Senior Minister of State COS Speech 2: Better Home and Community Care for our Seniors

Mdm Chairman,

1.            Our population is ageing rapidly. I fully agree with Mr Sitoh and Dr Lily Neo that we cannot respond to the challenges of an ageing population by just developing acute hospitals alone. Step-down, community and home care services and facilities are just as vital if not more so due to an ageing population. MOH is doubling up our efforts to develop a comprehensive suite of aged care services that are accessible, affordable and of good quality, to help our seniors age in place gracefully.

I.             Residential Care Services

2.            Mr David Ong asked about our progress on nursing homes. Two years ago, we announced our plans to build 10 new nursing homes and add some 3,000 new nursing home beds by 2016. I would like to thank various Members of the House for working closely with MOH to facilitate the smooth implementation of these projects. We are on track to achieve this target. Last year, we added some 1,000 nursing home beds to our national capacity. As we speak, five more Government-built nursing homes are under development and we will begin construction of another seven by early next year.

3.            Our approach is for the government to build and own the infrastructure, and then tender out to the best operator who can offer quality care at affordable prices. This allows us to tap on the expertise of both the private and people sectors in operating these homes, without burdening them with the cost of having to build the infrastructure. To complement this strategy, we need to make clear our expectations of the quality of care in nursing homes. Last year, we announced that we are developing a set of Enhanced Nursing Home Standards. These include a clearer articulation of standards for clinical care, psycho-social well-being, and organizational excellence.

4.            We have since refined and finalised the set of standards after a series of consultations with nursing home providers, caregivers of seniors and members of the public. The standards will be effective from 2015, with a one year grace-period given to providers before enforcement commences in 2016.

5.            Mr David Ong asked about the implementation of the standards. I would like to assure nursing home providers that MOH will not just set the examination without also providing the necessary “tuition” to providers to meet the new standards.  The Agency for Integrated Care (AIC) will introduce a full suite of assistance programmes to prepare nursing homes for 2015. Firstly, AIC will conduct voluntary baseline assessments of nursing homes in 2014 to see where they stand as against the standards. AIC will then develop customised programmes based on the gaps identified. As of end-February, 34 nursing homes have already signed up for these assessments. Of these, 12 have already gone through the assessments.  Secondly, AIC has developed new courses for nursing home staff. Participants may receive up to 90% subsidy on their course fees. Thirdly, AIC will launch a Guide in the second quarter of this year to help nursing home providers better understand how the enhanced standards can be implemented.

6.            I would also like to thank Mr Sitoh for his feedback on nursing home ward design. The nursing home standards are meant to be outcome-oriented rather than prescriptive or process-driven. Given the different circumstances of various nursing homes and the different clientele that they serve, the nursing homes should be given flexibility to achieve the desired outcomes in terms of dignity of care. They should not be dictated on specific matters such as design configuration of the homes. Nevertheless, MOH has and will continue to improve upon the design of nursing homes we build, recognising that the physical environment can affect care giving.  Last year, I updated members of this house on how we have injected more public spaces, greenery and even green spaces at ward levels in our new nursing homes for patients to enjoy. We will continue to study new designs that can provide greater privacy while maintaining operational efficiency and affordability of nursing homes.

II.            Care At Home

7.            Mr Sitoh Yi Pin, A/Prof Fatimah Lateef, Dr Lily Neo and Mr Low Thia Kiang spoke passionately about the development of home care. Indeed, I very much share your aspiration, to see the majority of our seniors well cared for at home rather than in any institutional setting.

8.            To achieve the vision of “care at home”, Mr David Ong is right that we will need to set up a much more holistic and integrated system to promote and support the care of our seniors at home. Let me assure him that MOH places great priority on developing a more comprehensive and accessible set of care services that extend into the community and homes.

III.           Home Care Development Plan : 5 Point Plan

9.            This year, MOH will focus more on home-based care development.  We will be enhancing the three “C”s this year –  expanding Capacity, making home care Comprehensive and enhancing Caregiver support.

10.         First, MOH has and will continue to invest in expanding home-based care services so that more seniors and their caregivers can benefit.

11.         We have worked with various hospitals to set up transitional care programmes to help patients who are discharged from hospitals to transit smoothly back home. These multi-disciplinary teams provide medical and allied health support for patients in their homes after they are discharged, so that they can recuperate and stay well in the community, and not have to be re-admitted again.

12.         Since 2010, we have built up a capacity to serve about 2,000 patients a year under transitional care programmes, and we aim to increase this capacity to about 3,300 patients by the end of this year.

13.         Many seniors living in the community may also have chronic diseases and functional impairment, and require long term home-based healthcare and personal care, to help them age gracefully at home.

14.         Since 2012, new and existing home care providers have received funding to help them scale up their home care services. In total, our providers can now serve 5,400 seniors needing home-based healthcare and 1,100 seniors needing home-based personal care a year. We are on track to achieve a capacity of 10,000 patients for home-based healthcare services and 7,500 patients for home-based personal care by 2020.

15.         As part of enhancing home care, we are also working with providers to expand home palliative care services. Mr Laurence Lien and Mr David Ong earlier asked about end-of-life care. MOH has been supporting the expansion of in-patient palliative care capacity. However, we also know that many caregivers have expressed their wish to care for their loved ones at home, even towards the end-of-life. We want to support caregivers during this period which can be especially stressful and difficult, by further developing home-based palliative care services. MOH will be announcing more of our plans to enhance palliative care services later this year.

16.         Second, we are enriching the scope of home care services available, and making our suite of home care services more comprehensive, so that we can better meet the diverse needs of patients and their caregivers.

17.         We know that home visits by doctors or nurses are inadequate to enable seniors to be cared for at home. Seniors who do not have full time caregivers at home need a lot more personal assistance in the day. Working caregivers are particularly stressed after their parents are hospitalised, as they have to find new care arrangements and are unfamiliar with how to care for their parents in the immediate period after discharge. In March last year, we introduced a new Interim Caregiver Service. This provides seniors with a much longer period of care -- 12 hours of personal care every day, for up to 12 days over a period of two weeks -- right after they are discharged from hospitals. It has helped seniors and their caregivers to enjoy a smoother transition home, and given caregivers more time to make longer term care arrangements. With additional help for 12 hours a day, caregivers can also get some rest. This service will be available in all major restructured hospitals and community hospitals this year.

18.         This year, MOH will also make available even more subsidised home care services. From the 1^st of April, MOH will subsidise the provision of home-based rehabilitation as part of the suite of subsidised home-based services available. Today, seniors can go to day rehabilitation centres for their rehab needs. However, some seniors may not be able to do so, because they are still quite frail and may be unable to sit through the journey to the centre, or there are physical barriers that make it difficult for them to leave the home to go to a day care centre.

19.         We want to catch the window where home-based rehabilitation can help improve their function. A therapist or therapy aide will visit the senior’s home to assess and carry out active rehabilitation for up to 4 months. The objective is to bring rehabilitation in a more timely manner to these seniors at home, enabling them to regain as much of their functional ability as possible within their daily living environment, and remain independent longer. Eligible seniors can receive subsidies for home-based rehabilitation services from April this year, up to a maximum subsidy of $97 per visit.

20.         Take the example of Mr Zulkifli, who suffers from diabetes and had to undergo an amputation of one of his legs above the knee. He was unable to leave his house for therapy sessions because he could not climb down the steps outside his main door, and he had no caregiver who was available to accompany him.  He underwent intensive rehabilitation at home under Tan Tock Seng Hospital’s Community Rehabilitation Programme, and shared that home therapy gave him the motivation to get out of bed and the confidence to keep going despite his setback. You can see that he’s a happy man there in the photo. I am very glad to hear that he is now able to negotiate the steps in front of his house with a prosthesis and crutches, and in fact has returned to work as an admin officer.

21.         Home environment assessment will also be added to the suite of subsidised home care services available. Therapists will visit the homes of seniors who are receiving home-based care services to identify home hazards and recommend home modifications to facilitate independent living, like having grab-bars or ramps for wheel-chairs. This helps them to transit safely from hospital to home. Similar to home-based rehabilitation, eligible seniors can receive subsidies for home environment assessment. The home care provider will also help them to tap on existing sources of funding like the HDB’s Enhancement for Active Seniors (EASE) funding for the necessary home modifications.

22.         Third, we are making home care more integrated and client-centric. Today, some seniors may find that home care services are delivered in a fragmented manner with a lack of coordination between separate health and personal care providers. This is not ideal as an individual’s health and personal care needs are closely intertwined.

23.         The Agency for Integrated Care will be working with several homecare providers to better coordinate, if not fully integrate, home healthcare and home-based personal care for our seniors at home. For instance, Touch Home Care, NTUC Eldercare and Thye Hua Kwan, have received funding to build up their capabilities and capacity so that they can provide a comprehensive package of services according to the needs of the client. They will be able to make a holistic assessment of a senior’s needs, draw up a comprehensive care plan with integrated health and personal care services, and explain this care plan to the senior and his family members. They will also help to make applications to relevant assistance schemes, monitor the senior’s medical conditions to ensure timely treatment and provide caregiver training and support.

24.         Take Mr Low Boon Leong for example. Mr Low is 66 years old and suffers from high blood pressure and kidney disease. He is single and lives alone in a rental flat. Mr Low currently enjoys a comprehensive, integrated package of services from TOUCH Home Care. TOUCH medical staff visit Mr Low twice a month to manage his medical conditions and help him pack his medications, while personal care staff visit him once a week to help him with household cleanliness. TOUCH also helps to arrange transport for his medical appointments.

25.         For providers who are not yet able to offer all the health and personal care services today, they will be expected to do a similar comprehensive assessment of seniors’ needs, and coordinate with other providers to meet these needs holistically.

26.         Fourth, MOH will enhance the way home nursing, home medical and home-based personal care services are funded to support this integrated approach to care. Today, MOH funds home care providers based on the number of home medical and nursing visits made, or the number of personal care hours a client is eligible to receive each week. Such a funding approach is suitable for seniors who only need infrequent or ad-hoc home care visits when they fall sick or need help at home.

27.         To encourage providers to take a person-centric view and to “own” and integrate care for their patients who need home care as a long term care option, MOH is studying a new way of funding. We are prepared to fund providers not on a per visit basis, but on a per-client basis, where we will provide a fixed amount of funding per month for each senior under their care, based on individual care needs. This new approach to funding will give home care providers a steady stream of financial support, so that they have the resources and flexibility to plan and deliver an integrated package of home care services needed by the senior. We expect to implement this new model of funding in the 3^rd quarter of this year.

28.         Finally, we will enhance the quality of home care services. The quality of home care services is important, because we want to give caregivers peace of mind that their mum or dad or loved one will be well looked after at home, when they are at work.

29.         MOH has worked with home care providers to develop a set of Home Care Guidelines, to articulate the level of care expected of all home care services. This includes good practices to enable coordination of care; enhance quality of care; promote independence; and encourage organisational excellence. MOH will be conducting a series of consultations with the home care sector, seniors and caregivers before finalising the set of guidelines.

IV.          Expansion of Centre-Based Eldercare Services

30.         MOH will also be expanding eldercare centres to complement home care services. Mobile seniors who can attend day care or day rehabilitation services at one of our eldercare centres can get out of the house, meet new friends and spend quality time interacting with others rather than staying alone at home.

31.          We aim to more than double the centre-based care capacity by 2020, by adding more than 3000 day-care places to our current capacity. We are also developing new “one-stop” Senior Care Centres in the community, where our seniors can receive day care, dementia day care, rehabilitation and nursing services all under one roof. This saves them the trouble of visiting different centres for different services. In the past two years, eight new centres in different regions across Singapore have opened, providing a total of more than 400 additional day places. This year, another 8 new centres will be opened, adding some 400 day places.

32.         Just like nursing home and home care services, we need to pay attention to the quality of care delivery in our centres. MOH has worked with day care operators to draw up a set of Centre-based Care Guidelines to articulate the quality of care expected of the centre-based services. The guidelines emphasize safe care and promoting seniors’ independence by involving them and their caregivers in making informed decisions about their own care.

33.         This year, MOH will also be conducting a series of focus group consultations with seniors and caregivers, to discuss this set of guidelines before they are finalised.

V.           Investing in Long Term Care

34.         Several members spoke about the need to invest in intermediate and long term care and make it more affordable. Let me assure members that we have been investing and will continue to invest in the development of affordable community care services.

35.         We have been increasing our support to the sector, both in enhancing affordability for patients and capital investment to scale up facilities. In July 2012, we significantly enhanced the subsidy framework for intermediate and long term care to cover all lower and middle income households. Currently, two-thirds of households are eligible for subsidies if they need these services.

36.          With this, MOH’s funding to the ILTC sector has grown significantly in the last two years. Funding to the ILTC sector is expected to reach around $260 mil for FY2013, an almost 80% increase from the $145 mil in FY2011. The $1 billion Community Silver Trust or CST has also provided VWOs around $88 mil of funding to date, with more applications pending processing.  From July 2013, we also allowed more flexibility for VWOs to use CST matching grants to meet recurrent operating expenses.

37.         Last year, we have also enhanced the Seniors Mobility and Enabling Fund to $50M. The Fund was expanded to include more devices, consumables, and subsidised transport services for clients receiving dialysis, dementia day care and rehabilitation services. I am pleased to inform Members that since July last year, more than $3.7M has been disbursed and more than 5,400 seniors have benefitted from the SMF enhancements.

VI.          Enhancing Caregiver Support

38.         We agree with Mr De Souza, Mr Chen, Dr Lam and Ms Lee that caregiving is no easy feat and we need to support caregivers.

39.         The expansion in home and community based services, taken together, will support caregivers and help them balance their caregiving and work obligations. In tandem with the expansion of services, MOH will also be working on outreach to caregivers to help them navigate the eldercare landscape and access the services they need. Last April, we brought all aged care functions under AIC. Caregivers of the elderly now only need to contact AIC for information and referral to eldercare services. We have also provided an online platform, Carers SG, for caregivers to show mutual support, share information, resources and experiences.

40.         Dr Lam asked if we could consider allowances for caregivers of the elderly and disabled. I think we want to avoid monetising family ties and filial piety which are intangible.   Instead, we provide financial help in other forms. For instance, The AIC administers the Caregiver Training Grant which provides subsidised training for caregivers to equip themselves with the necessary skills to care  for the physical and emotional needs of their care recipients. In the past year, some 5,400 caregivers have been trained.

41.         Ms Ellen Lee’s suggestion to encourage former caregivers of the  elderly to enter the aged care sector is also an excellent one. Today, some 12% of the caregivers trained under the Caregiver Training Grant scheme are middle-aged locals who are looking after their elderly loved ones at home. We will certainly think about how we can also reach out to former caregivers and inform them of the eldercare job opportunities available.

42.         This year, DPM Tharman announced the enhancement of existing tax reliefs, such as parent and handicapped parent relief and handicapped spouse, sibling and child relief, which will provide greater support for working caregivers.

43.         MOH will also go a step further and make respite services more accessible. We have rolled out the Nursing Home Respite Care (NHRC) Pilot, where subsidised NH care is provided to eligible seniors for between 7 to 30 days a year. 15 participating nursing homes have since come on board the programme, and this has benefitted some 130 clients.

44.          By the second half of this year, MOH will also partner a number of eldercare centres to pilot weekend respite services. Caregivers can drop off their seniors at these centres during weekends, for a few hours, if they need a respite or to run errands. Caregivers for persons with dementia may also approach ADA, NTUC Eldercare and Thye Hua Kwan Moral Charities for home-based elder-sitting service, where therapeutic activities are conducted for the senior while the caregiver takes a rest. Eligible caregivers who make use of these respite services can also receive government subsidies.

45.         Finally, in the third quarter of this year, we will put in place a one-stop call centre for caregivers. Caregivers only have to call this one number to access a whole variety of services, such as referral to care services, application for grants, and care coordination for loved ones with multiple needs. We hope that this will help Singaporeans get the support and services they need to care for their loved ones in the community more easily.

VII.         Care at Home : A Whole of Society Effort

46.         To achieve the vision of ageing-in-place or care at home, we need a whole of society effort.

47.         For one, a supportive workplace is important. A supportive work environment makes it much easier for caregivers to juggle between work and caregiving. Several members have raised the issue of eldercare leave. The Government will be reviewing this issue as part of our broader efforts to address the challenges of an ageing society.

48.          We can also contribute to caring for our seniors as a society. I think seniors will not only age gracefully but thrive, if we can build “Communities of Care” across Singapore, where everyone in the neighbourhood chips in to support frail seniors.

49.         We held a focus group discussion with over 100 caregivers last year to understand how we can better support. One thing we learnt was that having caring neighbours who help to support seniors living in the community will make a huge difference.

50.         I am very happy to say that several communities – Siglap, Marine Parade, Bedok, just to name a few – have rallied caring neighbours living in the vicinity to check on seniors who need care. For example, under the Eastern Health Alliance’s Neighbours for Active Living Programme, neighbours visit seniors with high care needs in their homes, help monitor their condition and also help out in other ways.  Take Ms Rohani, a 68 year old lady who lives in Marine Parade. She has multiple medical conditions and is on many medications. During the day when her family members are either at work or school, she is alone at home. Under the Neighbours programme, the Eastern Health Alliance team works with the local Senior Activity Centre, Goodlife!, to arrange for volunteers to visit her twice a week. The volunteers befriend her and keep her company, remind her to take her medication, and even help her to buy meals and groceries when needed. They also check on her regularly and alert the Eastern Health Alliance team if there are any issues.  

51.         I hope to see more communities stepping forward to do this, because every one of us can do our bit to care for seniors within our own vertical kampongs!

VIII.       Conclusion

52.         Mdm Chair, let me assure this House that even as we have taken bold steps this year to enhance the affordability of both acute and outpatient care for seniors, especially for our Pioneer Generation, we are just as focused in building up our home and community care services, as we are keenly aware that this is necessary to help our seniors age gracefully in place.

IX.          Community Mental Health

53.         Let me now move on to issues of mental health and women’s health raised by members. As Ms Tin Pei Ling said, she has raised this every year, and I have answered her every year. I am glad she has noted that things have improved. A/Prof Fatimah Lateef and Ms Tin Pei Ling asked about the progress of mental health programmes in the community. Mr Patrick Tay asked how to ensure that patients with psychiatric conditions in the community are well managed.

54.         The National Mental Health Blueprint was launched in 2007 and the programmes are still ongoing. Building on that foundation, we introduced a Community Mental Health plan in 2011 to ensure that patients continue to be well supported in the community. We have since set up various community teams, made up of mental health professionals and physicians, to better manage patients in the community. Our community teams provide clinical care and psychotherapy for patients, help to link them to other community services, and also provide education and support for patients, caregivers and the general public.

55.         Let me illustrate how individual patients and their families are supported by these community teams. In the northern region, a patient with mental illness usually receives treatment at the Specialist Outpatient Clinic or SOC at Khoo Teck Puat Hospital (KTPH). KTPH actively trains primary care physicians and community agencies in providing mental health care, and in this way, develops an integrated community mental health network. Even when the patient can be managed in the community, KTPH’s community team and its GP partners will continue to support the clinical needs of the patient. The patient may also be referred to other community partners like Clarity Singapore for counselling services or Singapore Anglican Community Services for urgent community response. Such community support teams have reached out to more than 2000 patients, and in the process have reduced the number of emergency admissions among their patients by half in FY2012.

56.         Our teams have done good work, but many in the community are still unaware of mental health illnesses or where to seek help. Thus, MOH has partnered community groups such as Thye Hua Kwan Moral Charities and Silver Ribbon (Singapore) to reach out to the public to increase awareness of mental health issues and the help available. We have also provided mental health training and education to the social service agencies and VWOs which can better reach out to residents.  To date, we have trained over 100 community partners including FSCs or Family Service Centres, SACs or Senior Activity Centres, grassroots leaders and volunteers. Our community partners can turn to our 24 hour Mental Health Helpline for immediate support and advice in managing mental health issues. Our outreach teams have also reached out to over 18,000 residents, and we aim to reach out to about 9,000 more seniors by end-2014.

57.         Last year, MOH has also reached out to grassroots Advisors, to co-create local partnerships, or local support networks, to better support residents with mental conditions.  For example, in Kembangan-Chai Chee and MacPherson divisions, we meet up with the grassroots organizations, town council, voluntary welfare organizations and the police to devise solutions to better support residents with mental conditions and who have been identified to need help by our local grassroots or social organizations. These groups help such residents by promptly linking them with appropriate social or health services.

58.         I would like to take this opportunity to thank the advisors and grassroots for their support in bringing these communities together.   Ms Tin Pei Ling asked about the challenges we face. Despite our best efforts, there could still be residents who refuse to be engaged. We are unable to legally compel them to comply with treatment if they are not causing harm to themselves or others. However, we are prepared to work with community volunteers or leaders to engage and persuade this group of residents to come for treatment. 

59.         One such resident was a 51 year-old lady who displayed violent and abusive behaviours towards her father. Staff from Fei Yue FSC at Bukit Batok, who had been trained in mental health, identified and referred the resident to our community support team for assessment. Our community support team conducted several home visits and managed to persuade the resident to receive treatment at IMH. The resident has since been discharged and our community support team will continue to monitor the resident’s condition and remind her to take her medication and go for her outpatient appointments.

60.         Moving forward, we will be addressing the effectiveness of our community mental health programmes and expanding those that have been successful. We are also working towards better integration between programmes.

X.           Women’s Health

61.         Ms Ellen Lee asked about the progress of the Women’s Health Advisory Committee or WHAC, which I chair. Since its establishment in May 2012, the Women’s Health Advisory Committee (WHAC) has reached out to more than 200,000 women. One of our priorities has been to provide affordable cancer screening for women, especially those from lower-income groups. Mammogram screening for breast cancer is especially important as it is the number one cause of death from cancer in women in Singapore.

62.         I am pleased that the Breast Cancer Foundation (BCF), in partnership with HPB, launched the BEAM15 or BCF Encouragement for Active Mammograms programme in March last year. This program provides heavily subsidised mammograms to lower income women through the polyclinics and a mobile bus with mammogram facilities called the Mammobus. The program was very well-received, with over 6,000 women taking up the offer within a 3-month period since its launch. With generous support from the Breast Cancer Foundation and Estee Lauder, more than 8,500 women in total have received screening to date. Of these women, about 1200 women required further assessments after their mammograms, and 48 of them were diagnosed with cancer.  

63.         Early detection and treatment of cancer through screening can lead to better long-term outcomes. The WHAC will continue to promote cancer screening for women by making it more affordable and accessible, especially for lower-income women.

64.         Last year, I was pleased to launch a health calendar developed by HPB called “Good Health, Better Life”. It teaches women from lower income families how to choose healthier foods at lower prices for themselves and their families. As you can see, it is full of pictures, fun and easy to read and understand. The pilot batch of calendars in Malay was distributed to about 3,000 Malay households with the help of religious organisations such as PPIS and MUISDepending on its success, we will also explore producing the calendars in other languages like Mandarin and customising them for different communities.

65.          The WHAC will also work through the Healthy Living Master Plan (HLMP) Taskforce, led by Parliamentary Secretary for Health, to cultivate healthy lifestyle habits from young. Parl Sec will elaborate more on this later.

XI.          Conclusion

66.         Mdm Chairman, to conclude, health and wellness are priceless. We hope to encourage individuals to take ownership of their health, and MOH will continue to strengthen our efforts to foster a whole of society approach to build a healthier and happier society.