Integrating Dementia Care in Singapore Dr Ng Liling

Integrating Dementia Care in Singapore Dr Ng Li-ling Psychiatrist Changi General Hospital Singapore

• • Overview System of dementia care Integration Challenges

World Alzheimer Report 2015 One new case of dementia every 3 seconds

The ideal system of care • • Prevention Awareness Recognition Assessment Diagnosis Management and treatment Crisis management End of life

Where are we now? • Awareness lacking • Dementia care tends to be hospital based • Health care and social care independent of each other • Dementia services are inadequate and fragmented • Caregivers have great difficulty manoeuvring the system • People with dementia and their families fall through the gaps

Integration • Integrate – “to make whole” • Comprehensive care • Integration – Disciplines – Acute and long term care – Hospital and community services – Health and Social services

The ideal system of care • • Prevention Awareness Recognition Assessment Diagnosis Management and treatment Crisis management End of life

Risk Factors and Risk Reduction Risk Factors Risk reduction strategy • Early Life • Improve access to secondary and tertiary education. • Improved detection and treatment of diabetes and hypertension • Smoking cessation • Increased physical activity • Reduction in levels of obesity – Low education • Midlife – Hypertension • Across the life course – Smoking – Diabetes

Integrate Health Promotion • Brain health promotion messages should be integrated in public health promotion campaigns – anti-tobacco or non-communicable disease (NCD) awareness campaigns “What is good for your heart is good for your brain”.

The ideal system of care • • Prevention Awareness Recognition Assessment Diagnosis Management and treatment Crisis management End of life

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“Ah Kong” – Royston Tan 20 th Sep 2010 www. hpb. gov. sg/mentalhealth

Raising awareness about dementia • • Early diagnosis - access to interventions and services Reduce stigma Educate caregivers and families Dementia friendly community - building support for people with dementia and their caregivers in their neighbourhood – E. g. Help people with dementia in community who get lost – E. g. Employers that are more sympathetic when caregivers need time off work in a crisis

The ideal system of care • • Prevention Awareness Recognition Assessment Diagnosis Management and treatment Crisis management End of life

Services • Assessment and management • Hospital care • Community based services – Home based – Day care – Caregiver support • Residential services • Training

Assessment • Memory Clinics • Specialist clinics – Geriatrics – Neurology – Psychogeriatrics • Primary Care • Shared Care with primary care physicians

Hypertension Arthritis Mild Stroke Unsteady gait Irregular with medication Chest Infection Diabetes Dementia Lives with family who are at work No carer at home in daytime Agitated and restless Financial problems

Nurses Doctor Specialists Respiratory physician Endocrinologist Neurologist Rehab physician Geriatrician Psychiatrist Psychologist Care attendant Occupational Therapist Speech Therapist Social Worker Podiatrist Dietician Physiotherapist Pharmacist

Integrating hospital services • Within a team first • Between departments – Joint ward rounds – Memory clinics run by geriatrics and psychogeriatrics • Between agencies • Between health and social ministries

Improving Dementia Care in Hospitals • Pilot project funded by Ministry of Health • Dementia friendly environment • Training of all levels of staff in dementia care in 4 wards • Occupational Therapist and Therapy Assistant to conduct activities in ward • Support of a Dementia specialist team

Dementia friendly community

Integrating services • • Within a team first Between departments Between agencies Between health and social ministries

Elderly services Social Services Health services • Befrienders • Home help • • • Neighbourhood links • Senior Activity Centre • Social Day Care Centre • Sheltered Housing Home medical Home Rehabilitation Home Nursing Day Rehabilitation Centres Dementia Day Care Centres • Nursing Homes

Rehabilitation Social Senior Care Centre (Integrated Care Facility) Dementia Care Nursing Care

Residential services Social Services Health Services • Sheltered housing / Hostels • Nursing homes – Physically fit – ADL independent • Homes for the aged / Social care homes – Destitute – No family support – Minimal assistance ADL – Medical and nursing care needed

Integrated Residential Services • Medical / Nursing • Psychosocial • Integrate with community based services – Day rehabilitation – Dementia day care – Home based medical, nursing and social care

Collaborations with Nursing homes • Community Psychogeriatric Programme supports several nursing homes to improve care – Training – Consultations for challenging behaviours – Multidisciplinary Case Discussions – Crisis – End of life – Reduce unnecessary transfers to hospitals

Clarity Courtesy of Dr Philip Yap, Khoo Teck Puat Hospital

Training • Knowledge • Skills • Attitudes Person Centred Care Treat the person with dementia not just the disease

Training • Limited manpower trained in dementia care • Different hospitals and agencies doing training in dementia care with different curriculum • Dementia Competency Framework

Integration • Comprehensive care • Integration – Acute and intermediate and long term care – Disciplines – Health and Social services • Integrate – “to make whole”

Principles of Integrating Service Common vision, values and goals Able leadership Situational analysis Attention to potential interface problems Focus on team’s development Shared comprehensive assessment processes Clear administrative, clinical and funding structures Interdependent cooperation in education, training, professional development • Good clinical governance and attention to quality • • Psychogeriatric service delivery: an integrated perspective, B Draper, P Melding, H Brodaty

Vision and Leadership • National Dementia Network – Representatives from hospitals, community health and social agencies, ministries of health and social family development, polytechnic, university – National Dementia Strategy – Challenges • • Membership Partnerships Communication Health and Social Systems

Developing Partnerships

Partnerships • Mutually beneficial relationship between organizations • Opportunity for hospitals and community organizations to identify shared goals, uncover gaps, and join forces to achieve improved health care and quality of life for individuals in their communities

Partnership • Model of partnership – Clear objectives – Who are the partners • Collaborative planning – Shared goals – Coordinated work plan – Assign lead person – Flexibility • Operational issues

Partnerships • Trust – differences in scope of expertise, work ethic, and communication – building a foundation of respect – transparent about goals – “we have come to learn” • Philosophy – Person centred care

Philosophy - 6 “C”s • • • Career Car Condominium Credit card Cash Country club membership • Kiasu-ism – “afraid to lose”

A-Z of Kiasu-ism • • • • A - Always must win B - Borrow but never return C - Cheap is good D - Don't trust anyone E - Everything also must grab! F - Free! G - Grab first talk later H - Help yourself to everything I - I first, I want, I everything J - Jump queue K - Keep coming back for more L - Look for discounts M - Must not lose face

• • • • A-Z of Kiasu-ism N - Never mind what they think O - Outdo everyone you know P - Pay only when necessary Q - Quit while you are ahead R - Rushing and pushing wins the race S - Samples are always welcome T - Take but don't give U - Unless it's free forget it V - Vow to be number one W - Winner takes it All! X - X'tra = More Y - Yell if necessary to get what you want Z - Zebras are kiasu because they want to be black and white at the same time

Healthcare Kiasu-ism • Fear of……. – Losing face – not asking questions – Losing to the “competition” - one upmanship – Doing things to protect ourselves / organisation vs for patient – Failing - so don’t try – Authority – not doing what you believe in and right – Losing authority / control – not delegating / sharing - territorial

Obstacles • • Professional arrogance Territory Rivalry Dysfunctional teams Empire building Management systems Funding Psychogeriatric service delivery: an integrated perspective, B Draper, P Melding, H Brodaty

Lions Home for the Elderly Ageing with Grace & Dignity