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Prior to beginning work on this discussion, review Chapters 5, 6, and 7 in your Intro to Health Care and required readings (attached) Analyze the levels of care in the U.S. health care system. The delivery mode you will be analyzing is Long-Term Care.Delivery Mode1Long-Term CareIn your initial response, begin by briefly analyzing your assigned delivery mode of care and address the following:Describe the type of care this option Consider the following:Explain the history of this mode and how it has evolved over time.Discuss the care given via the delivery mode.List two options to cover the costs of care and explain the limitations of health care insurance coverage for the delivery mode.Discuss, in addition, the following components that affect the delivery of care for your assigned mode:Include one ethical or legal concern.Include one regulatory or accreditation requirement.Include one psychosocial factor to consider (e.g., food scarcity or food desert, access to exercise, or cultural and religious concerns).
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Forging a Frailty-Ready Healthcare System to Meet
Population Ageing
Wee Shiong Lim; Sweet Fun Wong; Leong, Ian; Choo, Philip; Weng Sun Pang.
International Journal of Environmental Research and Public Health
Health;; Basel Vol. 14, Iss. 12, (Dec
2017): 1448.
DOI:10.3390/ijerph14121448
Abstract
The beginning of the 21st century has seen health systems worldwide struggling to deliver quality healthcare
amidst challenges posed by ageing populations. The increasing prevalence of frailty with older age and
accompanying complexities in physical, cognitive, social and psychological dimensions renders the present
modus operandi of fragmented, facility-centric, doctor-based, and illness-centered care delivery as clearly
unsustainable. In line with the public health framework for action in the World Health Organization’s World
Health and Ageing Report, meeting these challenges will require a systemic reform of healthcare delivery that
is integrated, patient-centric, team-based, and health-centered. These reforms can be achieved through
building partnerships and relationships that engage, empower, and activate patients and their support
systems. To meet the challenges of population ageing, Singapore has reorganised its public healthcare into
regional healthcare systems (RHSs) aimed at improving population health and the experience of care, and
reducing costs. This paper will describe initiatives within the RHS frameworks of the National Health Group
MoreMore
(NHG) and the Alexandra Health System (AHS) to forge a frailty-ready healthcare system across the
spectrum, which includes the well healthy (“living well”), the well unhealthy (“living with illness”), the unwell
unhealthy (“living with frailty”), and the end-of-life (EoL) (“dying well”). For instance, the AHS has adopted a
community-centered population health management strategy in older housing estates such as Yishun to
build
a geographically-based care ecosystem to support the self-management of chronic disease through
1. Introduction
projects such as “wellness kampungs” and “share-a-pot”. A joint initiative by the Lien Foundation and Khoo
The
of theaims
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seen an exponential
growth across
in population
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United
Nations
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Population
Prospects,ofthere
is an estimated
962 million
peopleGroup,
aged 60
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partners,
businesses,
and members
the public.
At the National
Healthcare
years and above,
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13needs
percent
global
population
[1].developed
With a growth
of about
innovative
projects
to comprise
address the
of of
thethe
frail
elderly
have been
in therate
areas
of: (a) three
admission
percent perthrough
year, this
figure
is projected
to hit 1.4 billion
in 2030. nurse-led
Globally, the
oldestassessment
old population,
which is
avoidance
joint
initiatives
with long-term
care facilities,
geriatric
at the
variously
defined
as 80 or
85geriatric
years and
older, has emerged
asinpatient
the fastest
growing
age
especially
in
emergency
department
and
assessment
clinics; (b)
care,
such as
thesegment,
Framework
for
developedcare
countries
[2]. Elderly, orthogeriatric services, and geriatric surgical services; and (c) discharge to
Inpatient
of the Frail
Full Text
care, involving community transitional care teams and the development of community infrastructure for postAlthough
the worldtransition
are rapidlytoageing,
evidence
that increasing
is accompanied
dischargepopulations
support; andaround
an appropriate
EoL care.
In the area
of EoL care,longevity
the National
Strategy for
by
an extended
period
ofdeveloped
good health
scarce
[3]. In most
populations,
the increase
in life
expectancy
Palliative
Care has
been
to is
build
an integrated
system
to: provide
care for frail
elderly
with advance
outstrips
increase
in healthy
life expectancy;
a consequence,
a greaterand
proportion
of one’s lifespan is
illnesses, the
develop
advance
care programmes
thatas
respect
patients’ choices,
equip healthcare
spent
with disability.
an expansion
of morbidity, which is in contrast to the Fries (1980)
professionals
to copeThis
withconstitutes
the challenges
of EoL care.
concept of the compression of morbidity [4]. The epidemiological transition away from communicable,
maternal, infant, and nutritional disease is also offset by an increase in non-communicable chronic disease,
along with increased disease burden from multi-morbidity and geriatric syndromes such as frailty and
dementia [5]. Clearly, disease-based conceptualisations are inadequate proxies for health in an older person.
Rather than the presence or absence of disease, the most important consideration for an older person is likely
to be their functional ability. This conceptual shift was reflected in the World Health and Ageing Report of the
World Health Organization (WHO), which emphasised function as an important outcome for ageing
populations by highlighting the concept of raising intrinsic capacity throughout the life course [5,6].
The complementary perspective is the prevention of frailty, which has physical, cognitive, social, and
psychological dimensions [7]. Frailty is a geriatric syndrome characterised by the loss of physiologic reserves,
which increases the vulnerability of the older adult following trivial stressor events, and leads to a higher risk
of negative health-related outcomes [8]. The prevalence of frailty in community-dwelling older adults in the
Asia-Pacific region is approximately 3.5-27% [9]. The “frailty syndrome” has been described as an emerging
public health priority, as it may represent a vicious cycle responsible for the onset of negative health-related
outcomes, a transition phase between successful ageing and disability, and a condition to target for restoring
robustness in the individual at risk [10]. The body of evidence indicates that a large proportion of communitydwelling older people present risk factors for major health-related events and unmet clinical needs [11]. If left
unaddressed, this may result in increased disability and the increased consumption of health and social care
resources; in one study, the incremental effect on ambulatory health expenditure approximates an additional
€1500 per frail person per year [12]. It can also result in significant caregiver burden and the accompanying
informal costs of caregiving, particularly in Asian populations, which are often heavily influenced by notions
of filial piety and obligatory care [13,14].
Against this backdrop, health systems worldwide are struggling to deliver quality healthcare amidst
challenges posed by ageing populations, the complexity of health states in old age, and increasingly complex
technology, which all have contributed to escalating costs. Most healthcare systems in the world have been
built on the disease-based acute care model, which originated in the clinical service model for handling acute
and defined disease episodes, and is singularly inadequate to meet the challenges ushered by the new era of
multiple interacting chronic diseases and the accompanying complexity of the physical, cognitive, social, and
psychological dimensions of the frailty syndrome [10,15]. This provides the impetus for the recent discourse
surrounding the utility of the frailty concept in guiding the development of health policies in caring for older
people. Woo (2017) eloquently argued that health systems and models of care should be realigned and
redesigned to be fit for purpose and better address the unmet needs of frail older people [16].
The public health framework for healthy ageing promoted by the WHO calls for four key areas of action by
governments on healthy ageing: aligning health systems to the needs of the older populations they now
serve; developing systems to provide long-term care; ensuring everyone can grow old in an age-friendly
environment; and improving measurement, monitoring, and understanding [5,6]. In line with the public health
framework for action in the WHO’s World Health and Ageing Report, meeting these challenges will require a
systemic reform of healthcare delivery that is integrated, patient-centric, team-based, and health-centred
through building partnerships and relationships that engage, empower, and activate both the patients and
their support systems. This paper will mainly focus on the first and third areas of the WHO report, using
Singapore as a case study.
2. Singapore as a Case Study
Singapore has a multiethnic population of about 5.7 million. The low infant mortality (2.4 per 1000 live births)
and high life expectancy (82.9 years) attests to the standard of healthcare [17]. Since the mid-1960s, when
the country developed into an economic powerhouse, Singapore’s population began graying at a speed that
matched many other industrialised economies. By 2000, with at least 7% of its population aged 65 and above,
Singapore had become an ageing society. In 2016, 13.7% of the population was aged 65 and above, and
Singapore is forecast to breach the 14% mark and become an aged society soon [17]. Not surprisingly,
population ageing has been identified as one of the major challenges confronting the healthcare system [18].
Singapore’s healthcare delivery system is a dual one of public and private care: 80% of inpatient care is
provided in public hospitals, while 80% of primary health care is provided by independently employed family
physicians [19]. A principal feature of the healthcare philosophy for the public system is that of individual
responsibility for health and the need for copayment for services provided. Public healthcare facilities are
primarily designed to provide subsidised healthcare services to Singaporeans, and consist of hospitals for
inpatient services and numerous polyclinics offering outpatient services. Although wholly owned by the
government, the public sector hospitals are operated as autonomous organisations in order to instill financial
discipline and devolve operational autonomy [19].
The traditional care delivery system tends to be facility based, hospital-centered, and more siloed and
fragmented in terms of care coordination [20]. While the advent of chronic disease management in the early
2000s has facilitated the follow through and coordination of care processes across the lifetime of an illness
[19], this approach is inadequate in the face of confluent multi-morbidity and ill-defined geriatric syndromes
that do not fit the single-disease model [5,10]. Evidence-based clinical guidelines work best in discrete
conditions, but have not for the most part, focussed on the integration of multiple interacting and possibly
competing chronic conditions within individuals [21]. Similar to the worldwide experience, acute hospitals and
emergency departments were generally neither elder-friendly nor frailty-ready. Not surprisingly, hospitalised
frail older adults constitute an at-risk population that was vulnerable to adverse post-hospitalisation
outcomes such as functional disability, institutionalisation, and mortality [22]. Post-discharge community
services were underdeveloped to support the successful transition from discharge to home, resulting in
recurrent hospitalisations accruing from an index admission. The lack of a systematic framework for advance
care planning meant that the perspectives and preferences of patients regarding their health and treatment
choices, which are especially pertinent in the context of end-of-life (EoL) care, were often not incorporated
into the care plan. Finally, at the health policy level, the funding mechanism in Singapore was previously
based upon episodes of care, and did not provide incentives for public healthcare providers to efficiently
organise and coordinate care across the whole range of services, or develop preventative and health
promotion activities [19].
2.1. Concept of Regional Healthcare Systems (RHS)
To meet healthcare challenges such as population ageing, increased chronic disease burden, and the need to
manage future growth in healthcare manpower and spending, the healthcare 2020 master plan was
announced in 2012 to improve the accessibility, affordability, and quality of healthcare in Singapore [23]. One
strategy that is being adopted to better integrate care across different settings is re-organising the healthcare
system into regional health systems (RHSs). Each RHS comprises an acute general hospital working closely
with community hospitals, nursing homes, hospices, home care, and day rehabilitation providers, as well as
government polyclinics and private general practitioners (GPs) within the geographical region. The purpose of
the RHS is to foster the vertical integration of services, and enhance synergy and economies of scale to
improve the quality of healthcare while keeping medical costs affordable. From the patient perspective, the
provision of integrated, seamless, and holistic care by the RHS enables patients and their caregivers to
navigate across providers more easily. It also empowers them to manage their care needs across different
stages of their healthcare journey, from diagnosis and treatment through to post-discharge follow-up.
Public healthcare facilities were initially divided into six RHSs. Preliminary results indicate that integration
efforts to enhance the primary, intermediate, long-term, and home care sectors, as well as consolidate
networks between hospitals and these care providers, have helped to streamline processes, support the
faster recovery of patients, and shorten the length of hospitalisation [24]. To better meet Singaporeans’ future
healthcare needs, the Ministry of Health recently announced that the healthcare system will be further reorganised into three integrated clusters from the existing six RHSs [25]. In the central region, the National
Healthcare Group (NHG) and the Alexandra Health System (AHS) will form one cluster under the National
Healthcare Group. In the eastern region, the second cluster under SingHealth will comprise Singapore Health
Services (SingHealth) and the Eastern Health Alliance, whilst the National University Health System (NUHS)
will merge with Jurong Health Services to form the third cluster under NUHS in the western region. This
reorganisation provides an opportunity to further foster integration through the design and coordination of
services within the cluster, and also inter-cluster cooperation for innovations in care delivery. The healthcare
funding structure will also be aligned to place a greater focus on health prevention and maintenance
programmes that incentivise individuals and families to stay healthy and be active participants in their health
matters.
2.2. Blueprint of the RHS Framework for the Central Region
2.2.1. Challenges and Key Directions
The central region serves around two-fifths of Singapore’s population. Since many of the older housing
estates are located in the central region, this catchment area also serves a higher proportion of the elderly
population. Based upon results of the 2015 census in the central region, more than two-thirds of older adults
aged 60 years and above are either living with illness (57.6%) or frailty (14.1%) [20]. Frailty was defined
empirically from database-derived variables using the phenotypic approach. The typical profile of the frail
group is older age, female gender, lower socio-economic status, living alone or with limited family support,
physical disability, and increased care needs. The top contributors to the frailty indicators are stroke and
dementia.
Against this backdrop, it is clear that the present modus operandi of fragmented, siloed, and facility-centric
healthcare with lots of hand-offs and care delivery organised around the doctor is both untenable and
unsustainable. The patient is often a passive recipient of care, with care provision often occurring on a
transactional basis in reaction to a medical need or a crisis presentation. Social determinants of health are
not adequately addressed during acute care episodes. There is also a big discrepancy in the quality of care
between hospital and home, with little community involvement. The reorganisation of the healthcare system
into RHSs prompted a paradigm shift in the approach toward ageing and health, namely: to move beyond the
hospital to the community; to move beyond quality to value; and to move beyond healthcare to health [23]. In
the central region, this translates into the reorganisation of care to achieve seamless and integrated care
across the continuum of health that emphasises prevention and planning, and actively engages community
partners through a team-based approach (Figure 1). Importantly, effective engagement with patients and their
caregivers is not about achieving patient “compliance” with professional recommendations, but rather about
promoting dialogue and building trusting relationships to activate patients, families, and their caregivers, so
that they are activated, engaged, and empowered in the care process. There is a growing body of evidence
showing that patients who are more activated have better health outcomes and care experiences [26].
[ Image omitted. See PDF. ]
2.2.2. Blueprint of the RHS Framework
A holistic framework is needed to provide a clear blueprint for the systemic shift towards forging a frailtyready healthcare system that spans the care continuum, including the robust (“living well”), the healthy with
chronic diseases (“living with illness”), those who become acutely unwell or develop complications from
chronic diseases (crisis and complex care), the frail who are vulnerable to adverse outcomes (“living with
frailty”), and finally, the terminally ill (“dying well”) [20]. Depending on the care needs, a calibrated modular
bundle of care services is then delivered via multi-disciplinary teams. These cover the domains of staying
healthy, proactive community care, admission avoidance, inpatient care, discharge to care, maintaining
independence, and dying well (Figure 2). For instance, for the “living with frailty” group, the relevant bundle of
care services would include discharge to care, maintaining independence, and admission avoidance.
[ Image omitted. See PDF. ]
2.3. Community Initiatives for Ageing-in-Place
Over the next two decades, the rapid demographic shift in Singapore will manifest in population ageing, lower
labour growth, and shrinking family sizes. With an increasing number of seniors and weaker family support,
the demand for aged care facilities and institutionalisation will grow. Yet, ageing-in-place and at home remain
the preference of many local seniors [27]. In line with the WHO’s priority areas of aligning health systems to
the needs of the older populations they serve and ensuring everyone can grow old in an age-friendly
environment [6], one key thrust of the RHS strategy is to orient systems around intrinsic capacity by
developing community initiatives that ensure access to older person-centred services that support ageing-inplace. It is important to address the attendant social factors that can influence health choices and
behaviours, and build trusting relationships between healthcare workers and patients in their homes and the
community where they make their health choices [28]. This is especially salient in the central region, where
the majority of the older population comes from the lower socio-economic strata and resides in older public
housing estates. We describe two examples to illustrate how programmes premised on a community-centric
population health approach can help meet the healthcare and social needs of the frail elderly to support
ageing-in-place.
2.3.1. Wellness Kampungs
To build resilience and sustainability into tomorrow’s health landscape, the Alexandra Health System adopted
the approach of going upstream to addr …
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