Wednesday, March 10, 2010

Elderly communities in our midst

Mar 10, 2010

Integrate elderly support services within HDB estates, says US expert
By Tan Hui Yee

FORGET Johor nursing homes. Forget setting aside land for fancy retirement villages. The solution lies right here in our heartlands, says ageing services expert Robyn Stone.

Older residents there need not be moved out of their flats once they need help living independently, says the 59-year-old senior vice-president of research at the American Association of Homes and Services for the Ageing, who worked on ageing issues with the Clinton administration.

Instead, welfare bodies can track their status in these communities and deliver medical services from door to door.

Professional caregivers can drop in at several homes at one go to lower travelling costs, and their service can be supplemented by community health workers made up of older residents who are trained to monitor the status of their less able neighbours.

Health-care and leisure facilities can be integrated within the estate, while technology can be used to link up the elderly for mutual support if they are dispersed over a wider area.

'There are so many things you can do if you use the housing block as a platform,' says the noted researcher on the sidelines of the recent International Housing Conference organised by the Housing Board (HDB).

Right now, caregiving here is provided mainly by family members, domestic workers or voluntary welfare organisations, or a combination of them. Yet, at least one or two elderly persons are found dead in their homes every year, raising questions about this approach.

Dr Stone says the Government could easily do more with less if it thinks out of the usual silos like housing and health and finds ways to integrate existing resources and track the welfare of its ageing population.

Retirement villages will not be needed once a significant cluster of elderly residents within an HDB estate form a 'naturally occurring retirement community'. Singapore, which is poised to have one in five people aged 65 years and above by 2030, could develop a number of these communities in its older towns.

This integrated model is more in line with what elderly persons want, given that several studies, including a 2009 one done by Singapore's Council for Third Age, have shown that they wish to remain independent in their golden years.

However, Dr Stone notes that many governments tend to be skittish about providing caregiving support for fear of eroding family ties. While the Government last week set aside $100 million to fund healthy ageing programmes, it also often reiterates that Singapore's system is based on 'self-reliance and family support'.

But the problem, Dr Stone says, is that you can depend on family only so much. She warns: 'You will break their backs if you don't think about a system that can help support them.'

This is the stark reality in East Asian societies such as Singapore, where sliding fertility rates have shrunk the number of caregivers per family, even as health-care costs soar. Last year, Singapore's resident total fertility rate slid to its lowest level of 1.23.

This being the case, she says that government help will likely shore up instead of chip away at family values. 'It's not about one or the other. In most families, there is familial piety regardless. Policy can't really force this too much one way or the other. People do care for their family for the most part.'

For example, contrary to common perception that Western families leave care- giving to the state or private sector, about 80 per cent to 90 per cent of all such care in the United States is provided by the family.

Dr Stone, who is single, is herself banking partly on family for support when she gets older.

'My goal is try to stay as healthy as I can for as long as I can and then hope that my niece or one of my nephews will take pity on me,' she says with a chuckle. One particular nephew, whom she is very close to, has told her 'he's not going to abandon me in the street'.

'And I actually think that's true. He would not.'

Families, she says, are unlikely to cut back on their caregiving if they receive carefully calibrated aid.

'It's a matter of how much. If you give a modest amount of resources which just complements what family care is already doing, there is evidence that it can allow the family to do its work for longer.'

A 2007 study by the US Department of Health and Human Services' Office of Disability, Ageing and Long-Term Care Policy found that reducing the physical strain and financial hardship of an informal caregiver - either a family member or friend - can help delay the care recipient's entry to a nursing home.

In addition, giving aid to family care- givers gets them more involved in the process and helps improve the quality of care given. 'You can train them so they know what they are doing and they know what to expect. If their family member is beginning to experience cognitive decline, they understand that. They will not be freaked out because their mother has dementia.'

Unfortunately, she notes, most countries with labour shortages take the easy way out by outsourcing caregiving to cheaper foreign labour.

'Israel relies a lot on the Philippines. In fact, they rely on them so much that... they don't even call them homecare workers. They call them Filipinas, because they are all from the Philippines.'

Meanwhile, about one in six Singapore families hires live-in foreign maids and the number of maids has grown despite the recession, from 160,000 in 2005 to 190,000 at the end of last year. Many of these workers juggle household duties with looking after children and the elderly.

But she questions: 'Is it a good policy to be importing untrained low-wage labour, to support your own vulnerable population?

'I don't really see that as a sustainable model. We can't just hire anybody off the street who doesn't know anything about caring for the elderly and expect them to take on significant responsibilities.'

Caregiving requires particular skills which are very different from domestic work. 'It's very different doing laundry and caring for an 85-year-old.'

Using foreign domestic workers for the job, therefore, is at best 'practical' but not 'really optimal'. Even technology can play only a complementary role at best, when it comes to caregiving. 'Unless we have robots, I don't think it's going to replace all hands-on care,' she says.

Some monitoring systems that are not well-conceived have turned out to be duds. Call bells are one of them, since the elderly person in question cannot get to one if he has a fall, or operate it if he has arthritis.

But motion sensors that allow the elderly to be monitored independently are helpful, though they have to be planned for and integrated into homes from the very beginning.

In fact, pretty much everything else about preparing for ageing requires long-term planning as it involves a careful integration of housing infrastructure, technology and community resources.

Ideally, all hardware and software should be designed to allow the elderly to be plugged into the life of the community.

Dr Stone, who is averse to nursing homes, points out that even nursing home providers these days are starting to look at building smaller homes integrated into existing neighbourhoods.

'A segregated approach would be a disaster,' she says.

In sum, she concludes that more than big money and grand infrastructure, it takes a lot of careful thought and people- focused planning to support a silver society.

She notes that 'when the Singapore Government wants to do something, it does it'.

With such proactive resolve, she is optimistic that if anybody can lay the groundwork for ageing well, it is Singapore.

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