Archive | April 2015

Informal Child and Elder Care in Singapore: South Central Community Family Service Center

At ACCESS Health International, we like to feature good examples of community and elder care. A recent visit to the South Central Community Family Service Center in Singapore reveals a thriving space where different generations of neighbors visit, work, and play with one another.

The South Central Community Family Service Center is located in the southern part of Singapore. The Center is shown as a red dot on the map.

The South Central Community Family Service Center is located in the southern part of Singapore. The Center is shown as a red dot on the map.

The South Central Community Family Service Center is just one of many other Family Service Centers in Singapore. Family Service Centers are an important part of the “Many Helping Hands” approach of the Singapore government toward social services. The Many Helping Hands approach emphasizes the involvement of multiple sectors in providing for the social welfare needs of people. Family Service Centers are run by Voluntary Welfare Organizations and are supported by the Ministry of Social and Family Development, the National Council of Social Services, Community Chest, or the Singapore Totalisator Board [1]. This is one way the government supports and encourages care provision by nongovernmental entities.

The South Central Community Family Service Center is unique in one respect. In January 2013, the Center became an independent entity with its own board of directors. The mission of South Central Community Family Service Center remains the same: to promote the wellbeing and self reliance of families. The main focus is supporting lower income individuals and families in the Bukit Ho Swee, Henderson, Redhill, and Indus Road neighborhoods. Between 2013 and 2014, the Center managed an average of four hundred cases. Casework involves counseling or referral to specialized services. For example, children from families lacking in basic necessities may face challenges in schoolwork or dealing with classmates. Center staff can counsel children or their parents on managing these problems. Where necessary, families are referred to other services, such as specialized psychiatric help or financial aid.

The entrance was decorated with cheerful cartoon sheep to welcome the year of the sheep.

The entrance was decorated with cheerful cartoon sheep to welcome the year of the sheep.

Besides casework, another focus of the Center is community engagement. To this end, Center staff organize events to involve nearby residents and create community spirit. As the Center is located on the ground floor of a block of residential flats, it is accessible and open to residents in the neighborhood. Our visit took place during the Lunar New Year period. As seen in the photo, festive decorations lining the entrance created a welcoming and friendly atmosphere.

Outreach worker Erwin showed us around the Center. Erwin explained to us that a guiding principle for the Center and staff is community cooperation and participation. This principle is informed by the Asset Based Community Development approach to community work. This approach ensures sustainability because initiatives are driven by the residents themselves. Residents volunteer to help care for their neighbors’ elderly relatives or children. Residents worked together to plant a community garden full of useful medicinal herbs.

Residents take ownership of the community garden and bond while caring for the plants. (Photo: South Central Community Family Service Center)

Residents take ownership of the community garden and bond while caring for the plants. (Photo: South Central Community Family Service Center)

The Center is a collaborative environment. The community garden is a visible fruit of this collaborative environment. The garden had been an empty space in front of the Center. Center staff wanted to galvanize residents to work on a common project. Residents contributed ideas and voted for the winning project: a medicinal herb and vegetable garden. Because the idea came from residents, the garden has been adopted and cared for by residents.

Residents contribute ideas to keep the garden fresh and growing. Residents can vote for the next plant type by placing a marble in the respective bottle.

Residents contribute ideas to keep the garden fresh and growing. Residents can vote for the next plant type by placing a marble in the respective bottle.

In the picture above, one can see a board where residents can vote on the next plant type. At the time of visit, sweet potato leaf was the leading candidate. The board itself was constructed by hand by a resident who is a carpenter by trade.

The Request and Offer board matches community resources to areas of need.

The Request and Offer board matches community resources to areas of need.

Inside the Center hangs another board, where residents can request items or services they need, or post offers of items or services they can give. The platform helps match community resources to people who need them most.

Residents streamed in and out of the Center throughout our visit. Erwin pointed out a pair of young siblings playing games on the couch. Erwin told me the siblings come to the Center after school ends to wait for their parents to get off work. I also saw groups of elderly chatting with one another at tables and chairs. The open space created by the South Central Community Family Service Center helps with informal child and elder care as residents look out for and engage with one another.

Outreach worker Erwin, in gray, briefs volunteers on a house visit activity.

Outreach worker Erwin, in gray, briefs volunteers on a house visit activity.

Near the end of our visit, there was a briefing for a large group of about twenty five volunteers, both young and old. They were preparing to give out yusheng packs to shop owners and residents at the Lengkok Bahru neighborhood. This showcased lower income families and children as goodwill ambassadors as part of this “Lo Hei Outreach”. The yusheng salad is traditionally eaten during the Lunar New Year, and Lo Hei is the dialect term for tossing the salad. Family and friends gather to Lo Hei together, signifying prosperity and togetherness. The briefing was punchy and positive with the staff recognizing the contributions of volunteers.

The South Central Community Family Service Center is an example of successful informal community and elder care. The staff and volunteers have created an open venue where residents are encouraged to join community activities and contribute their talents. Can their model of community involvement and ownership be replicated elsewhere? For example, could elder care as a larger industry move toward being more community based and operated? Share your thoughts with us by leaving a comment.


1. The Singapore Totalisator Board, also known as Tote Board, manages the surplus funds generated by Singapore Turf Club and Singapore Pools. They channel funds in support of various causes in Singapore such as arts and culture, social services, community development, education, health, and sports.

Advertisements

A New Perspective: Design Thinking for the Elderly

This post is the first in a series of articles focused on design thinking and aging. In future posts, we will explore the use of personas in designing solutions for seniors. We will also address problems identified by seniors themselves.

Imagining the ecosystem surrounding seniors in Singapore. Examples given are not exhaustive.

Imagining the ecosystem surrounding seniors in Singapore. Examples given are not exhaustive.

Last week, the ACCESS Health Singapore team attended a DesignSingapore forum titled Rethinking Health and Wellness for the Elderly. Among the fresh perspectives and opinions shared at the forum, one point really stood out to us: Often, designers who design products for seniors view seniors as isolated individuals. In reality, the elderly live and interact with others in their families and communities, such as family members and health professionals. They engage others in their external environment multiple times throughout the day: when getting coffee, seeing their neighborhood doctor, seeing specialists at hospitals, visiting community centers, going to the supermarket, and even through online sites and discussion boards. Behind these interactions, or touchpoints, lie many higher level entities that share an active interest in the wellbeing of the elderly, such as ministries or charities.

This learning point came from applying design thinking and ethnography to aging. One principle of design thinking is that all design activity is social in nature. Ethnography aims to explore social phenomena from the point of view of the subject, in this case seniors. At the forum, videos were shown of interviews with various seniors and their caregivers. These seniors and caregivers were asked what challenges they faced in daily living. Beyond these answers, researchers also followed the seniors on their daily activities, like cooking and exercising, in true ethnographic fashion.

In one clip, a frail senior was shown cooking for himself. His legs are weak so he sits on his wheelchair at the stove. But this position is often low and awkward. Upgrading to an adjustable height chair could make cooking easier for him.

A video still showing a senior cooking. An adjustable height chair could make cooking easier. (Photo: DesignSingapore)

A video still showing a senior cooking. An adjustable height chair could make cooking easier. (Photo: DesignSingapore)

One woman interviewed in the video had left her job to care for her father full time. Even while providing fulltime care, she said, there are moments when she cannot be there, physically, to catch her father if he falls. Such personal examples peppered the forum, turning abstract issues into real and moving stories.

When we think of the people, places, and organizations seniors interact with, many opportunities come to light. One senior featured in the video had lost his leg to amputation due to diabetes. After being fitted with a prosthetic, he still found it tiring to navigate his neighborhood. He told the interviewers that he was truly glad to receive a motorized personal vehicle from a welfare organization. Some limitations remain. Narrow corridors and places without ramps are inaccessible to him. However, he is now able to take public trains and go shopping, everyday tasks that would have been nearly impossible before. The motorized vehicle has improved his quality of life. In this case, an organization found a solution that has allowed this senior to engage more with the people and places around him.

A motorized personal transport like the one pictured can help seniors unlock and explore more of their community and environment. (Photo: Free Images)

A motorized personal transport like the one pictured can help seniors unlock and explore more of their community and environment. (Photo: Free Images)

Engaging ethnography and design thinking for the elderly may seem unconventional. But some researchers acknowledge the benefit of taking into account social and environmental aspects of aging. A recent BMJ article reviewed existing ideas and concepts of Successful aging refers here to physical, mental, and social wellbeing in older age. The authors found that traditional conceptions of successful aging focused largely on individual bodily health. For example, the Activities of Daily Living scale tests a senior’s ability to complete a basket of self care tasks. These tasks include feeding, toileting, and grooming.

The authors found in their review that psychosocial and external factors are important to successful aging too. Yet, the authors found that these factors are underrepresented in traditional models of successful aging. For example, the Activities of Daily Living scale does not measure social activities such as holding a conversation or enjoying a sport outdoors. The authors wrote, “[Successful aging] is clearly not simply a physiological construct, so it seems intuitive that psychosocial components should be included in otherwise biomedical models of [successful aging].” The authors concluded that conventional models for aging can benefit from including social and external components of seniors’ lives.

Design thinking and ethnography can be applied at all levels of the ecosystem surrounding seniors. Consider seniors, the people they interact with, the people and places they engage with, and the organizations that help support them. Imagine a senior living out a typical day in this environment. What gaps and opportunities do you see? Are there any potential collaborations between organizations? We feel these added perspectives will help craft more targeted, efficient products and solutions to help seniors.

US House of Representatives Votes to Repeal Medicare Sustainable Growth Rate and Strengthen Medicare Access

The United States Capitol Building. (Photo: House Press Gallery)

The United States Capitol Building. (Photo: House Press Gallery)

We at ACCESS Health have been watching the news closely for the last two weeks. The issue of interest was the vote by the United States (US) House of Representatives on March 26 to repeal the Medicare sustainable growth rate formula and to “strengthen Medicare access by improving physician payments and making other improvements.” The bill can be viewed here.

This event is noteworthy in a few ways. One is that the 392 to 37 vote reveals overwhelming bipartisan support for these changes. Another is that, if passed by both houses of Congress, the bill would change the US healthcare payment system significantly. The bill still needs to be passed by the Senate.

If passed, how will the bill affect healthcare in the US? First, the bill repeals the sustainable growth rate formula used by Medicare. The sustainable growth rate formula pegs provider reimbursements to economic growth, as measured by gross domestic product (GDP). In place of the sustainable growth rate formula, the bill proposes value based payment models such as accountable care organizations and bundled payment. Accountable care organizations link doctors, hospitals, and other health professionals together to develop tailored care plans for Medicare patients. These care plans encompass the entire care process, matching the appropriate service to patients’ needs and reducing duplication of efforts. The bundled payment system reimburses care providers based on expected costs for specific clinical issues. This prevents unexpectedly high costs for patients.

Presently, the US healthcare system uses a fee for service model to pay providers. This means providers are paid for each individual service or operation, regardless of necessity or efficacy. As described in Forbes, “[Fee for service] actually rewards providers financially when patients suffer complications or infections, and pays them more if [providers] order unnecessary tests or procedures.”

Changing this system would remove incentives for healthcare providers to push large numbers of services on patients. Replacing fee for service with value based payment models could improve patient outcomes while reducing costs.

Spending on healthcare as a percentage of GDP in the United States, Singapore, and the world. (Picture: World Bank)

Spending on healthcare as a percentage of GDP in the United States, Singapore, and the world. (Picture: World Bank)

In the future, the high percentage of GDP spent on healthcare in the US may fall. According to World Bank data, the United States spent nearly eighteen percent of its GDP on healthcare in 2012, the highest in the world. GDP savings on healthcare would allow higher spending in other areas, such as education.

However, it is still too early to tell whether the bill will pass the Senate. In addition, there are still many challenges to the change. Many healthcare providers still cling to fees for services models of payment. It is also challenging to define key performance values for providers. Will providers aim to reduce readmission rates or improve life expectancies of patients? At this point, performance values are not standardized. Nevertheless, the strong bipartisan support for the bill shows a consensus that the existing sustainable growth rate model is undesirable.

This movement represents a move toward a capitation payment system, which pays providers a set amount for each patient, regardless of service type. Capitation systems are used by countries like Italy, the United Kingdom, and Denmark. In addition to the US, fee for service is used in countries like Japan, Germany, and Canada.

Interestingly, China has used the fee for service system since the 1980s. China has experienced healthcare cost increases, poor quality, and a questioning of medical ethics. These factors have led to experimental healthcare reforms, since the 2000s. City and local governments were encouraged by the central government to redesign the healthcare system, with wellbeing of patients as a main goal. China tried bundled payment systems, with some success. Jining saw a thirty three percent reduction in expenditure, while Shanghai saw a seven to twelve percent reduction in cost per outpatient visit. However, these initial results are not conclusive of the superiority of a capitation system. China continues to experiment with and review healthcare reforms.

If the US moves forward with the repeal of the sustained growth rate for Medicare, other countries facing challenges with fee for service healthcare models may follow suit. The ripples of this bill are potentially larger than domestic US healthcare policy. What do you think of these policy developments? Tell us your thoughts by leaving a comment.