Singapore Innovating Health Series | Roundtable 2 Summary Report

ROUNDTABLE 2 SUMMARY REPORTAdvancing Senior Independent Living inSingapore via Policy, Operational andTechnological Innovations

Roundtable 2 | 8th March 2017 Advancing Senior Independent Living in Singapore via Policy, Operational and Technological InnovationsOverviewSingapore Innovating Health is intended to help build a platform to bring together acommunity to look at key areas of care delivery in Singapore with ageing being one ofthe focus areas with a view to tap on disruption and identify opportunities for changes inpolicy, operations and technology innovation.The ageing Asian population is projected to grow exponentially from now until 2030. Thishas become a disruptive demographic phenomenon which countries will have to look at interms of workforce, resources and how it will disrupt the economy as well.Emerging disruptive technologies that will shape new forms of care models in terms ofoperations and policies may ameliorate the impact to countries.In Roundtable 1, we segmented the ageing population and examined their respective healthand social needs. The segments identified are: • The Institutionalised – who are generally being care for in nursing homes • The At Risk – who can be aided through the community via social groups and clubs • The Supported at home – who rely on family, domestic workers, home medical and nursing care • The Well – who can join active ageing clubsIn the Singapore context, it was identified that we could do better in the following areas: • Provide assisted living options • Better training for volunteers and FDWs • Enhance GP participation and collaboration • Promote self-care and independence • Optimise technology useFor the Roundtable 2 discussion, the focus was on Assisted Living or Ageing-in-Place (AIP)and also where Technology could play a role.Regarding ageing in Singapore, we note the following facts: • The population is ageing at a rapid pace • The Ministry of Health is currently adding nursing homes and beds at a very rapid pace towards a ratio of 27 nursing home beds per 1000 elderly persons.However, nursing home is not the way that people want to go.Singapore Innovating Health Series | Roundtable 2 Summary Report 2

“I don’t ever want to be admitted here in my old age” - Director of a Nursing Home at the home she has managed for 15 years “Many residents live for years in these institutions not because of heavy nursing needs, but because there is no one to care for them at home.” - Safe but soulless: Nursing homes need a new narrative (Radha Basu) © 2016End of life needs are increasing. Statistics show 20 % of the elderly discharged from hospitalsare back within 30 days. As the number of elderly people choose to die-in-place, there is acorresponding increasing need for palliative care services. The “end-of-life” period is oftenpreceded by increased healthcare (and social care) needs. There is a gradual decline inhealth status requiring additional care and support.According to a study on what happens before people die: • 1/3 of those who were studied were in relatively good health shortly before they die • 1/3 had chronic organ failure such as chronic heart failure for some period before they died • 1/3 were really in poor healthSingapore Innovating Health Series | Roundtable 2 Summary Report 3

Assisted Living Innovations, Policy and Financial Model Dr Chang Liu Managing Director for Singapore, Mainland China & Hong Kong ACCESS Health InternationalDr Liu started by distinguishing between Cost Benefit vs. Cost Effectiveness. In Cost Benefitthe benefits are viewed in monetary terms. Whereas in Cost Effectiveness, the benefits canbe in terms of various measurements e.g. quality of life, social benefits. In most analyses,Cost Effectiveness is more often used because we don’t want to push everyone to evaluateeffectiveness solely on monetary values.He also noted that when making any economic analysis, it is important to ascertain whichperspective is being highlighted (patient / provider / society) and to try to align that withwhat society should be looking at. This will help drive prioritisation and how to best allocatelimited resources to create the biggest impact.He turned next to Ageing-in-Place. In Singapore, there is a big shift underway to movefrom a hospital-centric care towards more community-based, ageing-in-place solutionswith many initiatives launched promoting self-care, enhanced primary care services andcommunity-based services.He shared a framework for ageing-in-place and highlighted that there are two main parts: • Population health and disease prevention • Post-acute care and disease management Which part of ageing-in-place is more cost-effective - Population health and Disease prevention or Post-acute care and disease management?For most academics, the answer would be “post-acute care and disease management”. Thisis where most of the government spending is going into now. Most people think preventionis great, but it’s (actually) not that important. For the cost-effectiveness of post-acute careand disease management, many studies have shown that the quality of life has greatlyimproved because of transitional care at home and in the community or in reducing re-hospitalisation rate.Linus Tham from the National Healthcare Group noted that the cost and benefits do notalways accrue to the same ministry. This suggests that there is opportunity for greatercoordination across different ministries.There is still a need to develop “efficient and cost-effective” primary and preventive carethough better needs assessment and more precise targets need to be established. There isalso a need for “navigators” to help people work their way through the system.Singapore Innovating Health Series | Roundtable 2 Summary Report 4

He looked at why things don’t work as they should?He feels that this is usually due to (always) misaligned incentives.Taking the example of Health screening where there is a benefit to identifying at-riskindividuals early. He noted that the screening is easy but the subsequent follow up is thehard part. At the provider level, the general practitioner often feels there is low returns onthe effort required on his part. Hospitals will question whether their nurses deployed forhealth screening could be better utilised for patient care given the shortages in nursing.The patient often feels it is not worth their effort to get screened as many feel they arecovered by their health insurance.The other issue is that there will always be constraints in resources.The Government will have to choose how best to allocate funds and resources within thegiven budget. It is recognised that the poor with poor health are the ones who need themost help and who should be given more support. Patients and their families will still needto decide how best to spend their money on healthcare.Dr Liu concluded that there is a need to strengthen the Intermediate and Long Term Care(ILTC) sector and ensure a smooth transition from hospital to the community. There is stillwork needed to develop efficient and cost effectiveness primary and preventive care. What is the top factor for non-adherence to community-based LTC service referrals?Household income and affordability is the key factor here. Surveys show that cost isdefinitely a major consideration for rejection and/or non-follow up of long term care servicereferrals.Ms Loh Shu Ching of Ren Ci Hospital believes that it’s a mixture of convenience andaffordability. For example, patient goes to the hospital and gets high subsidy and is lookedafter 24 hrs/day, as opposed to going to day rehab centre where patient pays higher and isonly looked after for maybe 2 hours and the rest of the tome, the family still needs to lookafter patient.Dr Liu noted that affordability is not directly relevant to income in the study. No matter whatthe amount of family income is, their perceived affordability is similar.Singapore Innovating Health Series | Roundtable 2 Summary Report 5

Who is responsible for fulfilling the LTC needs for the middle class with some ADL limitations?The group generally felt that it will have to be some form of Public Private Partnership.Dr Eugene Shum from Eastern Health Alliance feels that it is artificial to say that the richneeds more or better care. He felt that the care needs should be the same for an illnessregardless of whether the person is rich or poor and that the non-care components shouldbe considered separately. With the care needs being looked at in this manner, the questionto be answered will be how the poor can be funded to receive the same level of care.Mr S. Devendran felt that in the Singapore context where nearly 80% live in public housingand with a good percentage of middle-income families, the sense of what is private andpublic long term care service often gets blurred.There should also be a move from passive towards more strategic purchasing for properalignment of incentives and also to optimise limited resources.Strategic purchasing can help achieve health system objectives. This can take the form ofadjustments in the volume and distribution of delivered services. There can also be changein the composition of input mix (staff, medicines, etc.) Provider behaviour may also changefor more appropriate care including for hospitalizations, use of high-tech diagnostics andprocedures, prescriptions, etc. Patient behaviour may also change for better treatmentadherence. Strategic purchasing practices to date have shown that it requires a high degreeof monitoring and information. One unanswered question is what happens when volumetarget is exceeded and the cap is reached?Singapore Innovating Health Series | Roundtable 2 Summary Report 6

Robotics and AI will re-design Healthcare Dr Fan Xiuyi Research Fellow, Joint NTU-UBC Research Centre of Excellence in Active Living for the Elderly (LILY) Nanyang Technological UniversityThe LILY Research Centre was founded in August 2012 by NTU and University of BritishColumbia (Canada).Smart Homes for Health has been actively researched. We have seen the following wavesover the years. • Intelligent building – 1980s - Intelligent consumer electronic devices - Security and safety devices - Easy communication devices • Smart homes for elderly – 2000s - 24h health monitoring - Smart assistive equipment • Smart homes for illness detection and prevention – 2010s - Physical and emotional care need - Targeted illness detection – dementiaIn the area of Medical Robotics, we have seen advanced in Surgical robotics systems likethe Da Vinci system, Service robots which provide portering services in hospitals, Tele-health robots which can provide companionship and home health monitoring services.The following technologies will enable new capabilities.The Internet of Things (IoT) will allow for new sensors which have better connectivity andaccuracy and yet are cheaper to allow for wider usage. Artificial Intelligence (AI), while nottotally new, will bring to the table deep learning for better data processing as well as manyrule-based approaches for better knowledge utilisation. These will allow for unobtrusivesensing for ageing-in-place. Various types of sensors are involved but the research at NTUdoes not use video for privacy reasons. Wearables will further add to the plethora of datathat can be collected and used.Dr Fan shared about the research being done in NTU where 5 HDB flats have been provisionedwith sensor and monitoring technologies. The overall architecture will see data from thetest HDB home being sent to a server backend.Singapore Innovating Health Series | Roundtable 2 Summary Report 7

There is a cognitive analytic service which utilises sensors to detect a person’s activitieswith analytics determining patterns and state to suggest wellness of the person. The dataallows for the development of a Living Well Index Systems with multiple indices: • Motion index • Healthy lifestyle index • Exercise index • Environmental index • Sleep index • Diet index • Well-being indexDr Fan shared a video demonstrating the following scenarios using various sensors andtechnologies: • Interactive TV • Taking items from fridge - Triggers purchase of things running low • System can generate story for the day’s activities which can be sent to family member • Tech has been deployed to 5 homes • Initial excitement gives way to the technology being ignored • Patterns get picked up • Technology does not distinguish between different people in the same household however this can be resolved when wearables are usedThe LILY’s vision is for a population level personalised healthcare model which will supporta move from the institution-centred care model towards a personalised care modelThe current open challenges are: • Moving from sensor data to healthcare answers • Achieving large scale user adoption • Resolving the human factors in ageing-in-place technologies • Solving the right problems, togetherSingapore Innovating Health Series | Roundtable 2 Summary Report 8

ConclusionBREAKOUT AWhat are the key characteristics of successful independent living and ageing-in-place forthe elderly? • Medical screening and preventive care are important. • However, the psychosocial aspect is also equally important in the form of enabling active lifestyles with good community and social support. It was noted that individuals must be motivated to want to live independent and want that quality of life. • The environment and ecosystem must be there where services are close by and easily accessible. The physical environment must also support the movement of the elderly.What are the key factors that can advance assisted living in Singapore? • The group felt that town planning is critical with community care services decentralised and available to facilitate ageing-in-place. • The infrastructure must allow for easy - Road access - Wheelchair accessibility - Use and design of kerbs must be considered • There will also be a need for a shift in mindset to “want to” live independently - Some expected to be supportedCreate a vision of an ideal model for senior independent living in Singapore • It was accepted that the community is important • The motivation to want to live independently must be there • Amenities and services must be available and easily accessible • The group also shared two models - In Sweden, the services come to the individual in their home - In Taiwan, there is a model to buy into a condominium estate where the services are available to the residentsIn summary, senior independent living is dependent on the individual wanting to liveindependently or perhaps ‘not having a choice’. As such, for a senior to age-in-place, itis important to ensure a community is built around them and to provide easy access toamenities and services depending on the standard of living (different models) for each ofthe senior group including Retirement Village/Residence, or Community base senior caremodel (C2H - Care to Home).Singapore Innovating Health Series | Roundtable 2 Summary Report 9

BREAKOUT BWhat unique “human touches” cannot be replaced by technology? • The group was clear that a humanoid robot is not human and that holding warm hand is more therapeutic and will provide better reason to live a meaningful life. • The group shared about a person who was invalid at home and bedridden. She lived for the 2-hour visit each day by the nursing help who also provided companionship.How can technology advance senior independent living and/or assisted living? • The group was clear that robots cannot replace the human. They felt that robots can augment and assist. • The group pointed out that the elderly is a heterogeneous group and therefore the technology will need to be more customised as the person becomes more frail and needs more help. • Work needs to be done to ensure that people will be comfortable interacting with the technology. • There may need to have protocols on how robots will be used and that feedback may need to be given to the government on a longer-term horizon. • The group also noted that the technology acceptance will vary depending on the time the person was born.Create a vision using disruptive technologies or robotics that can promote seniorindependent living • The group identified the following - Use of AI for comprehensive genetic based assessment which helps to evaluate risk and select treatment options - Command centre to monitor residents and deploy services as needed - Virtual/augmented reality for elderly so they can travel vicariously, visit with relatives or perform exercises - Augmented exo-skeletons for caregivers so they may lift the disabled, or exo- skeletons to assist the disabled elderly so they can stand up by themselves.In summary, the ‘human touch’ can never be replaced by robots and technology. Howevermany of these innovations will be needed to enable and advance independent living amongseniors by augmenting and overcoming the physical constraints of ageing by enablingthem to remain independently mobile in their physical environments which are also re-designed to facilitate this. The technology will also enable better monitoring of the elderlyin their homes and would be able to determine and deploy resources for example in anemergency.Singapore Innovating Health Series | Roundtable 2 Summary Report 10