COVID-19 Challenges Spark Opportunities For Senior Care In Singapore

SINGAPORE, Oct 30, 2020 – Singapore’s management of the COVID-19 crisis so far has resulted in one of the world’s lowest death rates overall, as well as among its most vulnerable and frail residents – those who live in nursing homes.

There have been four COVID-19 deaths among nursing home residents – and 28 nationally – to date. Significantly, at a time when across 21 countries, nearly half of all pandemic-related deaths are among residents of nursing homes¹, the figure in Singapore is at around 14 percent of all deaths. Overall, 20 residents and 5 staff members tested positive for the virus² in six nursing homes between March 31 and June 4. All the four who died were residents of a single home, Lee Ah Mooi Old Age Home, which had 14 cases overall³. The deceased, three women and a man, were all in their 80s or older and had multiple co-morbidities.⁴

There have been no cases in daycare centres or among users or staff of homecare services⁵.

While outbreaks in long-term care (LTC) have remained relatively low, this has come at the price of strains on the country’s LTC system. As the sector scrambled to find solutions – to closures of daycare centers, to restrictions on movements in nursing homes, and to the adoption of homecare – it set a path towards a new vision of long-term care. Notably, greater use of digital technology boosted the efficiency of some services, increased the variety of activities for seniors, and showed the potential for putting seniors at the center of care.

Overview of the Report

These are some of the findings from a new report that offers a quick recap of the first six months of the COVID-19 crisis as seen through the eyes of some of Singapore’s long-term care providers. It elaborates on the challenges faced – many of them inevitable – and lessons learnt as LTC providers worked round-the-clock in tandem with the government health and care agencies to safeguard and serve seniors who live in nursing homes or use formal daycare or homecare services. It also identifies emerging opportunities and local and global best practices from the care sector and other industries – especially with regard to technology – which are worth emulating to help make the sector stronger, more integrated and resilient in a post-pandemic world.

The 85-page report, Navigating a New Reality: COVID-19 Challenges and Opportunities for Long-Term Care in Singapore, was produced by international management consulting firm, Oliver Wyman, in partnership with the Lien Foundation. The researchers spoke to nearly 50 people, including leaders and staff of 21 long-term care operators who run nursing homes, daycare centers and homecare services in Singapore. Perspectives were also sought from policymakers, academics and 15 international experts. These were supplemented by a review of new policies implemented in Singapore since the beginning of the pandemic, as well as additional secondary research.

The report is an impressive systematic review of the unprecedented COVID-19 crisis, faced by the entire healthcare system and specifically – the Community Care Sector,” said Then Kim Yuan, Administrator of the Lee Ah Mooi home, one of the interviewees, who was on the frontlines of the race to safeguard seniors in Singapore’s care sector. “A global pandemic can only be defeated when such research results are openly shared and all stakeholders learn and work together as a community to respond calmly, responsibly, and with resilience.”

COVID-19 Impact on Singapore’s Seniors

Overall, nursing home residents currently account for only 0.03 percent of nearly 58,000 COVID-19 cases and 14 percent of 28 COVID-19 deaths in Singapore.⁶ Based on a total of 16,000 nursing home residents, the infection and mortality rates per nursing home resident are 0.13 percent and 0.03 percent respectively. A recently published international study on deaths in nursing homes highlighted that the proportion of deaths per resident in Singapore is the second lowest among 21 countries, barring South Korea.⁷ This compares with 4 to 6 percent in countries like the United States, United Kingdom, Spain and Belgium. In fact, in countries like Canada, Australia, Spain and Belgium, care homes have accounted for 60-80 percent of all pandemic-related deaths, despite being home to a small fraction of seniors.

Singapore is one of the fastest aging countries in the world. Nearly 900,000 people – or 22 percent of the resident population – are already in their 60s or older.⁸ Seniors here – though vulnerable – have been largely safe so far, thanks in part to prompt policy changes and some strict measures aimed at isolating residents of foreign worker dormitories, where 94 percent of the cases occurred as of October.

Navigating COVID-19 Policy Response

Operators also worked in tandem with the Ministry of Health (MOH) and the Agency for Integrated Care (AIC) – sometimes round the clock – to put in timely prevention and control measures to safeguard long-term care facilities. Throughout the pandemic, MOH and AIC have sought to avoid drastic actions and to suggest more incremental changes; operators commended the support from the government, though some noted they struggled to navigate changes with short turnaround times and the large volume of advisories. While critical for public health – and in many cases inevitable – these measures have stretched resources and capacity in a manner that could prove unsustainable in the long run.

There was also support in the forms of funding, technology, non-technological solutions, and knowledge sharing.⁹ MOH and AIC coordinated and distributed personal protective equipment (PPE, distributing supply from the national stockpile to each operator), and swab tests across the sector (for example, tests for all nursing home staff and residents from April to June).¹⁰ The widescale testing was particularly intended for early detection to prevent clusters from emerging. With the support of National Public Health Laboratory, AIC adopted pooled testing and received test results within 24 hours. MOH and AIC continue to study alternative surveillance protocols to further enhance early detection.

To date, funding has been awarded to long-term care providers, regardless of whether they receive government subventions, that applied for funding opportunities. This included:

• Video conferencing set up on a case-by-case basis (up to 5,000 Singapore dollars per center and SG$20,000 per organization). Repurposed digital tablets were also issued to nursing homes to enable nursing home residents to do video calls with their family members and caregivers, especially during the circuit breaker period.

• Implementation of a subscription-based appointment scheduling system (SG$75 per month)

• Staff transportation (up to $3,000 per organization)

• Staff welfare through the Sayang Sayang Staff Appreciation Fund (up to SG$3,000 per organization)¹¹

• Pristine Fund to keep eldercare centres hygienic and clean (SG$300 per centre)

AIC also set up the #StrongerTogether Fund to support long-term care providers who are hit by a confirmed COVID-19 case. The Fund helps long-term care providers to defray cost incurred (up to $50,000 per nursing home and up to $10K per centre) due to the COVID-related incident.

Specific to nursing homes, additional one-time funding was announced in May and June on a per-person basis for staff relocation to alternative accommodation (SG$500 hardship allowance in May for temporary relocation, SG$6,000 transitional grant, and SG$4,400 additional housing allowance for moving off-site residences). Funding was also provided for facility renovations for staff remaining on-site (SG$250 per staff member).

Challenges from First Six Months of the Pandemic

On the ground, long-term care faced challenges in five areas: continuity of care, physical space, manpower, seniors’ wellbeing, and primary caregivers.

In nursing homes, the risks were especially high with regards to physical space,given that many homes still have dormitory-style accommodation, with six to 10 seniors in a room. The problem was compounded by the presence of on-site staff dormitories – sleeping up to 10 workers in a room, many in bunk beds. To minimize infection risk, the operators needed to retrofit their facilities, especially in communal areas, split zones, and staff living quarters.

Nursing home staff, meanwhile, have faced high stress, both in their workplace – with some moving from eight- to 12-hour shifts – and personal lives, as some have had to relocate to on-site accommodation, hotels, or new off-site residences. In all, 3,600 resident-facing staff¹² – or around 40 percent of all nursing home staff – were moved to designated accommodation facilities on-site or at hotels. Providers were supported with funding to transit their staff into the new accommodation, which adhered to principles such as observing split zones and safe distancing measures, minimizing inter-mixing of staff, and ensuring the accommodation is well-ventilated.

Residents’ emotional wellbeing was also affected amid the frenzy of changes and a period without visitations from loved ones, leading to disengagement and stress – especially for seniors with dementia, who had a difficult time adjusting to changes, such as staff in PPE – as well as the risk of physical deterioration, with reduced therapy sessions.

Daycare centers were also put to the test, as their offline model came to an abrupt standstill during center closure, and many were forced to go online with mixed success. While there was reasonable take-up of digital services among less-frail and younger seniors, operators interviewed noted that this translated to only between 20 and 50 percent of seniors regularly engaging in virtual activities. For frailer and older seniors, only phone calls or messages were feasible, especially for seniors with no Internet connectivity and technology. Seniors with caregiving support at home were able to better engage. The online migration was not easy, as only about 58 percent of Singapore’s seniors are Internet users. Of this group, only 33 percent are computer users and 13 percent do not own any portable device – that is a laptop, tablet, smartphone, or mobile phone.¹³ Many operators had not done much digital preparation, and not all seniors were engaged or had sufficient tools, Internet connectivity or support from caregivers and family members at home to participate. As a result, the uptake of online activities was not a full migration.

Overall, this period of isolation at home posed difficulties to seniors and primary caregivers. Operators and geriatric experts have observed the mental and physical deterioration of seniors, and centers are now focused on deconditioning these effects, which include forgetting how to perform daily activities and clients with dementia not remembering the center at all. In some cases, seniors have not been able to return to centers due to their weakened conditions.

Caregivers faced a slew of challenges at home, navigating personal difficulties from COVID-19 along with new responsibilities to care for seniors with minimal support from other family members, due to community-wide lockdown, or services like home personal care. Even as centers have reopened, they must operate safe-distancing and other infection-control routines. Centers that were included in the study, as of August, were hovering at between 50 and 80 percent of typical capacity, with uncertainty over how long this will continue.

Meanwhile, COVID-19 has been a catalyst for further adoption of homecare, with demand growing for home medical and nursing care, says the report. Operators included in this study saw up to 20-percent growth in home nursing and 25- to 50-percent growth in home medical care. They saw a promising foray into telehealth, with many piloting the service for the first time: One operator reported a 90-percent growth in telehealth adoption and sees high potential for further expansion of teleconsultation services going forward. While homecare operators did face other challenges, the momentum of digital adoption was positive for them. Sustaining this will require a review of structural gaps such as financing coverage, as well as further innovations from operators in expanding their services.

Digital Technology as a Silver Lining

The report also highlights several best practices – from Singapore and overseas – on how greater use of digital technology can boost the efficiency of senior care services, increase the variety of activities for seniors, and show the potential of putting seniors at the center of care. The report focuses on existing technology solutions that must be reconsidered given exigent use cases from COVID-19, such as remote monitoring, medication adherence, assistive robots, and social connectivity solutions.

These can help create a future for long-term care in which aging-in-place is the default, and which places a renewed emphasis on quality of life. Diverse care options can be administered at home, and seniors can be offered a blended program of online and offline daycare services. The report calls for a major transformation across the long-term care sector, with a key role for digital technology.

“Beyond placing seniors at the forefront of policy making, the pandemic has also amplified the case for digital and technologies in the long-term care sector,” said Kitty Lee, Partner and the Head of Health and Life Sciences in Asia Pacific, and one of the authors of the report. “The momentum is here for the sector to leverage this increased willingness to adopt digital and to push the boundaries on care delivery for seniors.”

Transforming Long-Term Care

Oliver Wyman has defined six opportunities in LTC that are immediately actionable. Each applies technology to realize practical solutions that have already been put into use:

• Pivot to digital-led care models that are integrated closely with offline models. Examples include virtual daycare and telehealth, using remote monitoring and back-end analytics.

• Boost preventive health and wellness.Empower patients and plan for future disruptions by deploying sensor-based technology such as wearables and remote devices for medication adherence.

• Retrofit existing spaces in facilities to minimize the risk of infection. Redesign nursing homes and daycare facilities and introduce devices such as assistive robots and AI-based solutions (software for CCTV facial recognition and temperature screening, for example).

• Empower the workforce for the future. Use lessons from COVID-19 to redesign jobs and reorganize teams; engage and upskill volunteers; and free up staff using technology such as remote monitoring, IoT-enabled administrative systems, and assistive robots.

• Place greater emphasis on mental health and wellbeing in care planning. Focus on social connectivity through digital platforms and virtual reality-based programs.

• Provide greater support for primary caregivers via upskilling and wellbeing initiatives to better prepare them to navigate uncertainties. This can be done through digital communities and training for caregivers.

While pursuing these opportunities, the sector has the opportunity to initiate long-term improvements. One is to improve the continuity of care. Homecare has great potential for increased adoption, and operators interviewed by Oliver Wyman reporting a healthy growth in home medical care. Many of them piloted telehealth services. To sustain this momentum and shift more care options to the home, structural gaps will need to be reviewed, such as homecare coverage financing. There are also opportunities to integrate services that are currently provided by LTC providers, social care agencies, and Singapore’s Regional Health Systems. Physical spaces will need fundamental rethinking: Nursing homes should be purpose-built and have fewer residents per bedroom and decentralized communal areas. Daycare centers should consist either of large spaces that can be easily compartmentalized or smaller spaces in public housing blocks. A third priority is to strengthen the manpower available to the sector. That means finding solutions to the current limitations in Singapore by changing the system governing foreign workers and tapping into more local candidates.

Community care expert, Dr Ng Wai Chong, one of the interviewees who is helping seniors adopt technology, said that the urgent need for technological innovations to mitigate the situation cannot be overstated. "However, we really need more multidisciplinary research and marketplace experiments in geron-tech applications," said Dr Ng, who is Founder and CEO of NWC Longevity Practice. "At the end of the day, I’m still not quite convinced that Zoom meetings can replace a shared meal."

Reflecting on the Crisis to Date

Overall, the report found that Singapore’s long-term care sector – including the authorities, sector leaders and staff as well as seniors and their families – have shown collective strength during the crisis. However, COVID-19 has compromised the stability that is imperative to the sector. “Despite grave risks and thanks to coordinated and continuous effort, the sector has done relatively well to safeguard our seniors so far,” said Lien Foundation Research Director, Radha Basu. But as the pandemic shows no signs of abating globally, the work is far from over. “We hope some of the technology and other opportunities highlighted in the report can pave the way to a stronger, more resilient and integrated sector that is better able to balance safety with wellbeing during this pandemic and beyond.”

About the report
This report was written by Oliver Wyman in collaboration with the Lien Foundation, a Singapore-based philanthropic organization focused on eldercare. Based on close to 50 interviews with long-term care operators, experts, and policymakers in Singapore and abroad, the report highlights the experiences of nursing home, daycare, and homecare operators in the first six months of the pandemic (from February to July). The report recommends opportunities to fortify the sector, with digital and technology as key focus.

About Oliver Wyman
Oliver Wyman is a global leader in management consulting. With offices in 60 cities across 31 countries, Oliver Wyman combines deep industry knowledge with specialized expertise in strategy, operations, risk management, and organization transformation. The firm has more than 5,000 professionals around the world who work with clients to optimize their business, improve their operations and risk profile, and accelerate their organizational performance to seize the most attractive opportunities. Oliver Wyman is a wholly owned subsidiary of Marsh & McLennan Companies [NYSE: MMC]. For more information, visit www.oliverwyman.com. Follow Oliver Wyman on Twitter @OliverWyman.

About Lien Foundation
The Lien Foundation is a private philanthropic organization that pioneers solutions to improve lives and tackle the root of problems in eldercare and early childhood development in Singapore. It also works to improve access to clean water, sanitation and palliative care among diverse communities in south and southeast Asia. The Foundation's research publications, multimedia advocacy and design projects aim to seed public discourse in the hope that these can lead to better policies and practices in its various fields of work. www.lienfoundation.org.

^{1 Comas-Herrera A, Zalakaín J, Lemmon E, Henderson D, Litwin C, Hsu AT, Schmidt AE, Arling G and Fernández J-L (2020) Mortality associated with COVID-19 in care homes: international evidence. Article in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 14 October.
2 Graham, WCK, Wong, CH. (2020) Responding to COVID-19 in Residential Care: The Singapore Experience. LTCcovid country report, International Long-Term Care Policy Network, CPEC-LSE, 27 July 2020, Ministry of Health, Oct 16
3 Information from Lee Ah Mooi home. All the deaths occurred in hospital.
4 A sixth staff member tested positive for COVID-19 the day she returned to the Philippines after completing her contract in August 2020.
5 Ministry of Health, Oct 16
6 Information from Ministry of Health.
7 Comas-Herrera A, Zalakaín J, Lemmon E, Henderson D, Litwin C, Hsu AT, Schmidt AE, Arling G and Fernández J-L (2020) Mortality associated with COVID-19 in care homes: international evidence. Article in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 14 October.
8 https://www.singstat.gov.sg/-/media/files/publications/population/population2020.pdf
9 Knowledge sharing includes informational posters (such as staff hygiene) for care facilities and workshops (such as mask-fitting.)
10 The number of PPE and swab tests funded by MOH and AIC were not available upon request. The number of PPE sets distributed is based on caseloads submitted by operators (dependent on staff size and level of precaution required for specific services) while swab tests are made available for both mass testing exercises and for residents displaying ARI symptoms.
11 All financial figures provided in this report are denominated in Singapore dollars (SGD), unless stated otherwise.
12 Information from Ministry of Health, Singapore.
13 IMDA 2019: Annual survey on Infocomm usage in households and by individuals. In this data, seniors are 60 years of age or older.}