here are some of which I can think of:

1. A national caregiver organisation offering "membership" - liken a country club membership with perks like cheaper diapers from bulk purchases, and depending on the length of caregiving, we can then separate it into Silver, Gold, Platinum, and even Diamond Members (esp. one of my previous client with 2 cerebral palsy children who are severely disabled and brought both of them up into their thirties and going.) Plus perhaps transportation perks and even cafes for caregivers only to share and support each other. (Idea from Japan). 

2. A means of remuneration perhaps for Singaporeans quitting their jobs to care for their dependent elderly instead of institutionalisation.  This will be very difficult to achieve from the government point of view and how to fund the caregivers instead of funding the institutions (which is definitely more costly) and how to fund the informal caregivers. Formal caregivers current has both FDG and FDWG to offset some of the costs for families. But if they choose to care for their elders themselves, I don't see any form of financial support at present.

3. Starting a module on caregiving skills in Secondary schools or perhaps have a CCA on caregiving liken Red Cross/Girl's guide/Scout etc. The students can then have the skills and help out in respite care if needed. They will be a good source of support for families.

4. A more consolidated help portal for caregivers based on patient's conditions rather than listing them by services. For example, see my article on listing services based on the condition of the patient: http://www.lotuseldercare.com.sg/index.php/ideas/item/90-ideas-from-pre-mit-hacking-medicine-sg-workshop 

5. Certifying caregivers as a healthcare worker with courses, so that the FDW can upgrade their skills and knowledge and can use Singapore as a training ground. For local caregivers, once their family work is completed, they can be rehired as caregivers in other families to help guide and support. I have many FDW whom are such wonderful carers and often I felt it is very wasted for them to return home after patients has pass on. Their skills and local healthcare knowledge will be invaluable.

With such intense interest in the recent years on caregivers, I am sure there will be more initiatives in future on caregivers. Globally, it is a bigger issue and the topic was discussed in international conferences as well. But, that is for another time!

Upraising of Eldercare Industry – A Vibrant Year 2015

This is certainly been an exciting year for the eldercare sector, in terms of the many opportunities and grant calls.

I am privileged to be intimately involved in this sector, from manpower development, research, to cutting edge technology developments.

Here are some of the events that I was involved in Singapore 2015.

Care-at-Home Innovation Grant

Everyone was excited about this very first grant call on the research thrust “Ageing in Place” under the National Innovation Challenge (NIC) on Active and Confident Ageing. MOH organized a few events to update providers and tech companies alike with networking and matching sessions.

Cognitive Grant

Following the Care-at-Home Grant call, the 2^nd grant call of the series came and we are still in the midst of writing out the proposals. The Grant Call on Cognition is the second of the grant calls under the National Innovation Challenge (NIC) on Active and Confident Ageing. This grant call under the research thrust on “lengthening health span” has two objectives. First, the innovation aims to improve cognitive functioning and delay the onset of dementia in older adults. Second, the innovation aims to provide quality and cost-effective care for seniors with dementia in the community.

NUS Enterprise Small Change Festival

Small Change is a social movement by youths and for youths, to inspire innovative solutions to address social needs in Singapore. FB/Instagram: smallchange.nus 

I was very honored to be invited as a panel speaker on the theme of Ageing. The one thing I learnt is that Silver Tsunami should be termed as Silver Reservoir instead! I learn much from other senior panel speakers and their drive and focus on Elder services are unparalleled.

Here are some photos for the event which include other social issues:

https://www.facebook.com/smallchange.nus/photos_stream?ref=page_internal

NUS Enterprise: Modern Ageing Singapore

I was invited as a judge in this event in their Semi-Final rounds. Although I have seen and come across most of the innovations, nevertheless, it was a great event to boost tech start-ups in the Eldercare sector!

Here are some news report on this event:

https://www.techinasia.com/modern-aging-winner-startups

http://www.channelnewsasia.com/news/singapore/3-teams-receive-s-125-000/2319006.html?cid=fbsg

Asia Pacific ARTT-Network: Active Ageing

Design Singapore Council: Two New Books: Publications on rethinking health and wellness for the elderly

I am very fortunate to be invited for the book launching at National Design Center and given 2 very informative books on Eldercare and their needs.

The e books are online now and here are the links!

Design for Aging Gracefully: 

http://www.designsingapore.org/for_enterprises/Design_Research/DesignforAgeingGracefully.aspx

Empathetic Technology for Ageing – Rethinking Health & Wellness for the Elderly:

http://www.designsingapore.org/for_enterprises/Design_Research/EmpatheticTechnologyforAgeing.aspx

Design Singapore Council: Designathon 2016

ABOUT DESIGNATHON 2016

Designathon 2016 is a 36-hour design challenge that will bring together a diverse group of people to produce design solutions that will enable the elderly in Singapore to live beautifully in

their golden years.

THEME: Living Beautifully: Designing for Our Golden Years

How might we design to transform the experience of ageing for the elderly in Singapore and enable them to continue living their lives with dignity, grace, and equality as they age?

I was involved in the Pre-Designathon workshop and will be joining in the Designathon next year.

Other developments:

Unaging:  http://unframed.so/unaging/

AIA-Konica Minolta Digital Health Accelerator:  http://www.aia-km-accelerator.com/

I received an invitation to join in the Global Consultation on WHO strategy recently. Unfortunately, the event in held in Geneva, in WHO HQ. Fortunately, with modern information technology available, I was able to join in the webinar and listen to the contributions by Eldercare experts all over the world. Many agendas from the Global strategy draft were discussed. I have attached the draft strategy in this article at the bottom of the page as well.

The impression I felt was ageing issues were too broad, and every different countries had slightly different focus, different political climate, different resources and very different cultures. It is rather confusing for most parts and many did not stick to the discussion agenda, but putting forth when their countries or organisations are doing. In fact, the definition of at what age should you define an older person may differ from each region. It is a 2 days long event and I was able to sit through all the sessions. 

Many of the themes regarding healthy ageing or ageing in place is not new, and has been a recurring themes in many of these forums or discussions. Themes like a conducive environment to age in, housing and financial issues, long term care  and palliative services, trained frontline manpower, health literacy and promotion, research in gerontology issues etc has been repeatedly mentioned in such forums all over the world. WHO seeks to consolidate all of these ideas into a clear framework as a guide for every country. 

As a global leader in healthcare policies, WHO will have to power to set down some ground indices for every country to follow, thus, data can be compared and best practices might be share between countries with similar socio-economic factors. Many countries, especially the local income countries, may find more challenges and perhaps impossible to implement the finalised strategies as some of the delegates shared. They can also facilitate cross countries collaborations in implementing some of the strategies. 

Each countries take their turns to speak and comment and many shared their difficulties faced and some solutions done. It is an eye opener for many of us doing gerontology work.

In the past 5 years, there has been an increasing support for home based care for elderly chronic sick, bed bound patients. The Ministry of Health and Agency of Integrated Care has done much to support the dependent elderly patients through various policies. Primary health care and long term care sectors have been in the news often and are getting the support they deserve from the policy makers.

MEANS testing has been getting less “mean” and much easier to pass in recent years. Hence, MEANS testing dependent programs such as IDAPE has seen an increase in claims in the past few years.  CHAS is another program in recent years to help subsidised patients to see doctors at private GP clinics rather than at polyclinics. CHAS provides subsidies for medical services and other perks, which traditionally only polyclinic holds. One big advantage for CHAS clinics now is the ability to refer patients to Specialist Outpatient Clinic as a subsidised patient.

It has been a heartening 3 years.  Authorities are giving more support to our group of chronic sick, bed bound patients to get treatment in their own homes. Support for home-based care is now given only to home care programs from charities and known social enterprises such as NTUC Health.

Private providers for long-term care services are unable to ride onto this program. Hence, we are only seeing those patients that either failed MEANS testing or non-Singaporean.  There is a special group of non-Singaporeans patients who have been staying in Singapore for the past 50 years but never converted to a Singaporean citizenship or even permanent residency.   For the group of patient who are unable to pass MEANS testing, many of them are actually also HDB dwellers and stays with their unmarried daughter or son with a stable income. Ironically, to pass MEANS testing, it is better for the elderly NOT to stay with their children in order to get maximal subsidies since usually the elderly will not have any active income as they are retired.

In the past, the difference between private and VWO services may not be too great, apart from subsidised consultations. But now, with subsidised medications and Pioneer Generation subsidies, my group of patients are losing out quite a bit. They will not be able to get their prescription subsidized like those in polyclinic or hospital SOCs as PG card holders.  As I do not have a physical clinic, my service is unable to be included in CHAS program.  All my referrals back to hospital SOCs will be treated as private referrals.  It would often be more cost effective to just go to the Emergency department for services such as subsidised referrals! Most of my patients are severely bed bound, hence requiring home based service.  It is very difficult or almost impossible for them to go to a CHAS GP clinics or polyclinic to see doctor or to get referrals.  I see this as huge disadvantage for my patients.  Perhaps, it would be timely for the authorities to come out with new policies to bridge such a gap for this group of patients.

I had been running subsidised home care services with various institutions for the past 7 years. I had witnessed first-hand at the many good subsidized schemes that benefitted patients.  As I had recently stop working for a VWO, some of the patients from the VWO wanted me to follow-up with them, but the difference of cost and benefits between subsidised and private service is too great.  There are also other patients whom I see along the course of my work who would like to continue to be followed up by me.  But as I know they would lose out a lot in terms of subsidized benefits, I had to advise them or refer them to be followed up by VWOs.  It seems that being a good doctor to the patient, thinking for the welfare of the patient will result in a losing situation for my own company.

Lotus Eldercare feels like we are falling through the cracks as well in terms of policy, mirroring those patients we serve.

Our last blog on the visit:

https://social.shorthand.com/LotusEldercare/nyfS1LOaF0/visit-to-lacura-group-iii