A Brief Review Text by A/Prof Pang Weng Sun
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Health Services FEATURE for the Elderly: A Brief Review Text by A/Prof Pang Weng Sun How geriatrics started located in polyclinics distributed all rehabilitation beds. These were mostly over Singapore, with the exceptions of run by voluntary welfare organisations In 1984, the Ministry of Health’s (MOH) Kampong Ubi SCHCC and Ang Mo Kio (VWOs) supported through government Report of the Committee on the Problems SCHCC, which were located at a void funding. MOH also built and ran Ang of the Aged highlighted the issues of an deck and in Ang Mo Kio Community Mo Kio Community Hospital for a ageing population in Singapore. Dr FJ Hospital, respectively. The Department period of time before handing over to a Jayaratnam, then Head of Medical Unit I, of Health Service for the Elderly (HSE) VWO group. Tan Tock Seng Hospital (TTSH), was provided oversight of these SCHCCs tasked with setting up geriatric services. Additionally, MOH also saw the need then. Minibuses and ambulances He visited geriatric services in the UK to redevelop nursing homes. In the retrofitted with spaces for wheelchairs old days, “nursing homes” were largely and linked up with the British Geriatrics ferried elderly to these centres for Society to have local trainees sent to old folks’ homes set up by charitable rehabilitation. Wheelchair-bound organisations to look after the elderly UK for specialist training. Since 1988, elderly living in HDB flats that were internal medicine trainees were sent who had no families caring for them. not on floors with lift landings were Volunteer doctors provided medical care to geriatric medicine departments ferried down staircases with the help of in Glasgow, Edinburgh, Cardiff, while most homes did not have much motorised devices with caterpillar tracks nursing expertise. Residents who turned Newcastle, Southampton, London, (“stair crawls”). In 1994, AH also started a and subsequently to Australia, the US ill were promptly sent to hospitals. MOH Geriatric Day Hospital, catering to those saw the need to increase funding and and Hong Kong for training. Geriatric who had unresolved medical problems medicine departments were set up in improve nursing capabilities in these in addition to their rehabilitation needs. homes. A Resident Assessment Form TTSH (1987), Alexandra Hospital (AH; This was part of the larger Alexandra 1994) and New Changi Hospital (NCH; (RAF), modelled after the Australian Geriatric Centre that comprised geriatric Resident Classification Index, was 1998; later renamed Changi General medicine clinics, day rehabilitation, Hospital [CGH]). created to allow documentation of and an Independent Living Centre functional capabilities of the residents displaying and selling mobility aids Care for the community (ie, whether they needed assistance with and other appliances. The SCHCCs feeding, dressing, bathing, walking and MOH recognised the need to go beyond also started continence clinics for supervision of medications). The RAF hospitals and set up community the assessment and management of could then be used to classify residents services for the elderly. Thus, the Home elderly with urinary incontinence in by care needs (scores were based on Nursing Foundation, which had been the community. These were run by time-motion studies of how much providing community nursing since nurses trained in continence care and nursing time was required) and funding 1976, started setting up Senior Citizens’ supported by geriatricians. norms were adjusted so that those with Health Care Centres (SCHCCs) to provide As acute care hospitals had limited higher care needs were allocated higher day rehabilitation for the elderly with capacity for rehabilitation, community funding. MOH also set requirements for mobility problems. Most of these were hospitals were built to provide inpatient nursing norms for various categories. apr 2017 SMA News 05 There remained a group requiring heavy nursing care, such as patients with tracheostomies, and thus a Chronic Sick Unit was set up in the grounds of the old Woodbridge Hospital. This was eventually handed over to a VWO as well. The late 1980s and early 1990s also saw the development of hospice care. St Joseph’s Home had set up hospice beds, and a voluntary group started home care services initially under Singapore Cancer Society, which subsequently grew into the larger HCA Hospice Care. More hospice beds were added with the setting up of the Assisi Home and Hospice (currently Assisi Hospice) and Dover Park Hospice. The concept of home care also department with AH in the West, TTSH in extended to geriatrics and Tsao Going forward the Central and NCH in the East (picture Foundation started the Hua Mei Mobile Geriatric care will continue to evolve. above). Around that time, the Ministry Clinic, a home care service providing The elderly will need a spectrum of Community Development, Youth and support to the elderly in their own of care, including the promotion of Sports had also set up three community homes. Other home care services also healthy ageing; early diagnosis and care networks to coordinate social evolved, including TOUCH Home Care management of chronic disease services. Many of the VWOs involved in and Care for the Elderly Foundation and age-related disorders; prompt both health and social services found (Singapore)’s CODE 4 Home Care management of complex and crisis themselves caught up with meetings programmes. care; rehabilitation and supportive on both sides. An Inter-Ministerial care to maintain independence in the Committee (IMC) was formed and the community; advance care planning; Progress in the IMC Report on The Ageing Population and end-of-life care in the final stages healthcare landscape was published in 1999, highlighting of their journey. Services in each cluster By the mid-1990s, there were geriatric the challenges faced by the ageing must address these needs in a timely medicine departments; community population and made recommendations and cost-effective manner. Central to hospitals; SCHCCs that provide day across ministries. service provision is the engagement of rehabilitation, home medical and home In 2000, MOH restructured healthcare the older person and his or her family, nursing; nursing homes; hospices; services into two clusters – National to truly allow older people to live and and a chronic sick unit. HSE by then Healthcare Group (NHG) and Singapore leave well. had evolved into the Department of Health Services (SingHealth) – and much Continuing Care in MOH. Attention was of the efforts then focused on improving paid to funding support and elevating healthcare delivery in hospitals and standards of care. In conjunction with A/Prof Pang Weng Sun primary care. Community services, is currently Chairman, service development, MOH continued largely ran by VWOs, then had to work Medical Board, Yishun with the training of geriatricians and with various hospitals and healthcare Community Hospital. gerontology-trained nurses, and set institutions. This became a greater He has been working in geriatric services since up polytechnic programmes to train challenge when it evolved to six clusters physiotherapists and occupational training in geriatrics (ie, NHG, SingHealth, National University in 1989. He is also therapists. Diploma courses were the Health System [NUHS], Eastern Health Vice-Dean, Clinical priority then, so that more therapists Alliance, Alexandra Health System and Affairs, with the Lee could be trained in a shorter time to Jurong Health System). Agency for Kong Chian School of Medicine. meet rehabilitation needs. Integrated Care was then set up in 2009 As more organisations flourished, as a national care integrator to assist coordination of services became clusters’ work with the VWO setting more difficult. MOH decided to divide in the delivery of care. In 2017, MOH Singapore into three zones and set up announced the reorganisation into three three Coordinating Committees for clusters (ie, NHG, NUHS and SingHealth). Geriatric Care (CCGC). Thus, CCGC-West, From the perspective of elderly care, CCGC-Central and CCGC-East were this reduces complexity and allows for assigned to the three geographical better co-integration with community zones. Geriatric care in each zone was services, not unlike the earlier plans in supported by a geriatric medicine the mid-90s. 06 apr 2017 SMA News.