Relevant studies on ageing – related issues

Community-based person-centred primary care
 

EVANS, J. M., BAKER, G. R., BERTA, W., & BARNSLEY, J. (2013). THE EVOLUTION OF INTEGRATED HEALTH CARE STRATEGIES. ADVANCES IN HEALTH CARE MANAGEMENT, 15, 125–161.
PURPOSE: To examine the evolution of health care integration strategies and associated conceptualization and practice through a review and synthesis of over 25 years of international academic research and literature. METHODS: A search of the health sciences literature was conducted using PubMed and EMBASE. A total of 114 articles were identified for inclusion and thematically analyzed using a strategy content model for systems-level integration. FINDINGS: Six major, inter-related shifts in integration strategies were identified: (1) from a focus on horizontal integration to an emphasis on vertical integration; (2) from acute care and institution-centered models of integration to a broader focus on community-based health and social services; (3) from economic arguments for integration to an emphasis on improving quality of care and creating value; (4) from evaluations of integration using an organizational perspective to an emerging interest in patient-centered measures; (5) from a focus on modifying organizational and environmental structures to an emphasis on changing ways of working and influencing underlying cultural attitudes and norms; and (6) from integration for all patients within defined regions to a strategic focus on integrating care for specific populations. We propose that underlying many of these shifts is a growing recognition of the value of understanding health care delivery and integration as processes situated in Complex-Adaptive Systems (CAS). ORIGINALITY/VALUE: This review builds a descriptive framework against which to assess, compare, and track integration strategies over time.

LEE, K. H., LOW, L. L., ALLEN, J., BARBIER, S., NG, L. B., NG, M. J. M., … TAN, S. Y. (2015). TRANSITIONAL CARE FOR THE HIGHEST RISK PATIENTS: FINDINGS OF A RANDOMISED CONTROL STUDY. INTERNATIONAL JOURNAL OF INTEGRATED CARE, 15. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4843175/ 
Background: Interventions to prevent readmissions of patients at highest risk have not been rigorously evaluated. We conducted a randomised controlled trial to determine if a post-discharge transitional care programme can reduce readmissions of such patients in Singapore.  Methods: We randomised 840 patients with two or more unscheduled readmissions in the prior 90 days and Length of stay, Acuity of admission, Comorbidity of patient, Emergency department utilisation score ≥10 to the intervention programme (n = 419) or control (n = 421). Patients allocated to the intervention group received post-discharge surveillance by a multidisciplinary integrated care team and early review in the clinic. The primary outcome was the proportion of patients with at least one unscheduled readmission within 30 days after discharge.  Results: We found no statistically significant reduction in readmissions or emergency department visits in patients on the intervention group compared to usual care. However, patients in the intervention group reported greater patient satisfaction (p < 0.001).  Conclusion: Any beneficial effect of interventions initiated after discharge is small for high-risk patients with multiple comorbidity and complex care needs. Future transitional care interventions should focus on providing the entire cycle of care for such patients starting from time of admission to final transition to the primary care setting.  Trial Registration: Clinicaltrials.gov, no NCT02325752

LILLY, M. B., ROBINSON, C. A., HOLTZMAN, S., & BOTTORFF, J. L. (2012). CAN WE MOVE BEYOND BURDEN AND BURNOUT TO SUPPORT THE HEALTH AND WELLNESS OF FAMILY CAREGIVERS TO PERSONS WITH DEMENTIA? EVIDENCE FROM BRITISH COLUMBIA, CANADA. HEALTH & SOCIAL CARE IN THE COMMUNITY, 20(1), 103–112. http://doi.org/10.1111/j.1365-2524.2011.01025.x 
After more than a decade of concerted effort by policy-makers in Canada and elsewhere to encourage older adults to age at home, there is recognition that the ageing-in-place movement has had unintended negative consequences for family members who care for seniors. This paper outlines findings of a qualitative descriptive study to investigate the health and wellness and support needs of family caregivers to persons with dementia in the Canadian policy environment. Focus groups were conducted in 2010 with 23 caregivers and the health professionals who support them in three communities in the Southern Interior of British Columbia. Thematic analysis guided by the constant comparison technique revealed two overarching themes: (1) forgotten: abandoned to care alone and indefinitely captures the perceived consequences of caregivers’ failed efforts to receive recognition and adequate services to support their care-giving and (2) unrealistic expectations for caregiver self-care relates to the burden of expectations for caregivers to look after themselves. Although understanding about the concepts of caregiver burden and burnout is now quite developed, the broader sociopolitical context giving rise to these negative consequences for caregivers to individuals with dementia has not improved. If anything, the Canadian homecare policy environment has placed caregivers in more desperate circumstances. A fundamental re-orientation towards caregivers and caregiver supports is necessary, beginning with viewing caregivers as a critical health human resource in a system that depends on their contributions in order to function. This re-orientation can create a space for providing caregivers with preventive supports, rather than resorting to costly patient care for caregivers who have reached the point of burnout and care recipients who have been institutionalised.

LIM, A. Y., TAN, C. S., LOW, B. P., LAU, T. C., TAN, T. L., GOH, L. G., & TENG, G. G. (2015). INTEGRATING RHEUMATOLOGY CARE IN THE COMMUNITY: CAN SHARED CARE WORK? INTERNATIONAL JOURNAL OF INTEGRATED CARE, 15. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4548709/ 
Introduction: Singapore’s rapidly ageing population and chronic disease burden at public hospital specialist clinics herald a silver tsunami. In Singapore, ‘right siting’ aims to manage stable chronic disease in primary care at a lower cost. To improve the quality of rheumatology care, we created shared care between rheumatologist and family physician to reduce hospital visits. Methods: Clinical practice improvement methodology was used to structure shared care of stable patients between hospital rheumatologists and eleven community family physicians; one ran a hospital clinic. A case manager coordinated the workflow.  Results: About 220 patients entered shared care over 29 months. Patients without hospital subsidies (private patients) and private family physicians independently predicted successful shared care, defined as one cycle of alternating care. Discussion: Our shared care model incorporated a case manager, systematic workflows, patient selection criteria, willing family physician partners and rheumatologists in the absence of organizational integration. Health care affordability impacts successful shared care. Government subsidy hindered right siting to private primary care.  Conclusions: Financing systems in Singapore, at health policy level, must allow transfer of hospital subsidies to primary care, both private and public, to make it more affordable than hospital care. Structural integration will create a seamless continuum between hospital and primary care.

LIU, C., EOM, K., MATCHAR, D. B., CHONG, W. F., & CHAN, A. W. M. (2016). COMMUNITY-BASED LONG-TERM CARE SERVICES IF WE BUILD IT, WILL THEY COME? JOURNAL OF AGING AND HEALTH, 28(2), 307–323. http://doi.org/10.1177/0898264315590229 
Objective: This study examines the relationship between caregivers’ perception of community-based long-term care (CBLTC) services and the service use. Method: We used first two waves of the longitudinal data set of 1,416 dyads of care recipients and their caregivers in Singapore. Four perceived attributes of LTC services—service quality, convenience, social connectedness, and affordability—were measured on a 5-point scale. Results: Among the four perceived attributes, perceived affordability was significantly associated with future utilization for all types of CBLTC services. Perceived service quality and convenience was significantly associated with center-based LTC services use. Discussion: Caregivers are critically involved in the decision of using CBLTC services, and their perception of service characteristics is significantly associated with the uptake of CBLTC services. It is important to incorporate both care recipients’ and caregivers’ needs and preferences when designing and promoting integrated health care delivery models.

LIU, G., YAP, P., WONG, G. H. Z., XIAO WEI, H., & CHYE HUA, E. (2015). DAY CARE CENTERS FOR SENIORS IN SINGAPORE: LOOKING BACK AND LOOKING AHEAD. JOURNAL OF THE AMERICAN MEDICAL DIRECTORS ASSOCIATION, 16(7), 630.e7–630.e11. http://doi.org/10.1016/j.jamda.2015.04.004 
The burden of care for frail elderly persons on families and the society is ever real as our population ages. Given the dual-income nature of many working families, day care centers offer a strong alternative to nursing homes for families wishing to provide custodial care and meaningful engagement for seniors while continuing to uphold their filial duties. Recognizing this, several initiatives, such as SPICE (Singapore Programme for Integrated Care for the Elderly) and Weekend Respite Care, have been launched to enhance the services of Singapore’s day care centers. This article traces the evolution of this process, distills current challenges, and offers policy recommendations to improve Singapore’s day care services for seniors.

LOW, L. L., VASANWALA, F. F., NG, L. B., CHEN, C., LEE, K. H., & TAN, S. Y. (2015). EFFECTIVENESS OF A TRANSITIONAL HOME CARE PROGRAM IN REDUCING ACUTE HOSPITAL UTILIZATION: A QUASI-EXPERIMENTAL STUDY. BMC HEALTH SERVICES RESEARCH, 15, 100. http://doi.org/10.1186/s12913-015-0750-2 
Improving healthcare utilization is essential as health systems around the world grapple with the escalating demands for acute hospital resources. Evidence suggests that transitional care programs are effective to improve utilization of healthcare. However, the evidence for transitional care programs that enhance the home medical care model and provide multi-disciplinary patient-centered care is not well established. We evaluated if a transitional home care program operated by the Singapore General Hospital was effective in reducing acute hospital utilization.

LOW, S. G., NG, L. C. L., TAN, J. S. W., & VASANWALA, F. F. (2015). HOW TO CARE FOR HOMEBOUND PATIENTS? PROCEEDINGS OF SINGAPORE HEALTHCARE, 2010105815619433. http://doi.org/10.1177/2010105815619433 
As a result of an ageing population, low birth rates and longer life expectancies in developed countries, there is an increasing worldwide prevalence of patients with functional decline, dependence and impairment of activities of daily living. The medical follow-up of these functionally dependent patients poses a challenge, especially in the traditional outpatient settings where transport of these patients to a clinic is required. Delivering care for these dependent patients in their own homes remains one of the better ways of providing optimal care for them. We describe two cases, one identified from the community and the other from a hospital setting, which necessitated the activation of home care for continued management of these patients. This article discusses how our current community and hospital home care resources can be used to care for homebound patients, and how we can overcome current limitations in delivery of home care in our healthcare system.

MALHOTRA, C., CHAN, A., DO, Y. K., MALHOTRA, R., & GOH, C. (2012). GOOD END-OF-LIFE CARE: PERSPECTIVES OF MIDDLE-AGED AND OLDER SINGAPOREANS. JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, 44(2), 252–263. http://doi.org/10.1016/j.jpainsymman.2011.09.007 
Context: Understanding preferences for end-of-life care is important for planning and improving services that provide such care. However, little is known about the perspective of Singaporeans regarding good end-of-life care. Objectives: To identify the key components of good end-of-life care as perceived by middle-aged and older Singaporeans (≥50 years). Methods: Nine focus groups were conducted with a total of 63 participants. Preferences regarding end-of-life care were discussed. Thematic analysis was conducted on the transcribed results of the focus groups. Results: Eight components of good end-of-life care were identified: 1) have physical comfort at the end of life, 2) avoid inappropriate prolongation of the dying process, 3) maintain sensitivity toward religious and spiritual beliefs, 4) avoid burden on the family, 5) avoid expensive care, 6) be cared for by a trustworthy doctor, 7) maintain control over care decisions, and 8) achieve a sense of completion. Conclusion Eight components of good end-of-life care involving the person, family, and health services were identified among middle-aged and older Singaporeans. A focus on better management of pain, training of caregivers and doctors, shared decision making, and availability of affordable care may improve care at the end of life.

NG, G. T. (2009). SUPPORT FOR FAMILY CAREGIVERS: WHAT DO SERVICE PROVIDERS SAY ABOUT ACCESSIBILITY, AVAILABILITY AND AFFORDABILITY OF SERVICES? HEALTH & SOCIAL CARE IN THE COMMUNITY, 17(6), 590–598. http://doi.org/10.1111/j.1365-2524.2009.00858.x 
This paper reports on a survey of providers of caregiver support services in Singapore (N = 36). The overall aim of the survey was to provide feedback to service planners and programme staff on the delivery of services to caregivers and opportunities for improvement. A questionnaire, comprising both closed and open-ended questions, was used to collect data. The results showed that most health and social service providers offer counselling, case management, caregiver assessment, financial assistance and information. A minority provide emergency, short-stay respite care and day care. About one in three provide transportation services, which featured as a barrier to service utilisation. Other barriers identified were time commitments, lack of awareness of services, cost of care, caregivers’ sense of responsibility, lack of alternate care arrangements and distrust. The survey also characterises the hard-to-reach caregivers as homebound, illiterate, socially shy and isolated, of low income and poorly educated. Most service providers emphasise that financial support is necessary in order to improve the prospects of family caregivers.

ØSTBYE, T., MALHOTRA, R., MALHOTRA, C., ARAMBEPOLA, C., & CHAN, A. (2013). DOES SUPPORT FROM FOREIGN DOMESTIC WORKERS DECREASE THE NEGATIVE IMPACT OF INFORMAL CAREGIVING? RESULTS FROM SINGAPORE SURVEY ON INFORMAL CAREGIVING. THE JOURNALS OF GERONTOLOGY SERIES B: PSYCHOLOGICAL SCIENCES AND SOCIAL SCIENCES, 68(4), 609–621. http://doi.org/10.1093/geronb/gbt042 
Objectives: To assess the instrumental support from a foreign domestic worker (FDW) as a moderator of the association of 4 types of impairments (physical function, memory, behavior, and mood) among older persons (OPs) with caregiving-related outcomes among their informal caregivers (CGs). Method: Data from a national survey of 1,190 Singaporeans aged 75 and older receiving human assistance for functional limitations and their CGs were used. Severity scores for the four OP impairments were calculated. A modified version of the Caregiver Reaction Assessment (CRA) assessed the impact of caregiving in four domains: disturbed schedule and poor health, lack of finances, lack of family support, and CG esteem. Linear regression models, one for each CRA domain, with interaction terms of the four impairment severity scores with FDW support, were developed. Results: FDW instrumental support, reported for 50% of the OPs, moderated the direct association of OP physical impairment with disturbed schedule and poor health (p = .009), OP memory impairment with disturbed schedule and poor health (p < .0001) and lack of finances (p = .02), and OP behavior impairment with lack of family support (p = .001). Although such support buffered the inverse association of OP behavior impairment with CG esteem (p = .01), it also buffered the positive association of OP mood impairment with CG esteem (p = .02). Discussion: FDW support is associated with better caregiving outcomes. Given its aging population, the number of FDWs in Singapore is likely to increase as families try to cope with caregiving for their older members. This has policy implications for (a) immigration patterns into Singapore and (b) training of and support networks for FDWs.

PENKUNAS, M. J., CHAN, A. W. M., WONG, C. H., KORNE, D. F. DE, TAN, S. M., & WONG, S. F. (2016). THE ROLE OF A MULTICOMPONENT HOME-HEALTH INTERVENTION IN REDUCING CAREGIVER STRESS IN SINGAPORE: A QUALITATIVE STUDY. THE JOURNALS OF GERONTOLOGY SERIES B: PSYCHOLOGICAL SCIENCES AND SOCIAL SCIENCES, gbw008. http://doi.org/10.1093/geronb/gbw008
Purpose: The relationship between caregiving and negative health outcomes is well established in the literature. Previous studies have shown that community-based programs reduce caregiver stress. However, the mechanisms by which this happens have not been well investigated. This qualitative study examines caregivers’ experiences as a part of the Aging-In-Place intervention, a home-health program in Singapore targeted at frequently hospitalized patients and their caregivers. Method: We interviewed 32 caregivers to study the underlying processes by which caregiver stress was ameliorated. Transcripts from semistructured interviews were analyzed thematically within the theoretical framework of the stress process model. Results: Primary stressors related to routine patient care were reduced through the intervention program that provided health monitoring to patients and facilitated linkages to community-based services. Increased access to advice and medical information provided by intervention staff reduced caregivers’ uncertainty, a substantial secondary stressor. Caregivers who employed a foreign domestic worker (FDW) gained additional reductions in both primary and secondary stressors. Discussion: The multidimensional home-health intervention reduced both primary and secondary stressors for caregivers. FDWs constituted a resource that caregivers could rely on and the training provided to FDWs by intervention staff further reduced caregiver stress. Implications for program planning and future research are discussed.

TAN, N. C. (2014). PAIR UP FOR PRIMARY CARE EXCELLENCE: PERSPECTIVES FROM A PRIMARY HEALTHCARE PROVIDER IN SINGAPORE. SINGAPORE MEDICAL JOURNAL, 55(3), 110–116. http://doi.org/10.11622/smedj.2014030 
Singapore is facing an increasing non-communicable disease burden due to its ageing population. Singapore’s primary healthcare services, provided by both polyclinic physicians and private general practitioners, are available to the public at differential fees for service. The resultant disproportionate patient loads lead to dissatisfaction for both healthcare providers and consumers. This article describes the ‘PAIR UP’ approach as a potential endeavour to facilitate primary care physicians (PCPs) in public and private sectors to collaborate to deliver enhanced primary care in Singapore. PAIR UP is an acronym referring to Policy, Academic development, Integration of healthcare information system, Research in primary care, Utility and safety evaluation, and Practice transformation. The current healthcare landscape is favourable to test out this multipronged approach. PCPs in both sectors can ride on it and work together synergistically to provide quality primary care in Singapore.

VENKETASUBRAMANIAN, N., ANG, Y. H., CHAN, B. P., CHAN, P., HENG, B. H., KONG, K. H., … CHEAH, J. (2008). BRIDGING THE GAP BETWEEN PRIMARY AND SPECIALIST CARE--AN INTEGRATIVE MODEL FOR STROKE. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE, 37(2), 118–127.
Stroke is a major cause of death and disability in Singapore and many parts of the world. Chronic disease management programmes allow seamless care provision across a spectrum of healthcare facilities and allow appropriate services to be brought to the stroke patient and the family. Randomised controlled trials have provided evidence for efficacious interventions. After the management of acute stroke in a stroke unit, most stable stroke patients can be sent to their family physician for continued treatment and rehabilitation supervision. Disabled stroke survivors may need added home-based services. Suitable community resources will need to be harnessed. Clinic-based stroke nurses may enhance service provision and coordination. Close collaboration between the specialist and family physician would be needed to right-site patients and also allow referrals in either direction where necessary. Barriers to integration can be surmounted by trust and improved communication. Audits would allow monitoring of care provision and quality care enhancement. The Wagner model of chronic care delivery involves self-management support, shared clinical information systems, delivery system redesign, decision support, healthcare organisation and community resources. The key and critical feature is the need for an informed, activated (or motivated) patient, working in collaboration with the specialist and family physician, and a team of nursing and allied healthcare professionals across the continuum of care. The 3-year Integrating Services and Interventions for Stroke (ISIS) project funded by the Ministry of Health will test such an integrative system.

WEE, S.-L., LIU, C., GOH, S.-N., CHONG, W. F., ARAVINDHAN, A., & CHAN, A. (2014). DETERMINANTS OF USE OF COMMUNITY-BASED LONG-TERM CARE SERVICES. JOURNAL OF THE AMERICAN GERIATRICS SOCIETY, 62(9), 1801–1803. http://doi.org/10.1111/jgs.13003

WEE, S.-L., LOKE, C.-K., LIANG, C., GANESAN, G., WONG, L.-M., & CHEAH, J. (2014). EFFECTIVENESS OF A NATIONAL TRANSITIONAL CARE PROGRAM IN REDUCING ACUTE CARE USE. JOURNAL OF THE AMERICAN GERIATRICS SOCIETY, 62(4), 747–753. http://doi.org/10.1111/jgs.12750 
This study evaluated the effectiveness of a national transitional care program for elderly adults with complex care needs and limited social support. The Aged Care Transition (ACTION) Program was designed to improve coordination and continuity of care and reduce rehospitalizations and visits to emergency departments (EDs). Dedicated care coordinators provided coaching to help individuals and families understand the individuals’ conditions, effectively articulate their preferences, and enable self-management and care planning. Participants were individuals aged 65 and older hospitalized and enrolled from five public general hospitals in Singapore between February 2009 and July 2010 (N = 4,132). The coordinators worked with participants during hospitalization and followed up with telephone calls and home visits for 1 to 2 months after discharge and coordinated placements with appropriate community service providers. Unplanned rehospitalization and ED visit (up to 6 months after discharge) rates were compared with those of a comparator group of individuals who did not receive care coordination using propensity score-based weighting. Participant and caregiver surveys on quality of life and self-rated health were also administered. Recipients of the ACTION program had fewer unplanned rehospitalizations and ED visits after discharge. Propensity score–adjusted odds ratios of participants versus control for number of unplanned rehospitalization and ED visits were 0.5 (95% confidence interval (CI) = 0.5–0.6) and 0.81 (95% CI = 0.72–0.90) 30 days after discharge and 0.6 (95% CI = 0.6–0.7) and 0.90 (95% CI = 0.82–0.99) 180 days after discharge. Quality of life and self-rated health were better 4 to 6 weeks after discharge than 1 week after discharge. These findings confirm the effectiveness of the ACTION program in improving the transition of vulnerable older adults from hospital to community. Such transitional care should be considered as an integral part of care integration.

YEOH, B. S. A., & HUANG, S. (2009). FOREIGN DOMESTIC WORKERS AND HOME-BASED CARE FOR ELDERS IN SINGAPORE. JOURNAL OF AGING & SOCIAL POLICY, 22(1), 69–88. http://doi.org/10.1080/08959420903385635

As with other developed nations where rapid population aging has led to increasing health care and social care burdens, Singapore has searched for ways of paying for and providing long-term care for its increasing numbers of elders. The Singapore state, faced with the prospect of one-fifth of the population aged 65 or older by 2030, has reinforced its basic principle of rendering the family the ‘primary caregiving unit’ and home-based care as the highly preferred option for eldercare. Our paper demonstrates why, despite the range of alternative care arrangements available or emerging on Singapore’s eldercare landscape, the employment of live-in foreign domestic workers as care workers for the elderly has become one of the more common de facto modes of providing care for the elderly. In this context, we discuss the politics of eldercare in the privatized sphere of homespace and conclude with policy implications relating to the employment of foreign domestic workers as caregivers for the elderly.