Lotus Eldercare attended IAHSA-China and U.S Commercial Service Event in Shanghai on the 23rd April 2015. This event features Ms Ying Guo, General manager from United Family Home Health service. Her presentation is on "An Overview of United Family's Home Healthcare Initiative" 

A China’s home healthcare service is at its infancy stages and home services are mainly catered to a small percentage of those who can afford these premium services. United Family Home Healtcare services can be considered one of the pioneering ones. One striking difference from us is they offer home services to post partum ladies which is popular in Chinese tradition to "zuo yue" or a 1 month period of highly supervised recuperation. The services are more on home primary care and subacute care with phone consults and visits by physicians and nurses sold as a package. Clients can be those older persons whose children are overseas and want professionals to keep an eye on their loved ones back home in China. They are also setting up palliative care with the support if their oncology department in their hospital. Patients are often referred out from their parent hospital (United Family Hospital). Main concern will be the cost and all patient pays out of pocket. There is none or limited insurance policies to support such services at this point of time. Someone in the audience also pointed out that even if such insurance policies are in place, there is not much take up by the Chinese as well.

This event is mainly attended by private healthcare organizations and there is not a huge number of such organizations here in proportion to their population.

With 1 in 3 resident in China over age of 60 in 2050, there will be a huge demand for such services in future with an aging and increasingly affluent population. 

The Chinese Government will have be step in and support initiatives such as United Family's Home Healthcare services in the near future as chronic sick patients load increases. Hospitals and eldercare facilities will not be able to cope with the demand. New policies such as advance care planning, aging in place initiatives and compression of morbidity measures must be implemented. Policies as such to improve care and manage resources as well as people's expectations as the residents are increasingly educated.

We are actively implementation such policies in Singapore and can possibly be a model for China's cities in future. Right now, it is still a long torturous road ahead and the private and NGO's in China must step up and start processes to ease the growing healthcare issues for the dependent sick group.

            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

Nasogastric tube feeding is becoming increasingly common, as chronic sick patient load increases in our aging population. Nasogastric tube feeding traditionally is not recommended for use in long term care, it is usually only used for 4 to 6 weeks.  However, due to certain patient’s, clinical and operational factors, it is routinely use for long term care in the acute hospitals in Singapore.

Singapore’s market has been using Abbott’s Flexiflo nasogastric tubes, both size 12 and 14 in the past 5 to 10 years. However, Abbott has since decided to discontinue some of their enteral products in 2012. The stocks of the tubes in Abbott’s warehouse lasted another 2 years. In early 2014, the market was introduced to 2 other brands of nasogastric tubes for long term usage.

Insertions of nasogastric tube carry potential risks.  In the hospital’s standard protocols, post intubation placements will be confirmed radiologically. Hospitals also have the additional advantage to use endoscopic, fluoroscopic, electromagnetic and even surgical aided insertions. In the community, the insertions of nasogastric tubes are almost always done blind.  Non-visual placement confirmation techniques that are used in the community are air inflation and auscultation, looking out for symptoms with a trial feeding of small amounts of water with pulse oximetry monitoring and aspiration of gastric contents to confirm acidity with pH indicators.

Our patients in nursing homes and home care services using long term nasogastric tube feeding are often those with severe neurological injuries from traumatic brain injuries, stroke diseases and various forms of encephalopathies (hypoglycaemic, hypoxic etc); and the elderly population with dementia or swallowing impairment from functional and physical decline from various medical conditions and end organ failures. This group of patients will have increased risks during the insertion of nasogastric tube, with even higher risks when inserting a nasogastric tube into a demented, agitated elderly. In this group of demented patients, nasogastric tubes are usually poorly tolerated and would be removed by the patient repeatedly, causing much stress and anxiety to the care givers.

The main and most obvious risk of nasogastric insertion is mal-positioning. Mal-positioning of tubes can range from 0.3% intrapleural (Valentine and Turner) up to 2.4% (Sorokin and Gottlieb n= 2000) of the adult cases, with those inserted into the trachea, bronchus or even pleural spaces as the key causes of morbidity and mortality. Pulmonary formulae infusion with choking, pulmonary infections /abscesses and pneumothorax can occur in mal-positioning. Oral malposition is very common and easily detected in uncooperative and agitated patients undergoing tube insertions.

Since each insertion posed a risk of mal-positioning and various associated complications, the less frequent the tube is changed the less chance there is that the tube will be mal-positioned. Corflo and Kangaroo are nasogastric tubes, and since nasogastric feeding are not thought to be a long term solution in traditional way of usage, their official standard recommendations is to be used for only 4 weeks. However, in Singapore, for many long term chronic sick patients, nasogastric feeding can continue for even 10 years or more in some cases. Flexiflo tubes are being used previously for 2 to 3 months usually without any issues for majority of the patients. Now, with around 1 year of experience with Corflo and Kangaroo tubes, they have been shown in my practice to be able to last around 2 to 3 months or more (our threshold is still maximum 3 monthly changes so we do not have experience on longer periods). The removed tubes (after 3 months) are observed and noted to still be in functional conditions.

If these tubes were to be changed monthly, and blindly inserted in community, the cost, possibility of mal-positioning of the tubes and direct trauma or discomfort to the patient will be raised by 300%. This is in my opinion, is very unfair to the patient (in having the discomfort of getting the tube replaced monthly – 12 times a year vs 4 times a year), the family (raising the cost suddenly by 300% in terms of the services and buying of the tubes) and the operator (with 300% increase in malposition risk and other associated complications which may or may not culminate to law suits against the institution)

Hence, Lotus Eldercare will recommend both Corpak’s Corflo and Convidien’s Kangaroo feeding tubes to be changed every 2 to 3 month period with proper care and maintenance.

We also have recommendations from Corflo attached here.

Here are the corflo tubes after more than 3 months, they are actually totally still usable apart from some expected discoloration from gastric contents!

Taken from BGS Blog with permission from Dr Lee Liang Tee

https://britishgeriatricssociety.wordpress.com/2014/12/30/geriatric-medicine-in-the-little-red-dot/

Geriatric Medicine in the “little red dot”