The Big Read: With more seniors needing care, is assisted living the answer for S'pore's 'missing middle' and their caregivers?

Experts interviewed by TODAY said that the issue of caregiving options has become even more pronounced in light of
Singapore's rapidly ageing population. Ili Nadhirah Mansor/TODAY

• With Singapore society ageing rapidly, one particular eldercare option has sprung up in recent years — community or assisted living to help seniors with basic daily activities 
• It is touted as a possible solution for the “missing middle” — seniors who cannot live independently but are not too ill to be cared for in nursing homes
• But experts, industry players and caregivers pointed to various factors on why assisted living services has not taken off faster, including costs, regulatory ambiguities and manpower shortages
• At the same time, there are different challenges in expanding other caregiving services such as foreign domestic helpers and day care centres 
• Experts believe that the right way forward is a shift in approach from reactive to preventive measures in eldercare, and more sustainable public-private partnerships

BY RENALD LOH

BY NAVENE ELANGOVAN

July 1, 2023


SINGAPORE — The last domestic helper who cared for Mr Christopher Tan’s wheelchair-bound 76-year-old mother packed her bags and took off without a word in the early hours one day in 2021, leaving her all alone in a small apartment.

“(My mum) needs help to go to the toilet, to shower (and) to change,” said the 51-year-old accountant, who told TODAY that it was fortunate that “nothing bad happened” following the helper’s sudden departure.

She was the fifth helper whom Mr Tan had hired over the course of two years, but none had worked out or managed to get along with his mother for one reason or another.

As Mr Tan and his sister both live with their own families, they began to look for other care options for their mother after the incident.

For caregivers like Mr Tan, searching for the right care arrangement for their elderly parents can be a long and stressful process, especially when their needs fall in the middle of being able to live independently and having to be constantly looked after in a nursing home.

“I think the gap exists when you’re somewhere in between — you’re not that healthy, but you’re not that sick, and you’re still well enough to be in the community,” he said.

Experts such as Ms Chia Hui Xiang from the Saw Swee Hock School of Public Health at the National University of Singapore (NUS) calls this group of seniors the “missing middle” — people who face difficulties in one to three activities of daily living and do not have enough family support, but are not so severely disabled that they require a nursing home.

These activities of daily living refer to bathing, feeding, dressing, toileting, transferring and mobility — the ability to sit, stand and move independently.

Mr Tan is among an estimated more than 210,000 caregivers in Singapore — many of whom have had to compromise their careers, finances and sometimes their own health to look after their aged loved ones.

Those unable to care for the seniors full-time themselves typically turn to hiring a foreign domestic helper, and more seem to be doing so.

The total number of foreign domestic workers as of December last year is 268,500, more than 8 per cent higher than five years ago, according to statistics from the Ministry of Manpower (MOM).

Other caregiving alternatives include engaging home care service providers on an hourly basis and sending the aged to senior day care centres, though this can sometimes be easier said than done due to cost and capacity issues, among others.

Many of these seniors may also not qualify to stay in nursing homes, which typically have a wait list and accept only those who are physically or mentally impaired, unable to be cared for at home and have exhausted all other care options.

Experts interviewed by TODAY said that the issue of caregiving options has become even more pronounced in light of a rapidly ageing population.

In 2010, about one-tenth of Singaporeans were aged 65 and above. In 2020, this figure rose to one in six, and by 2030, about one in four Singaporeans will be over the age of 65.

More elderly people will need assistance as they get older.

A 2014 study by Duke-NUS Medical School academics predicted that the number of seniors requiring assistance for activities of daily living would increase from 31,738 in 2010 to 82,968 by 2030, an estimated 7 per cent of Singapore’s senior population.

Earlier this year, in announcing the 2023 Action Plan for Successful Ageing, the Ministry of Health (MOH) said that come 2030, around 100,000 seniors will require help with at least one daily living activity, while about 83,000 seniors will live alone.

In response to the growing need for more eldercare services, one particular type of care arrangement has sprung up in Singapore in recent years — community or assisted living, which provides professional assistance to elderly who require some help with basic activities of daily living as well as the company of other seniors.

It is an option that Mr Tan has turned to for his mother.

With Singapore expected to be a super-aged society by 2026 and with reports of caregiver fatigue and burnout on the rise, TODAY looks at the range of care options available for the elderly and whether assisted or community care living can help address the country's caregiving needs for seniors, particularly among the so-called “missing middle”.

ASSISTED LIVING IN THE SPOTLIGHT

According to the Singapore-based Assisted Living Facilities Association, an assisted living facility is designed to cater to seniors who are “too dependent on help to be able to maintain independent living, but still cognitively capable and autonomous enough to benefit from the social care that may not be a priority in a nursing home”.

Ms Chia of NUS said that seniors with dementia are one such group.

Although some face cognitive difficulties like forgetfulness, many are still able to carry out activities of daily living such as bathing themselves, said Ms Chia, a researcher who specialises in ageing issues.

While these seniors might prefer to age at home, or turn to day care centres or freelance care workers for caregiving support, others may prefer to age in a facility with other seniors instead.

This is especially so for those whose family members cannot care for them, who live alone or with their elderly spouse, said Ms Chia.

Dr Belinda Wee, who co-founded the Assisted Living Facilities Association in 2018 and an assisted living facility named St Bernadette Lifestyle Village along Bukit Timah Road in 2015, believes that it is crucial for seniors to be placed in the most suitable facility based on their needs in order to age as healthily as possible.

She added that assisted living facilities can play a key role in filling that gap.

“We started assisted living here because we saw a need. If you medicalise people’s care too much, they lose their functions quickly,” she said, adding that seniors can stave off frailty by having nutritious meals, exercise and social interaction — elements that assisted living facilities readily provide for their clients.

The St Bernadette Lifestyle Village at Bukit Timah, which is a rented landed facility, houses eight seniors who live in their own private ensuite room.

It has since expanded to include branches at Adam Road and Sembawang, both also housing eight seniors each. They pay about S$4,600 to S$5,800 each month, depending on location and room type and are looked after by trained caregivers rostered round the clock.

Red Crowns Senior Living, another local care provider that started offering assisted living services in April 2021, came under the microscope when MOM announced last month that it was investigating the firm for a possible breach of foreign manpower laws.

Red Crowns, whose operating model involves renting Housing and Development Board (HDB) flats and condominiums for use as assisted living facilities, is currently serving 130 elderly clients in 33 homes across Singapore.

One of them is the mother of Mr Tan, who lives in a four-room HDB flat with two other elderly patients and two domestic helpers.

Clients of the company whom TODAY spoke to last week expressed concern over MOM’s probe and feared that there would be few alternatives should the investigation result in its closure.

Red Crowns charges S$2,900 to S$6,300 per month for assisted living, depending on location and caregiving service.

The fees charged by Red Crowns and St Bernadette include meals. They also provide social activities for the residents.

Notwithstanding the controversy surrounding Red Crowns, plans are afoot for other privately-run assisted living facilities.

Last Tuesday (June 20), the Urban Redevelopment Authority (URA) and MOH announced that the tender for a Parry Avenue site intended for a private assisted living facility was awarded to Pre 20, a subsidiary of developer Perennial Holdings and one of three tenderers.

The development in the Kovan area will comprise 200 assisted living apartment units, a nursing home with 100 beds, a wellness clubhouse and a geriatric care centre.

Its residents have the option of renting one- or two-bedroom units ranging from 366 sq ft to 666 sq ft for a minimum of three months, and the development will come with private lifts and access to balconies, sky terraces and lush green communal areas, said a spokesperson from the company.

It hopes to start operating in 2026 or 2027.

Ms Pauline Ong, a 78-year-old who currently lives alone in a condominium unit with a helper, said that she would consider moving into the Parry Avenue assisted-living development in the future.

She said it appeals to her as it would give her the opportunity to live among like-minded seniors but also give her the privacy and freedom she wants.

“That is a place where it’s not somebody who says ‘grandma, move in’. I think it’s a place where grandma herself says ‘I want to go’,” said Mrs Ong, who used to run a management consultancy.

Outside of privately-run facilities where residents pay a monthly fee, HDB has also launched two assisted living public housing projects in Bukit Batok and Queenstown called Community Care Apartments in the last two years, with another one in Bedok slated for launch later this year.

The three projects have a total of about 600 flats.

Besides buying the flats with leases ranging from 15 to 35 years, residents have to pay a fee to subscribe to a basic service package, which includes services such as 24-hour emergency monitoring and response as well as basic health checks.

Seniors who require help with their activities of daily living, or household services such as meal delivery, laundry, and housekeeping, may opt for these services at an added cost.

In response to TODAY's queries, HDB said that the Bukit Batok and Queenstown launches saw close to 90 per cent of units taken up at the end of the booking exercises.

“We will continue to monitor the demand for Community Care Apartments, and adjust the plans accordingly,” said the agency, adding that it is developing a pipeline of these apartments across different locations as it expects demand to “remain strong”.

Responding to TODAY's queries, URA and MOH said that the Parry Avenue assisted living development will complement the Community Care Apartments and other private sector-led initiatives by providing more options that cater to different preferences, lifestyles and housing needs.

“The encouraging participation of bidders and successful award of the tender for the pilot private assisted living site at Parry Avenue suggest market interest in this new housing option. The Government will take this into account with other planning and market factors in making future decisions on assisted living options,” said URA and MOH in their joint reply.

COULD ASSISTED LIVING HAVE TAKEN ROOT EARLIER, GROWN FASTER?

Experts said that while Singapore is finally seeing more assisted living options, they could perhaps have been developed earlier and at a faster rate.

TODAY had reported as far back as 2018 about gaps in community-based eldercare, despite the Government’s big push for it amid a rapidly ageing population, including heavy investments in building up infrastructure and manpower resources.

That year, the Government had announced that it was studying potential sites for assisted living developments in the public and private residential markets.

As it stands, the first Community Care Apartment units in Bukit Batok are expected to be ready next year and the private assisted living facility at Parry Ave will not be ready till even later.

And even then, the total number of seniors these facilities and the current ones can take in are a small fraction of the “missing middle” group.

Industry insiders and experts cited manpower constraints, land costs and regulatory ambiguity as some factors why assisted living has not taken off in Singapore earlier.

According to Dr Wee, several developers had previously approached the Assisted Living Facilities Association to enquire about the possibility of setting up assisted living facilities in Singapore.

However, the cost of land and labour shortage served as major barriers — leading them to opt for other markets like Malaysia or China.

“Many people actually are very interested in this space, but they can't really come on board until the Government actually gives a clear guideline on how to go about starting assisted living facilities,” she said.

Ms Chia agrees, adding that the authorities should have specific regulations for assisted living facilities to provide guidance for providers and protection for residents.

The researcher said that assisted living service providers had informed her that it was unclear if they should follow regulations for residential housing or nursing homes.

Such regulations include fire safety regulations or the number of foreign domestic workers or unrelated people who can live in one residence.

“From our conversations with providers, we understand that they have to check with various government authorities on which government regulations should apply…and there is a lot of uncertainty and red tape because they are assessed on a case-by-case basis,” said Ms Chia.

She also noted that the long-term care sector is very heavily dependent on foreign workers and that it is challenging to attract local healthcare workers to work in community settings.

The high cost of land also raises the cost of assisted living services, as operators seek to recover their investment, said Ms Chia.

She pointed out that currently, private assisted living facilities use residential land which is more expensive than land zoned for nursing homes.

“The high price of residential land has been a challenge for service providers to enter the assisted living facilities market and provide affordable assisted living options,” she said.

Indeed, seniors and their loved ones interviewed by TODAY also cited concerns about the affordability of assisted living services, especially in the long run.

Ms Lee Joo Lian, an 82-year-old resident who moved into St Bernadette Lifestyle Village at Bukit Timah in April, described the facility as “homely” and said that she appreciates the care provided by the staff.

While the former junior college teacher who is single and has no surviving family can afford the fees of S$4,600 monthly now, she does not know “how long (her) finances can last”.

Her “back-up option” is to sell her existing three-room HDB flat in Toa Payoh.

“There should be more places (like this in Singapore), but it is expensive,” she said.

Similarly, another resident, 84-year-old Tay Kay Siong, said that he had not been keen to move in as he felt that the cost was “a bit pricey”. He pays close to S$5,000 a month.

“It’s a lot because all our working life…we don’t even earn up to that amount when we retire,” said the former primary school teacher.

Nevertheless, Mr Tay, who has walking difficulties, said that he eventually chose to stay there as he could still afford the price and it suits his needs.

Among other things, Mr Tay has the privacy of a single room and the location is close to Tan Tock Seng Hospital where most of his medical appointments are.

At present, the Government provides subsidies for various caregiving needs via MOH and the Agency of Integrated Care (AIC), including the Home Caregiving Grant — which goes up to S$400 a month to ease caregiving costs.

According to the AIC’s latest statistics, more than 45,000 beneficiaries have received the Home Caregiving Grant since its launch in October 2019.

MOH also provides subsidies for residential long-term care services like nursing homes, which covers anywhere from 20 to 75 per cent of the total cost, depending on the applicant's monthly per capita household income.

For non-residential long-term care services like home care or centre-based day care, which can cost up to S$1,600 a month, subsidies covering 30 to 80 per cent are also available.

However, none of these grants covers seniors who live in assisted living facilities.


HOW ABOUT OTHER CAREGIVING OPTIONS?

With anecdotal evidence often suggesting a mismatch in demand and supply in the eldercare industry, TODAY’s checks with multiple eldercare service providers in Singapore found that while vacancies for day care centres and nursing homes are mostly filled, the challenges that these facilities face go beyond simply plugging-and-placing.

Ms Mary Wee, senior manager of Care Corner Seniors Services, said that even though one of its day care centres in Toa Payoh has 20 vacancies, it has a waitlist of about 17 elderly clients.

This is because the non-profit organisation is currently not able to provide transport arrangements due to a lack of elderly-friendly vehicles and staff to drive them.

She added that the proximity of day care centres is also an important consideration for seniors and their next of kin.

“As such, in more mature estates, if we do not increase the capacity (of day care services), we may face a capacity crunch,” Ms Wee said.

For St Luke’s ElderCare, while it can accommodate 189 residents at its nursing home and up to 1,970 elders at its day care centres, the waiting time for its day care services is around a month, while admission to its nursing home is subject to the number of discharged cases.

Caregivers interviewed by TODAY said that there is still a strong stigma attached to nursing homes, with some likening them to a prison — making them hesitant to send their parents there.

“You have no freedom of movement (there), every time you want to go out you must ask for permission,” said Mr Tan, the caregiver.

For 42-year-old Singaporean Jeremy Goh, admitting his parents in their seventies into nursing homes here would be a “last resort”.

“I feel like the more you treat them (as if) they don’t have the ability, the more dependent they will be. So I think you need to give them that sort of independence,” said Mr Goh, who is working in the education sector in Melbourne, Australia.

While hiring a foreign domestic worker is a cheaper and more accessible option, experts told TODAY that it should not be treated as a “one-size-fits-all” solution, nor would it work in the long term.

“You're putting two vulnerable groups together, because this helper is also coming from a different culture. The expectation of how seniors are is also different from what Singaporean seniors exhibit,” said Dr Wee.

She said one of the residents at St Bernadette previously had 40 foreign domestic helpers, but none of them worked out.

Dr Kelvin Tan, head of the Minor in Applied Ageing Studies programme at the Singapore University of Social Sciences (SUSS), added that the reliance on foreign domestic workers is not a sustainable model of caregiving as the countries they hail from are also ageing.

“So, one day they are going to cut that away from us and we will be in trouble,” he said.

Meanwhile, personalised part-time in-home care services, which on average cost upwards of S$20 an hour, are experiencing an increase in demand.

Ms Gillian Tee, chief executive officer and co-founder of care service provider Homage, said that even though it has a network of over 10,000 trained care professionals, it still experiences periods where it sees “exceptionally high demand, particularly during Covid-heightened periods where we were not able to fulfil all requests”.

She said that Homage delivers more than one million hourly care sessions annually, adding that a lot of its clients are families who need respite care when their helpers are away or having rest days.

Helping, another company which offers elderly care services in addition to other cleaning services, said that it receives about 3,000 hours of requests for its elderly care services over the span of a month on average.


WHAT CAN BE DONE?

To manage the ageing population better and provide caregivers with more help, there has to be a fundamental shift from “reactive” to “preventive” measures in the country’s approach to tackling the issue, said experts and eldercare services providers.

Mr Tommy Tan of Hovi Care, which provides various eldercare services, said that it would be a “mammoth task” to meet the growing demand for nursing homes and day care centres given the ageing population projection.

"We are seeing the Government’s efforts over the last few years to increase capacity in manpower through enablement, education and facilities in active ageing centres, nursing homes and even recently assisted living, however we are unsure if the Government could ramp up the supply fast enough to meet the demand as we moved into super-aged society in 2030," he said.

“One possible way is for the Government to support and encourage the private sector to build up more facilities to augment the public-funded centres.”

Dr Tan of SUSS also suggested having co-living spaces with shared caregiving services for seniors as this would be the most feasible option for seniors in land-scarce Singapore.

To encourage private operators to set up assisted living facilities, they will have to be convinced that they can make money and sustain their business model in the long term, said Dr Tan.

Dr Thang Leng Leng, an anthropologist from NUS and president of the Gerontological Society of Singapore, said that Singapore could also learn from countries such as Japan and Australia, where there is housing provided within the same institution ranging from assisted living for more able seniors, to nursing care for elderly that need more care.

Such “continuum housing” is a good option for people to know that they can receive care within the same site when they need more support, she said.

Nevertheless, she noted that unlike Singapore, these countries also have large grounds to provide retirement housing alongside nursing homes.

In their statement announcing the tender for the Parry Ave site, HDB and URA had said that the concept proposal submitted by Pre 20 “demonstrates a comprehensive care model that provides residents of the proposed development with a continuum of care to enable them to age in place”.

TODAY has reached out to MOH on how it is boosting caregiving capacity for seniors and whether there are specific plans to help the “missing middle” group.

The possibility of expanding options and support for caregivers at a grassroots level was another idea mooted by experts.

For example, while only Community Care Apartments will have community managers to help its elderly residents with their needs, experts said that such community managers can be embedded at other HDB blocks to assist seniors living there.

Such a community manager can be a point-of-contact for seniors and their caregivers in a block, and assist them with questions about senior services or in case of emergencies, said Dr Thang from NUS.

Unlike case managers at eldercare centres who only provide assistance to their own clients, a community manager would assist all seniors at a block, she said.

Ms Joan Pereira, a Member of Parliament for Tanjong Pagar Group Representation Constituency, said that the common feedback she receives from residents on issues related to caregiving are the cost of engaging caregivers and helpers, waiting lists at nursing homes, and dealing with caregiver burnout.

As Singapore ages, she expects to see more families facing situations where working adult children must support both their ageing parents as well as their young children.

On what more could be done at a grassroots level for caregivers, Ms Pereira shared that her Henderson-Dawson ward has partnered with non-profit organisation Caregivers Alliance to hold caregiver-to-caregiver training.

“Graduates of this training programme have access to support groups, volunteer opportunities and support for respite activities through the network of fellow caregivers and volunteers.

“There are also senior care centres located within the community who can offer subsidised day care to seniors while their family members are away at work,” she said.

Experts said that technology is another tool that can help to ease the manpower shortage in caregiving services.

SUSS’ Dr Tan said that technology for smart living, such as voice-activated electrical devices, or motion sensors, can help to alert caregivers if a senior is immobilised.

While such technology is currently used by some households and eldercare facilities, its adoption should be more widespread, he said.

Dr Thang said that people within the community, such as retirees, could be trained to work as part-time caregivers as well to alleviate the manpower shortage to some extent.

Ultimately, experts and practitioners familiar with Singapore’s eldercare industry agree that both the public and private sectors have to work more closely together to provide more options than what currently exists, if the country is to enable its seniors to age well.

For now, piloting new concepts like assisted living and encouraging more private operators are a step in the right direction, though operators must be confident that such models are financially viable.

Experts cautioned that the stakes are high if Singapore is not able to offer enough suitable caregiving options in the coming years as its population ages.

In such a scenario, Dr Tan of SUSS said that more people may have to leave the workforce to care for their ageing family members, while the cost of caregiving services will spiral due to higher demand.

He added: “We should really prepare ourselves early.”