Sunday, July 24, 2016

Singapore - Number of seniors with complex care needs set to rise in Singapore: AIC

SINGAPORE: About 100 seniors have benefitted from a house visit programme initiated by the Agency for Integrated Care (AIC).

With support from several community organisations, the pilot that started in 2015 has teams of healthcare professionals visiting seniors with multiple chronic conditions regularly at their homes to monitor their health and social well-being.

It enables seniors to manage their conditions better and reduce unnecessary hospital admissions.

A senior who has benefitted from the programme is Mdm Tay. She is diabetic and has various health conditions, including bilateral visual impairment and a weak heart. Her heart is unable to pump blood efficiently and this leads to fluid build-up in her limbs. Mdm Tay also underwent surgery in May to amputate the toes on her left foot.

Since February this year, a team from Ang Mo Kio Family Service Centre visits Mdm Tay at her flat each week.

The team, comprising a case manager and a support staff, monitors her hospital appointments, and ensures that she is able to manage on her own daily.

"Back then, I often took the wrong medication because I can't see clearly,” said Mdm Tay. “As a result, I was constantly going in and out of the hospital. I was very frustrated. I wanted to give up on my medication and thought it was better to just die."

Mdm Tay said the team motivates her to want to get better. Today, she takes her medication on time and visits the hospital only for regular check-ups.

Ms Jocelyn Toh, case manager at COMNET Senior Services at AMKFSC Community Services, said: "There are opportunities to think of simple ways to help her resolve this problem. I label the pill boxes, so for example, the ones without any indication will be the morning dose and the ones with the rubber band is the afternoon dose. Different indications help her differentiate the different dosages so she will take her medication correctly."

For frail seniors like Mdm Tay, who have complex medical conditions and receive little to no help from their families, case managers are a form of social support. They also act as a bridge to relevant agencies should they require other forms of assistance.

"They are unsure of the community resources they can utilise to help them so what we do is to come in and help them navigate around the system so they are linked to the services they require, Ms Toh added.

The aim of this programme is to empower seniors to live independently. According to AIC, the number of seniors with complex care needs is set to rise as Singapore's population ages. Thus, there is a need to hire more case managers.

Mr Ng Koon Sing, head of COMNET Senior Services at AMKFSC Community Services, said: "Different sectors are competing for case managers, be it the youth sector, the family service sector, so there's this challenge of shortage of manpower where everybody is competing from the same pool."

Case managers typically have some form of medical background, and this makes the pool even smaller.

Ms Lee Ngok Lin, President of Case Management Society Singapore, said: "Most of the case managers are healthcare professionals. With their healthcare knowledge and understanding of the healthcare system, it would be easier for them to apply their knowledge and help the patient more efficiently."

It is hard to determine how many case managers there are in Singapore, as they serve various segments of the healthcare industry from hospitals to voluntary welfare organisations. Her society has about 200 members, a number that has held steady in recent years, despite Singapore's ageing population.

Ms Lee, who also heads the case management team at Khoo Teck Puat Hospital, added: "Case management is relatively young in Singapore, so maybe a lot of people are not aware of case management and what we do.

“With the ageing population, I can foresee that we will need more case managers, because the elderly will be more frail as they grow older and have more chronic conditions. So, they need closer support in the community.”

The programme is a two-year pilot that began in 2015. AIC is working with the Health Ministry to evaluate its effectiveness in keeping seniors within the community, before it decides on whether to expand the programme.

- CNA/xk

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