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Study makes 19 recommendations to help more people age well in the community

SINGAPORE — With more Singaporeans ageing at home and in the community instead of nursing homes, more should be done to grow and regulate community-based eldercare, the Lien Foundation said on Tuesday (Aug 14).

SINGAPORE — With more Singaporeans ageing at home and in the community instead of nursing homes, more should be done to grow and regulate community-based eldercare, the Lien Foundation said on Tuesday (Aug 14).

Among 19 recommendations made in a new in-depth study commissioned by the philanthropic foundation: More public spending in community and home care to ease the cost burden on users and providers, improving respite care options, greater availability of data and a stronger regulatory framework for providers.

Around 14,000 people used subsidised home and centre-based services in late 2017, up from 12,000 a year earlier, according to the Ministry of Health (MOH)'s figures. The number of subsidised nursing home residents, meanwhile, has remained stable at around 10,000.

More than half a million Singapore residents last year were aged 65 and above, and the number of senior citizens will grow to 960,000 by 2030.

The study, titled Care Where You Are, was authored by Associate Professors Elaine Ho and Shirlena Huang from the National University of Singapore's department of geography. They conducted focus group discussions and interviews with a total of 103 individuals.

The insights of caregivers and care providers "tell us that while much is going right in Singapore, everyone with a stake in eldercare needs to do more, now", the authors wrote.

"The number of elderly is going up every year. If services are available but the elderly do not use them, we have to ask why. If families decline or cut short home nursing visits because they worry about costs, we have to ask what do we do about that? If available financial schemes drive the elderly to hospitals instead of care services because Medisave allows them to pay hospital bills but not eldercare bills, we have reason to ponder…And if community and home care will become increasingly integral to an ageing Singapore, we have to ask if this sector needs more holistic governance."

Despite the focus on helping seniors to age in place, only 2.5 per cent of the MOH's overall healthcare budget — or S$240 million — was spent on home and centre-based care in Financial Year 2016, the study stated.

While more private providers have been entering the scene, only two of about 55 of such home care providers are subject to Government regulations because they receive Government subventions.

The Government aims to have 17,000 nursing home beds, 10,000 home care places and 6,200 day-care places by 2020.

However, the study found that costs of community care are generally higher than nursing home costs, before subsidies.

The unsubsidised monthly cost of looking after a severely disabled senior at home can go up to S$3,100, while the full cost of using day care and transportation to the centres can go up to nearly S$2,500 a month. Meanwhile, the median monthly unsubsidised cost of a nursing home place is about S$2,400.

As a result, families who require home and centre-based care may forgo it because co-payment amounts are too high. Lower-income families still need to fork out 20 per cent after means-tested subsidies, while lower middle-income households have to co-pay 40 to 50 per cent for long-term care services.

Capacity may also still be falling short of need. The Agency for Integrated Care received 7,800 referrals for day care services in 2015 when only 3,500 day care places were available. The number of places increased to 5,000 last year.

The lack of governance for private home and centre-based care could jeopardise the quality of home care workers, said the study.

Unlike nursing homes and childcare centres, home and centre-based care is not licensed in Singapore.

While the MOH introduced guidelines for home and centre-based care providers in 2015, the guidelines are not mandatory. Most providers that do not receive subventions mostly set and monitor their own standards, such as training and accrediting their workers.

In response to the study, the MOH said it has already been "exploring the capacity and accessibility of aged care services, in particular home and community care services".

The ministry is reviewing the need for more formal regulation of the sector under the upcoming Healthcare Services Act, which will replace the Private Hospitals and Medical Clinics Act.

"We will take a risk-based approach (i.e. higher level of regulation for areas with higher risks) in this review, so that the provision of safe and good quality service does not add excessively to regulatory costs for providers, and consequently raise the cost of care for seniors," the ministry said.

It added that over the last decade, the Government has increased total spending in the primary, intermediate and long-term care sectors by almost four times — from S$1.3 billion in FY2007 to FY2011, to S$5.1 billion in FY2012 to FY2016.

On respite care, the study said Singapore needs expanded overnight respite care options as well as on-demand services for those who require respite at short notice.

Caregivers are currently not able to pay for such care support through Medisave and have to apply for the service days in advance, the study noted.

The MOH said in response that respite options include weekend care at 11 eldercare centres and longer-term or overnight care (from several days to a month) at over 40 voluntary welfare organisation-run and private nursing homes.

For eligible seniors who use respite care at eldercare centres, subsidies of up to 80 per cent are available, as well as help from MediFund where applicable. "We acknowledge that more can still be done to support caregivers. We are working to expand respite options, strengthen access to social and emotional support for caregivers, and enable better access to information and referral services in the community," the spokesperson said.

Higher CareShield Life premiums for women 'goes against the inclusive ethos of social insurance'

Even with higher and lifelong payouts for severely disabled individuals under the CareShield Life insurance scheme, many Singaporeans may be under-insured for long-term care, said the authors of a study released on Tuesday on ageing well in the community.

While CareShield Life – which will replace the current ElderShield severe disability insurance scheme in 2020 – is a welcome first step, concerns have been raised over its strict eligibility criteria, relatively low payouts and the fact that women need to pay higher premiums.

CareShield Life's criteria to qualify for benefits exclude those who need financial help before they are unable to perform at least three activities of daily living, said the study's authors, Associate Professors Elaine Ho and Shirlena Huang of the National University of Singapore.

A graduated payout rate, depending on the number of activities of daily living one is unable to perform, would benefit older Singaporeans with different degrees of disability, they said. The six activities of daily living are eating, bathing, dressing, transferring (from a chair to bed, for instance), going to the toilet, and walking or moving around.

Women generally have higher life expectancy and greater risk of disability. But the authors noted that women traditionally earn less, and getting them to pay higher CareShield Life premiums "goes against the inclusive ethos of social insurance".

Despite premium subsidies offered by the Government, older women in particular may choose to opt out of the scheme. "It is worth relooking premium parity, especially since women usually shoulder the bulk of unpaid caregiving work," the authors said.

The differences in premiums for both genders has generated much debate in recent weeks, with a public petition launched and several Members of Parliament raising the issue in Parliament.

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