Kampung Bahagia 2030 (Vol I)

KAMPUNG BAHAGIA 2030

REDEFINING SENIOR LIVING WITHIN THE COMMUNITY

KAMPUNG BAHAGIA 2030 REDEFINING SENIOR LIVING WITHIN THE COMMUNITY

M. ARCH THESIS DOCUMENT VOLUME 1 CHEONG CHI YAN

acknowledgements This thesis document could not have been made possible without the constant guidance and valuable advices from my mentor, Dr Chong Keng Hua. I would also like to thank the experts in the field, Dr Belinda Wee, Prof Tan Hwee-Xian and Ju Jiaming, as well as the seniors for extending their time to share their insights with me.

Last but not least, I would like to extend my heartfelt gratitude to my family and friends for the moral support and continous encouragement they have given throughout the journey. To God be the glory.

abstract In 2030, one in three seniors in Singapore will require assistance with carrying out daily activities. Despite the government’s efforts in providing various living and care options for the seniors, such options are inadequate to meet the demands of the future cohort of seniors, who are more educated and harbour bigger aspirations compared to their forefathers. Most seniors shun institutionalised settings such as nursing homes. Home and centre-based care can prove to be costly and inefficient. In view of the various living and care options that are already in place, this thesis seeks to provide an additional option to plug into the existing gap, rather than a ‘solution’. Assisted living facilities, which bestow seniors with assistance with activities of daily living while providing them with dignity and autonomy, is a care option which is sorely lacking in Singapore. Organised by philantropists, the few assisted living facilities in Singapore are small-scale and expensive. In March 2019, proposals have been put forth to incorporate assisted living facilities into public housing estates.

This thesis seeks a new paradigm of utilising elevated and underused void deck spaces for assisted living. In the future, such typological innovations could possibly be incorporated into environmental decks of newer Built-to-Order(BTO) flats.

content

1

SINGAPORE 2030: A SUPER-AGED SOCIETY understanding the seniors SENIORS IN SINGAPORE: a diverse demographic HOW OLD IS OLD: young-old, old-old, oldest-old HOW OLD IS OLD: category of seniors SOCIAL PASSAGE: changes in mindset as one ages LIFESTYLE IN OLD AGE NEEDS IN OLD AGE: physical and emotional needs

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DILEMMA OF SENIORS IN SINGAPORE exploring the current living and care options LIVING LONGER = AGEING WELL? AGE-IN-PLACE: FILIAL PIETY AND FAMILIAL SUPPORT? Current Housing and Care Options for Seniors: Summary Chart NURSING HOME: still a taboo?

HIRING OF MAIDS: the easy way out?

HDB SENIOR GROUP HOMES: is it sufficient?

HDB SENIOR COMMUNITY HOME HDB 2-ROOM FLEXI FLATS INTEGRATED 2-ROOM FLEXI FLATS

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AGEING-IN PLACE = AGEING WELL? examining the case of ‘ageing-in-place’ HOW TO ENABLE AGEING-IN-PLACE IN SINGAPORE? HOME AND CENTRE-BASED CARE: is it necessarily replacing nursing homes?

ACTIVE AGEING HUBS: the solution?

TECHNOLOGIES: how does it enable ageing-in-place?

AGEING-IN-PLACE: is staying in the same apartment necessarily what the seniors need?

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THE CASE FOR ASSISTED LIVING understanding assisted living HOW TO DEFINE INDEPENDENCE? HIEARACHY/ CLASSIFICATIONS OF ACTIVITIES OF DAILY LIVING SENIORS’ DILEMMA: what if i can no longer manage myself independently?

ASSISTED LIVING: is this the housing solution for seniors who require help with adl?

WHY ASSISTED LIVING WITHIN THE COMMUNITY?: addressing the gap of deinstitutionalisation and affordability IS ASSISTED LIVING NECESSARILY A SUCCESS?: potential problems ANY OF SUCH ASSISTED LIVING FACILITIES IN SINGAPORE?

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CLASSIFICATIONS OF ASSISTED LIVING understanding the types of assisted living according to typologies TYPES OF CLASSIFICATIONS OF ASSISTED LIVING TYPES OF ASSISTED LIVING RESIDENCES(ALR): basic, enhanced, special ASSISTED LIVING IN DIFFERENT COUNTRIES CONTINUING CARE RETIREMENT COMMUNITIES (CCRC): overview CONTINUING CARE RETIREMENT COMMUNITIES (CCRC): estate-scale UNIVERSITY-BASED RETIREMENT COMMUNIES: estate-scale NATURALLY OCCURING RETIREMENT COMMUNITIES: estate-scale 4-5 STOREY APARTMENTS: building complex 3-STOREY APARTMENTS: building complex PODIUM AND TOWER TYPOLOGY

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CONCEPTS OF ASSISTED LIVING RESIDENCIES understanding the types of assisted living according to typologies DUTCH LIFETIME NEIGHBOURHOOD DANISH COHOUSING MODEL HOMESHARE HOUSEHOLD MODEL JAPANESE TAKUROUJO JAPANSESE GOJIKARA MURA DUTCH CARE COOPERATIVE VILLAGE VILLAGE MODEL

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OTHER DESIGN CONSIDERATIONS other things to note for design of assisted living units OF WHAT SCALE? FLEXIBLE CONFIGURATIONS TYPICAL FLOOR PLANS OF ASSISTED LIVING UNITS AFFORDABILITY HOW TO EASE NIMBY SYNDROME: design elements to achieve deinstitutionalisation

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WHERE DO WE GO FROM HERE? possible ways forward for singapore WHY ASSISTED LIVING IN HDB? MIXED-USE TYPOLOGY: brief introduction MIXED-USE TYPOLOGY: examples MIXED-USE TYPOLOGY: why incorporate assisted living facilities onto the podium?

CENTRAL AREA: why incorporate assisted living facilities into highly urbanised areas?

Tanjong Pagar Plaza Potential Design Questions

APPENDICES BIBILIOGRAPHY

1 SINGAPORE 2030: A SUPER-AGED SOCIETY understanding the seniors SENIORS IN SINGAPORE: a diverse demographic HOW OLD IS OLD: young-old, old-old, oldest-old HOW OLD IS OLD: category of seniors SOCIAL PASSAGE: changes in mindset as one ages LIFESTYLE IN OLD AGE NEEDS IN OLD AGE: physical and emotional needs

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seniors in singapore: a diverse demographic The World Health Organisation defines an aged society as one where 14% or more of the population is aged 65 years and above.

2012

In Singapore, the percentage of residents 65 years and older is projected to double from 9.3% in 2011 to 19% in 2030. By 2030, Singapore will join the ranks of ‘super-aged’ societies, with one in four senior citizens. The rising old dependency ratio will impose enormous burdens on strained middle, who, esteeming their duty to parents, support several dependants, including their offspring as well.

2026

The median age of the Singapore population would climb from 40 years in 2015, to 47 years in 2030 and 52.8 years in 2050.

2018

Age 20-64

2030 Old- Age Support Ratio

Age >65

Source: Department of Statistics Singapore

Total Residents/ %

In 2050, even with immigration, the population pyramid will be inverted. In particular, the number of female seniors is projected to outweigh the number of male seniors as females tend to live longer.

The dependency ratio will also halve to almost 1:1, with one adult supporting a child or an elderly person. In 2015, there were 100 adults – persons aged 20 to 64 years – supporting about 50 children and elderly persons. But by 2050, 100 adults would have to support about 95 children and elderly persons.

Age <15 Age >65 Source: Department of Statistics Singapore >85 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4

2014

Population Pyramid in 2012 and 2050

2050 Males Females Source: CIMB, Population White Paper

Today Online(2017). Elderly to make up almost half of S’pore population by 2050: United Nations. Retrieved from https://www.todayonline.com/singapore/elderly-make-almost-half-spore-population-2050-united-nations

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how old is old: young-old, old-old, oldest-old In his illuminating essay ‘The Adventure of Growing Old: On Growing Old and Staying Young’, Herrad Schenk identifies three transitional phases of old age: the Gogos(55/60-70/75 years), the Slow-gos(70/ 75-80/85 years) and the No-gos(80/85+).

In Singapore, studies have shown that accounting for educational composition, it is highly likely that there will be fewer young-old with functional disability and more oldold with functional disability than expected without accounting for educational composition.

Studies have shown that seniors were more likely to visit the emergency department for medical reasons. Besides, rate of home care use and hospitalization, ambulatory health care services, outpatient as well as inpatient services will increase. The older-old are also more prone to developing dementia and require help with activities of daily living. Seniors with dementia and poor functional ability are also less likely to stay at home. It is thus proposed that medical services be customized to the needs of elderly patients should be developed.

In the United States, active senior volunteers help the older seniors with daily activities such as housework. Besides providing the young-old with an income, the young-old are still actively involved in the society in a meaningful way. After all, in the face of caregiver crunch, it is proposed that we relook into tapping on the vast pool of informal caregivers.

physical ability declines Young-Old (Age 65-74) retrenched empty nest syndrome personal achievement

Old-Old(Age 75-84)

Oldest-Old (Age 85+)

chronic health issues widowhood loneliness need for transport

chronic health issues institutionalism greater consumption of medical services loss of dignity dependence decrepitude death

stages of aging Self-Sufficiency

Interdependence

Full Dependency

do not require help with daily activities

need support from family caregivers

might still be able to age-in-place wuth in-home nursing or community-based support

might experience initial signs of memory loss

might require residential memory care

might experience anxiety and depression

Lee Gan, Goh(2017). Managing Complex Medicine in Family Medicine Settings. Retrieved from https://www.cfps.org.sg/publications/the-singapore-family-physician/article/1129_pdf Alma M. L. Au, Stephen C. Y. Chan, H. M. Yip,et al., “Age-Friendliness and Life Satisfaction of Young-Old and Old-Old in Hong Kong,” Current Gerontology and Geriatrics Research, vol.

2017, Article ID 6215917, 10 pages, 2017. Retrieved from https://doi org/10.1155/2017/6215917.

Lee, S. B., Oh, J. H., Park, J. H., Choi, S. P., & Wee, J. H. (). Differences in youngest-old, middle-old, and oldest-old patients who visit the emergency department. Clinical and experimental emergency medicine, 5(4), 249–255. doi:10.15441/ceem.17.261 Ansah JP, Malhotra R, Lew N, Chiu CT, Chan A, et al. (2015) Projection of Young-Old and Old-Old with Functional Disability: Does Accounting for the Changing Educational Composition of the Elderly Population Make a Difference?. PLOS ONE 10(5): e0126471. https://doi.org/10.1371/journal.pone.0126471

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how old is old: category of seniors

social passage

To allow documentation of functional capabilities, resident assessment form was created. Residents were classified by care needs. Nursing homes receive patients who are Category III and Category IV in the Resident Assessment Form classification, whilst those in Category 2 are sent to sheltered homes.

disengagement theory

While it aids in providing the seniors with care as efficiently as possible, it often neglects the various stages that one elderly goes through as he ages.

While the baseline remains that functional or living conditions decline over time, people may experience a temporary decline in wellbeing, and tend to return to their baseline level of wellbeing via an active engagement with the new states. With a few exceptions (e.g., severe pain, high level of loneliness), changes in mental health due to functional losses are usually temporary and if one remains in the same social milieu (e.g., in terms of marital status and institutionalization) mental health will remain the same.

As people age, withdrawal from certain roles and interpersonal relationships become desirable, enhanced by the societal perception of retirement. Withdrawal, made worse by isolation, is a grave situation that many seniors will have to face, especially after the death of one’s own spouse.

Therefore, access to community facilities become important for this group of elderly. Apartments with kitchens in addition to meal programmes should also be provided should a homemaker decide not to cook.

What is there to do at such an old age? Just‘ 吃饱等死’(waiting to die).

Mr Ngaw

Retiree who lives alone

activity theory Category 1 physically and mentally independent require little assistance with activities of daily living(ADL)

Category 2 semi-ambulant require little assistance with activities of daily living(ADL)

The positive correlation between activity levels and life satisfaction suggests that some older adults tend to replace lost roles with new ones to maintain activity levels.

Some seniors have a tendency of keeping certain habits or surround themselves with objects that are familiar to them. Couples who used to host large gatherings might prefer apartments with large kitchens even if they no longer prepare meals. One of the design implications is that the space must be large enough to be able to accomodate personalised furnitures familiar to such elderly.

continuity theory Category 3 wheelchair-bound or bed-ridden may have moderate dementia

Category 4 highly dependent heavy nursing needs

Categories of Patients according to Resident Assessment Form

With advanced age, we might develop a stronger need to maintain our needs and routines. Some seniors will assume roles that are similar to the ones they took on. For instance, a chief executive officer might choose to become a charity board president. Therefore, access to lifelong learning or to spaces that interacts with the community becomes important.

How Does Subjective Well-Being Evolve with Age? A Literature Review(2013). Retrieved from http://ftp.iza.org/dp7328.pdf Hoglund, J.D.(1985). Housing for the Elderly: Housing for the elderly: privacy and independence in environments for the ageing.

Killock, John(2014). Is cohousing a suitable co-housing typology for an ageing population within UK? Retrieved from http://kollektivhus.nu/pdf/BoydAugerScholarship2011FinalReport. pdf

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lifestyle in old age

needs in old age

Some of the critical elements of quality of life include: comfort, privacy, dignity, individuality, autonomy, spiritual well-being, security, relationships, functional competance, meaningful activity, and enjoyment.

Some seniors require specialised care needs such as cognitive impairment, blindness, deafness, dementia or mobility issues.

‘Autonomy’, for instance, can be augmented via the implementation of lit memory boxes for display of photographs and momentoes outside resident rooms, affirming the unique history of each resident and assisting with wayfinding.

‘Meaningful activities’ is realised through the location of residential scale therapy and activity kitchens in the neighbourhoods for use by residents.

‘Dignity’ is accomplished by the inclusion of private occupancy rooms with en-suite baths.

physical health Health is a major concern of the elderly. Adequate provision of medical and nursing care is essential. Preventive care should be incorporated into the future residences of the elderly, too. Exercise and sports program should also be made available.

As their bodily functions decline, seniors tend to become less active and confine oneselves in the room, thereby engendering isolation.

safety

money and time

On on hand, Dr Emi Kiyota, an environmental gerontologist, argued that privacy is a fundamental human need. She held that from a patient’s point of view, even a very small single toom is better than a more spacious multi-bedded room. Privacy and safety can go hand in hand. For instance, if residents are at risk of falling off the bed in their rooms, the height of the beds could be lowered and the floor can be covered in soft padding. Residents living in smaller home-like living areas tend to come out of their rooms and socialise with their housemates and staff.

Many seniors wish to be financially independent and not ‘burden their children’.

companionship

The total care philosophy - which the elderly themselves often vehemently reject- is one that creates a burden because it is very disabling.

The elderly are rarely seen as a resource in their own lives.

Bill Graham Psychologist

In Singapore, the number of seniors working into their golden age is increasing. Retirement is an alien concept especially for the working poor.

housing Residents will also demand more participation in management decisions, using staff for support. Senior accomodations should have barrier-free accessibility to accomodate seniors who have poor functional ability.

hobbies and leisure The prevalence of elderly reading newspapers from cover to cover, debating over political issues at kopitiams, is a shining testament to the fact that seniors are concerned about political and environmental issues. They want to remain active and active as a functional member in the society.

After age 65, the number of women living alone will increase. Wives are usually five years younger than their husbands and the average life expectancy of women are longer than men. Therefore, women have greater odds of living in single-person households. These women tend to feel lonely after they are widowed. Companionship services, or socialisation amongst residents should thus be promoted.

security and dignity Seniors desire a sense of security. However, seniors who require assistance with activities of daily living should not be treated like toddlers. To preserve one’s dignity and autonomy, even in old age, seniors should be provided with help only when required.

2 DILEMMA OF SENIORS IN SINGAPORE exploring the current living and care options LIVING LONGER = AGEING WELL? AGE-IN-PLACE: FILIAL PIETY AND FAMILIAL SUPPORT? Current Housing and Care Options for Seniors: Summary Chart NURSING HOME: still a taboo?

HIRING OF MAIDS: the easy way out?

HDB SENIOR GROUP HOMES: is it sufficient?

HDB SENIOR COMMUNITY HOME HDB 2-ROOM FLEXI FLATS INTEGRATED 2-ROOM FLEXI FLATS

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living longer= ageing well?

Seniors experience acute life changes in their 50s. They might be experiencing old-age vulnerabilities such as marginalisation, inadequate social protection and welfare measures. Some might also be retrenched or displaced by younger colleagues. It is also a time when their grown-up children leave home. Multiple stress points and social disconnection could trigger depression, which might in turn brew into sucidial thoughts. Despite the apparent dip of senior suicide cases in official figures, many suicide cases went unreported.

‘It is very worrying that many elderly are turning to suicide as the only choice to end their pain and struggles, when they should be enjoying the lustre of their golden years.’

Christine Wong Executive Director Samaritans of Singapore As one ages, mental health might deteriorate, especially in the face of life changes such as departure of grown-up children death of spouse. According to a study conducted by Ministry of Community Development, seniors living alone are most prone to depression, followed by having to live

with others other than their spouse and children. In particular, female seniors tend to fall into depression compared to their male counterparts.

With the diminishing of the ‘kampung spirit’, we have inched towards greater loneliness. Sociability plays an important role in protecting people from the experience of psychological distress, enhances well-being and may prevent or slow physical decline.

‘I come to void deck everyday. What to do- my children go to work and they only come back at 3pm. If stay at home all day long, very lonely.’ an elderly man who people-watch at the void deck everyday One in five elderly persons in Singapore aged 75 and above show signs of depression, according to the Singapore Longitudinal Ageing Study in 2012 by the National University of Singapore’s Yong Loo Lin School of Medicine. Depressive mood swings can be related to other health issues, like limited mobility and senile dementia, as well as loneliness and financial anxiety.

8.0 6.0 4.0 2.0 0.0

living with spouse, no children

living with spouse and children

not living with spouse; living with children

living alone

living with others

Male Depressive Symptoms Score for Older Persons, by Living Arrangement

Female

Ministry of Community Development, Youth and Sports: Social Isolation, Health and Lifestyles Survey 2009 Channelnews Asia. 30 July 2018. Number of elderly suicides at all-time high: SOS. Retrieved from https://www.channelnewsasia.com/news/singapore/suicides-elderly-singapore-all-timehigh-sos-10565002 Thompson, J, Malhotra. R., Love, S., Ostbye, T, Chan, A., & Matchar,D.(2014, January). Projecting the number of older Singaporeans with activity of daily living limitations requiring human assistance through 2030. Annals, Academy of Medicine Singapore, 43(1), 51-56. Population White Paper 2018 Ministry of Social and Family Development. 2015 . Ageing Families in Singapore. Retrieved from https://www.msf.gov.sg/research-and-data/Research-and-Data-Series/Documents/Ageing%20Families%20Report%20Insight%20Series%2020151124.pdf Population.sg Team, National Population and Talent Division, Prime Minister’s Office. (2016, August 22). Older Singaporeans to Double by 2020. Retrieved from https://www.population.sg/artiles/older-singaporeans-to-double-by-2030 Lim, Kelvin, “Who Cares? Thoughts about Caring for the Elderly in Singapore”,(Marshall Cavendish Editions, 2017) Thang, Leng Leng (2016). Being a Good Grandparent: Comparative Intergenerational Relationships in Japan and Singapore. Retrieved from http://www.fas.nus.edu.sg/cfpr/media/images/ lhzbcolumn/2016/Sep16E.pdf

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age-in-place: filial piety and familial support?

Singapore has always been highly dependent on familial support as the primary line of defence against ageing. The Asian cultural value of ‘filial piety’ notwithstanding, our forefathers’ generation have more children, and hence the responsibility to take care of the aged was spread among several siblings.

However, with rising living costs, longer working hours and couples having to take care of the seniors and their own children, things are set to change.

Even if the seniors live under one roof with their children and grandchildren, things might not be as rosy as it seem.

We hear stories of estranged family members sharing a flat but not a meal, or a live-in domestic helper showing great care for a frail old lady with an always absent daughter, or the deep friendships among poor, independent senior citizens without family in a shelter, and

in our Asian society. Senior citizens are obliged by the government and the children alike, to remain active and independent, so as not to encumber the society by and large.

The Tans share a home, but little else, the fabric of their family torn apart by friction and feuds. The older couple don’t get along with their daughter-in-law. She, in turn, refuses to cook for them.

Radha Basu Understanding the Silent Silver Surge

The supposed intergenerational interaction might not necessarily occur as frequent as perceived, especially when compounded with latent yet potentially difficult in-law squabbles. Language barrier and difference in conversational topics aside, the younger generation usually spend most of their time at school or at work, leaving the seniors alone at home, who would then meet up with their friends at the market or kopitiam.

Ng Hui Hsien Artist, writer, researcher

That said, regardless of the tensions and strains within family and community that might arise, social values such as interependence is still highly valorised.

Often, what is generally perceived as a harmonious relationship between the young parents and seniors might simply be a transactional exchange at play. In reality, reciprocity, be it economical or practical, run through many families.

With greater female participation in the labour force, some Singaporeans view it convenient to chuck their children under their parents care. After all, it is ‘free of charge’. Social fissures which erupted in western countries three decades ago have also somewhat occured slowly, but surely,

A significant number of seniors would want to be freed from the responsibility of greatgrandparenting. These seniors, usually comprising middle-class, desire to to be self reliant and valorise autonomy. They harbour higher aspirations and desire to lead an active ‘third age’. Not only would most these over-60s prefer to ‘maintain their own households’, a.k.a. live independently, they are, surprisingly, open to the notion of moving out and into a retirement village/ seniors’ apartment.

Maintain my own household independently/ with my spouse

Not mind staying in retirement village

Not mind staying in seniors’ apartments

Live near at least one of the children

Not mind staying in a nursing home

Expectations of Living Arrangements in Old Age

Live with one of the children

Age 30-44 Age 45-59 Age 60-75

Lien Foundation(2016). Supporting Silver Aspirations in Singapore.

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current housing option for seniors for elderly couples who want easier housekeeping

MOVE OUT

smaller flat Silver Housing Bonus Scheme (cash bonus up to $20,000)

2008

2-room flexi flats

proportion of seniors in different flat types

shortest lease: 15 years longest lease: 45 years $36,000 for 36sqm.

the proportion of seniors living in 3-room and smaller flat types, as well as rental flats have declined. It points to an increasing demand for larger units with more rooms. for multi-generational families who wish to stay under one roof

tri-generational flats 4 bedrooms, 3 bathrooms, 2 of which are ensuite.

7 in 10 seniors live in 3 or 4-room flats.

for wheelchair-bound seniors with little or no familial support

6 in 10 seniors aged above 55 prefer to continue living in existing flats.

senior group homes assisted living within public rental flats two to three wheelchair-bound seniors share a single HDB room and toilet

8 in 10 seniors aged above 65 prefer to continue living in existing flats. for lower-income flat owners who are aged 63 and above

7 in 10 non-subletting households were unwilling to consider tenants even if they had spare rooms and found an ideal tenant.

STAY ON

lease buyback scheme unlock home equity by selling the remaining years of lease back to HDB

sublet flats or rooms about 37% of seniors sublet rooms(HDB SHS 2013) HDB Sample Household Survey 2013 Ministry of National Development 2013

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current care option

hire a domestic worker $850 per month hired on a full-time basis must live in with employers

integrated home and daycare home care for cat 3 and 4 patients; daycare for cat 1 and 2 patients $3100 per month for seniors with multiple care needs or assistance with daily activities Eligible for nursing homes but prefer aging-in-place for seniors with caregivers or can be safe when alone at home

nursing homes $1200 to $3500 per month 24 hour medical and nursing care for seniors who cannot be cared at home or within the community for seniors who require help with most daily activities specialised care and support for dementia patients typically open wards or 8-15 bedded wards activities including waking, sleeping, bathing are scheduled central kitchen are off-limits to residents and visitors

active ageing hubs rehabilitative and social programmes for seniors staying within the vicinity daycare places for seniors staying within the vicinity in new public housing estates

The Straits Times (2016). Seniors’ home scheme under review. Retrieved from https://www.straitstimes.com/singapore/seniors-home-scheme-under-review Ministry of Social and Family Development(2017). Clarifications On Senior Group Homes Scheme Retrieved from https://www.msf.gov.sg/media-room/Pages/Clarifications-on-Senior-Group-Homes-scheme.aspx Refer to HDB InfoWEB for further and up to date information. Housing & Development Board, “Types of Flats,”HDB InfoWEB, March 6, 2017, http://www.hdb.gov.sg/cs/infoweb/residential/buying-a-flat/new/types-of-flats; Housing & Development Board, “For Our Seniors,” HDB InfoWEB, March 8, 2017, http://www.hdb.gov.sg/cs/infoweb/residential/living-in-an-hdb-flat/for-our-seniors.

Lee Kuan Yew School of Public Policy (2013). Housing: How should Singapore’s Housing Development Board (HDB) Help Older People Monetise their Housing Assets and Age in Place?

Retrieved from https://lkyspp.nus.edu.sg/docs/default-source/case-studies/housing-monetisation-and-ageing-in-place.pdf?sfvrsn=79c3960b_2

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nursing home: still a taboo?

nursing home: manpower issues

medicalised, dormitory style

underpaid and overworked staff

Traditionally, nursing homes are modelled on acute hospital wards. Such a medicalised and dormitory-style model came to prominence due to real estate constraints and government’s push towards standardisation and cost efficiencies. 8 to 12 residents share a dormitory and common toilet.

Corridors are long, dark and dreary, and occasionally stinks of urine. Admittedly, the quality of care has improved over the years and most residents are largely kept hygienic.

However, in the name of efficiency, the medicalised model of nursing homes have not progressed with the advancement of medical technologies.

The sheer amount of gruelling hours and the number of residents that a nursing home staff has to look after can be taxing. Compounded with homesickness, it might lead to depression of staff. Although food and accomodation are provided for free, the basic starting salaries for healthcare assistants have been suppressed to as low as $350- 400 per month, which is less than the pay of a foreign domestic worker and an entry-level hospital staff. The lure of jumping ship to other sectors, which tend to offer better incentives, bonuses and allowances, proves to be strong.

Many cookie-cutter, medicalised, mega nursing homes of today still conjure up morbid images of how shophouses dubbed ‘Death House’ in Sago Street, where they lived out their last days on the second floor.

Besides, most residents have complex needs and multiple illnesses. When more staff has to be deployed to look after Category 3 and 4 patients as stipulated in the MOH guidelines, even lesser staff are deployed to manage Category 1 or 2 residents. As a result, staff might only have barely enough time to attend to residents’ basic needs, invariably neglect the residents’ psycho-social needs.

Excerpt from Safe but Soulless by Radha Basu However, gone are the pioneer generation that have themselves experienced, or witnessed firsthand, how their forefathers live in cramped shophouses in Chinatown, where at least six to twelve people share a room and had to use communal kitchens, bathrooms and toilets. The future cohort of seniors, or even the young-olds of today hold greater aspirations and place higher value on privacy and dignity, aspects that are often overlooked by nursing homes.

It’s just like a carwash, but faster! I put you in a conveyor belt, okay, put water on you, put soap on you, rinse you, and then another group Dr Lina Ma Director Lions Home for Elders

filial piety and deeply-seated stigma Given the morbid portrayal of nursing home as a gloomy, clinical and dull place for residents to live out their last years still deeply etched in the Singaporean psyche, it is no wonder that the nursing homes are widely perceived to be the last resort. The Confucius value of filial piety still runs strong in Singapore and might discourage children from sending their parents to nursing homes even when they genuinely need residential care. It might even simply be out of fear of being ‘judged’ by outsiders for sending one’s own parents to nursing homes.

Oliver Wyman. The Economics of Singapore Nursing Home Care. Retrieved from http://www.lienfoundation.org/sites/default/files/20160728%20Economics%20NH%20LF%20 KCNF%20vF.pdf Singapore Management University. 2018. The Eldercare Ecosystem: It takes a village. Retrieved from https://www.smu.edu.sg/news/2018/04/27/eldercare-ecosystem-it-takes-village Thompson, J., Malhotra,R., Love, S., Ostybye, T., Chan, A., & Matchar,D. (January 2014), ‘Projecting the number of older Singaporeans with activity of daily limitations requiring human assistance through 2030’. Annals, Academy of Medicine Singapore, 43(1), 51-56.

Koren, M.J. (2010). ‘Person-centred care for nursing home residents: The culture-change movement.’ Health affairs 29(2): 312-217

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nursing home: do they serve the residents well? efficiency over dignity

one-size-fits-all approach

Many nursing homes resorted to being task-oriented than people-centric as a result of caregiver crunch. Most elderly residents are safe, clean and kept free from falls, but at the expense of tying them down to the bed. As a result, residents’ privacy and dignity are severely compromised. According to Lien Foundation, 9 in 10 families were satisfied with the physical care rendered by nursing homes. However, residents’ dignity and autonomy are found wanting. For instance, many nursing home staff resort to putting residents on diapers so that they only have to schedule a fixed time to change that.

Residents are largely clean, safe, fed and cared for based on a strict, regimented schedule in a dormitory setting, all in the name of efficiency. The psycho-social wellbeing of residents are unfortunately neglected. Residents often do not get to choose when to wake up, shower or have meals.

It is no wonder that one in five residents are clinically depressed. Prearranged social care programmes such as drawing, colouring and playing with building blocks can also be demeaning and do not cater to individual’s interests. Notwithstanding noble intentions, admitting relatively healthy seniors into dismal and regimented setting of nursing homes might rob them of their joy and purpose in lives.

If you are only focused on safety and efficiency, you can actually compromise a person’s quality of life, well-being and sense of selfworth, and paradoxically end up harming the Dr Philip Yap Geriatrician

perceived need greater than actual need Caretakers often perceive and render greater help to the seniors than they really need. Patients in an institution are not allowed to perform many tasks which are important at home, damaging one’s self-confidence. Quite a few of the wheelchair-bound seniors that I have talked to do housekeeping themselves and have turned down goodwill from volunteers for help. However, with the mentality that it is better to be safe than sorry, staff often falls into the trap of overprovidence of care, which can potentially worsen the residents’ wellbeing. Anecdotes of how nursing homes residents were strapped to the bed with a body jacket to prevent falls abound. One Swedish researcher found that with older persons irreversible effects of hospitalism can in some cases be observed already after only six hours of institutionalization.

Another patient. fed up with regiment and routine, deliberately banged a table continuously asking to be discharged. She was.

Safe But Souless: Nursing Homes need a New Narrative.

out of touch with community Many homes were located far away from HDB. Moreover, seniors are not allowed to leave the compound without permission. Trapped in this medical-model care, the seniors are often deprived of opportunities to interact with the outside world. The seniors become unecessarily dependent and become disconnected with the wider community. Many seniors become inactive and disengaged.

The baseline remains that no matter how well-designed some nursing homes are, they are, ultimately, institutitions.

It goes against one’s cultural grain and mindset to be sending one’s own parents such as nursing homes, especially when the elders have been cared for at home for centuries.

Cornell University ILR School. 1986. Independent Living and Attendant care in Sweden: A Consumer Perspective. Retrieved from https://digitalcommons.ilr.cornell.edu/cgi/viewcontent. cgi?referer=https://www.google.com/&httpsredir=1&article=1424&context=gladnetcollect

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proposed nursing home model: silver hope Various proposals have been put forth to shift from medicalised, dormitory-style nursing home model. Habilitative models of care, such as the Green House Model, have brought about positive outcomes, such as improvement in quality of life and care. Lien Foundation, Khoo Chwee Neo Foundation and experts have come together and proposed the ‘Silver Hope’ model, which incorporates the habilitative model. In the proposed Silver Hope Model, there are only single/ double bedded rooms in 20:80 ratio within a home-like setting. En-suite bathrooms are modelled after typical HDB’s master bedrooms. The self-contained units with dining and living facilities encourage independence, autonomy and personalisation.

1-bed

WC

1-bed

Household 1 (220sqm)

WC

dining/ living/ pantry

Sluice Room Meeting Room Nurse Station 2-bed

WC WC

2-bed

2-bed

WC

2-bed

Standardised, medicalised, dormitory-style

Nursing Care

Types of Wards Size of Rooms

Quiet Room Consultation Landscaped Room Garden Isolation Room

Household 3 (220sqm)

Household 4 (220sqm)

WC

Layout of 1x Household

Environment

Household 2 (220sqm)

Institutional, hospital ward setting

Layout of 1x Floorplate ‘Silver Hope’ Model Residential, homely environment and small group setting

Emphasis on the provision of nursing care and assistance in ADL

Emphasis on person-centred care and aging with dignity

Typically open wards or 8–15 bedded wards; wards are segregated by gender

Single/Twin-sharing, for added privacy; Twin-sharing rooms may be used by couples or siblings

Follows MOH’s proposed minimum space of 6 sqm per patient bed

Single Room: 12–16 m² Twin-sharing Room: 21–24 m²

Facilities

activity rooms, therapy rooms and rehabilitation centre

Bathrooms

Typically shared bathrooms 1 WC, 1 shower, 2 wash basins to 16 beds

Activity rooms, therapy rooms, fitness gym, outdoor exercise corner, Dementia Day Care, garden, cafe with al-fresco dining, grocery store, hair salon Ensuite bathrooms for better privacy 1 WC, 1 shower, 1 wash basin to 1 or 2 beds

Lien Foundation. The Economics of Singapore Nursing Home Care. Retrieved from http://www.lienfoundation.org/sites/default/files/20160728%20Economics%20NH%20LF%20 KCNF%20vF.pdf

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hiring of maids: the easy way out? loss of privacy

overworked and ‘burned out’

Even the seniors who are able to afford one might choose not to hire one, for they might not be comfortable with the notion of having a stranger at home. Some male seniors are also wary of employing a female caretaker for fear of unwarranted gossips.

Under the traditional intergenerational family model, the responsibility of having to look after a senior who requires round-the-clock supervision are often shared between several caregivers. When the onerous duty of having to look after a disabled senior falls squarely on the shoulder of one caregiver, the caregiver might be overworked and ‘burned out’, compounded by the lack of regulation of the maids’ working hours and job scope. Maids often find themselves having to handle other household chores as well, leaving the seniors unattended to.

communication issues Language barrier also complicates the issue. Maids who are unable to comprehend the seniors would not be able to appropriately attend to the seniors’ request. The subsequent lack of meaningful and deeper interaction is invariably lost.

The seniors will have hurdles trying to communicating their non-physical needs to their sole caregivers, potentially exacerbating the seniors’ mental wellness, especially if the senior has no one else to confide in.

‘They will always agree with you but you are not very sure if they actually understands you or are just being culturally polite. ’ Dr Ian Leong Head of Continuing Care Department Tan Tock Seng Hospital

untrained personnels as primary caregivers Maids who have no prior experience in nursing frail elderly on medication might not be able to dole out appropriate care to the senior. For instance, nurses are taught to spot sidns of distress even if the seniors cannot speak. However, an untrained caregiver could miss such signs. However, employers often expect the helpers to perform nursing functions such as managing medication, tube feeding, handling insulin injections, carrying out blood tests and the like. Untrained maids should not be primary caregivers.

‘My mother had to be hospitalised for four weeks as my maid did not flip my mum’s body as she was told. ‘ Madam Oh Clerk

deliberate abuse/ neglect Some maids take the easy way out and vent their frustrations on the seniors, who are often too frail to defend themselves. The hurling of verbal or physical abuses are not uncommon, and some maids even stab the disabled seniors to death.

‘The helper would wheel my mum to the void deck and disappear for a long time. The helper also took some of my mum’s belongings. She only had to take care of my my mum, and yet did not keep her bedroom clean and sometimes did not feed her. . ‘’

inefficient care model

Madam Aw Part Time Tutor

Moreover, with caregiver crunch, such one-on-one care can be seen as inefficient, as he/she could look after a few more residents in the nursing home instead. Some seniors are already unable to afford a foreign domestic workers, especially one who is medically trained.

higher prestige of hospital staff Working at hospitals, instead of nursing homes, are perceived to be more prestigous and prospective with lucrative bonuses. In hospitals, one can get his/her hands on the cutting edge of medicine, allowing one to garner more learning experiences. On the other hand, job scope at nursing home is deemed repetitive and strenuous, with mundane jobscope such as changing diapers, showering and feeding residents and serving medicines prepared by nurses. The high attrition rate also engenders a weak relationship between the residents and the caregivers.

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hdb senior group homes: is it sufficient? for seniors who are too frail to live alone The Senior Group Homes (SGH) seek to provide physically-impaired seniors with assisted living in rental flats via coordination of social and care services. It comes in clusters of five to eight rental units in a public housing block, accomodating up to 250 seniors, and where the units are not necessarily next to each other. This serves to delay premature institutionalisation of seniors.

It strives to enable the seniors with little to no familial support to ‘age within the community’ through a mutually supportive environment. Roommates are assigned as buddies and are meant to look out for one another.

clusters of five to eight rental flats in a block

The group homes provide comprehensive support via meals on wheels, medical escort transport as well as home nursing. There are visually imparied seniors in group homes. However, these group homes are unable to support adults with moderate disabilities as there is no round-the-clock supervision.

All in all, senior group homes aim to promote autonomy, independence and personal responsibility in managing self-care. It aims to do so by leveraging on existing community services and network to maintain clients in the community.

how effective is it in aiding one to ‘age within the community’?

Despite the high demand for senior living units, the takeup rate is quite low.

Many units are left empty. For one, only frail seniors who are eligible for rental flats can apply, when the real demand for assisted living comes from seniors who live in bigger flats. Two to three people, including wheelchair-bound ones, had to share a single HDB room and toilet, so space was a big constraint. It was difficult to match people and living with complete strangers takes some getting used to. Seniors, being frail themselves, might sometimes be unable or unwilling to live with and look after others. Moreover, such facilities are not designed to provide round-the-clock assistance, education and family, religious and social backgrounds have to be taken into account. Besides, the flats in senior group homes are dispersed, it is hard to bring people together.

three seniors live in a one-room flat

availability of staff only during office hours

‘Having just one toilet for for three seniors is not a good idea.

Seniors spend more time in the toilet because they want to be careful not to fall. ’ Ms Lucy Tan Director of Peace-Connect Cluster Operator

The Straits Times(2016). Seniors live here as one community. Retrieved from https://www.straitstimes.com/singapore/seniors-live-here-as-one-community Ministry of Social and Family Development. Services & Programmes For Elderly. Retrieved from https://www.msf.gov.sg/policies/Helping-the-Needy-and-Vulnerable/Supporting-Vulnerable-Elderly/Pages/Services-and-Programmes-for-Elderly.aspx The Straits Times(2016). Seniors’ home scheme under review. Retrieved from https://www.straitstimes.com/singapore/seniors-home-scheme-under-review

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hdb senior community home

case study: awwa community home for senior citizens, ang mo kio Not to be confused with Senior Group Homes, Senior Community Home (SCH) provides accommodation for low-income, more ambulant and independent seniors without family support. Housed on the second to fourth levels within a HDB rental block, it enables seniors with little or no family support to remain integrated in the larger community. Occupying levels two to four of the block, it is home to 140 seniors today.

Ongoing Health Supervision/ Screening

24/7 nursing help

Two to three elderly people live in each one-room rental flat, and amid the units are purpose-built spaces such as recreation rooms, with TVs screening shows in different languages, a laundry room, a â&#x20AC;&#x153;nursing stationâ&#x20AC;? for nursing care, and a kitchen.

The AWWA home has a team of social workers and care staff. It also has nurses on duty 24/7, enabling the seniors to age-within-community.

Complementary physiotherapy / Occupational therapy / Speech therapy

Recreational activities / Community

AWWA Senior Activity Centres Daily Activities Monday

Tuesday

Thursday

Wednesday

Friday

Saturday

Sunday

9am Breakfast

Ration Distribution

9.30am Otago Exercise

Morning Walk 10am Give out TCM Queue No

Volunteer Activity/ Handicraft Session

Bokwa at courtyardor void deck

Volunteer Activity (ad-hoc)

10.30am Bag Weaving with Adeline

Weekly Announcement 12pm

Lunch

12pm Lunch

2pm Volunteer Activity

TCM at Level 4

BINGO

Lunch 1.45pm

2pm

4.30pm

Cristofori

Volunteer Activity

SMRT Dinner

3pm

4.45pm

Taichi

Dinner from volunteer Lisa

AWWA: People Giving to People. Retrieved from https://www.awwa.org.sg/services-for-seniors/senior-community-home/ The Straits Times(2016). Seniors live here as one community. Retrieved from https://www.straitstimes.com/singapore/seniors-live-here-as-one-community

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hdb 2-room flexi flats for seniors aged 55 and above looking to downsize for easier maintenance/ monetisation

why segregation of seniors?

Formally known as studio apartments, 2-room flexi flats are usually located within mature housing estates with well-established transportation networks. Typically standalone blocks, these elderly-friendly studio apartments such as Golden Jasmine in Bishan estate and Golden Tulip in Bukit Merah View were introduced island-wide. Recent developments are now integrated within blocks with other flat-types. Elder-friendly features and provision of senior-centric services and health facilities within the SA blocks benefited the seniors. These flats were also one of the methods recommended by the HDB for those above 55 years to monetise their existing larger flats and downgrade to a smaller flat on a Lease Buyback Scheme (LBS) to receive a stream of income in their retirement years.

Although 2-room flexi flats are embedded within the community, they are usually standalone blocks, embracing age segregation by keeping the elderly in institutional care or communities.

Seniors aged above 55 have the option of choosing the length of the lease, ranging from 15 to 45 years. HDB requires two-room flexi leases to cover the applicants and their spouses up to the age of at least 95. A vast majority, of 91 percent, went for the shorter leases. This option is also popular among seniors who have no children to pass the flat on to. Some seniors also ‘right-size’ to 2-room flats when their married children have moved out and they find the flat to be larger than what they need.

Fitness station at Golden Tulip, Bukit Merah.

‘Do not segregate elders from the rest of society and condemn them and the rest of their lives in an old age archipelago.’

Dr Bill Thomas Founder of The Eden Alternative

HDB surveys suggest that the elderly prefer to stay with their spouses, close to their children and families, rather than in specialised elderly accommodation. Admittedly, under Married Children Priority Scheme, elderly parents can live near their married children.

However, most seniors are keen to age in same flat and expressed no intention to move within five years, according to HDB Sample Household Survey 2013. The seniors also reported a sense of belonging to their public housing towns and satisfaction with their flat and neighbourhood.

‘Right-sizing’ to 2-room flats, therefore, do not cater to such seniors as it requires them to move into an unfamiliar environment.

Rehab centre at Golden Tulip, Bukit Merah. There is a lack of visual connection between the pedestrians and the seniors in the centre, enhancing the clinical and institutional vibe, so frequently associated with these centres.

How societies should rethink eldercare with multi-generational housing (2018). Retrieved from https://www.population.sg/articles/how-societies-should-rethink-eldercare-with-multi-generational-housing

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hdb 2-room flexi flats

case study: golden jasmine, bishan

Context

Mature estate well-equipped with amenities No of Storeys 16 Capacity 176 Key Features landscaped deck large open plaza near entrance quiet garden rest areas

Currently, residents are aged between 55 to 65, and are still mobile, but these flats are designed to be where the elderly can â&#x20AC;&#x2DC;age-in-placeâ&#x20AC;&#x2122; and live comfortably in the same flat for perhaps the next 30 years. Golden Jasmine taps on the surrounding amenities and enables the continuation of independent living into later life.

senior service centre

On the ground floor, a physiotherapy and traditional Chinese medicine clinic caters for residentsâ&#x20AC;&#x2122; ailments. The landscaped deck above engenders a range of outdoor spaces, allowing them to enjoy a gentle stroll or active exercise in the community garden or at the fitness station.

At its entrance, a large open plaza encourages owners to participate in the early morning Tai Chi, while quieter garden rest areas make it possible for wheelchairs to slot in directly in between the able-bodied garden benches, giving residents a sense of social inclusion.

Seniors service centres take up about half of the void deck of the block, responding to emergency situations. They provide the seniors and their family members the assusrance of mind that say, should falls happen, they have some help to turn to.

physiotherapy

TCM

counselling

35

built-in kitchen

disabled bathroom

built-in kitchen

household shelter

dining household room shelter living room

disabled bathroom living room

dining room

bedroom bedroom

These compact two-room units are designed for a single resident, or an elderly couple, choosing to downsize after their families have grown up.

meeting plaza drop-off porch

community garden fitness station

Refer to HDB InfoWEB for further and up to date information. Housing & Development Board, “Types of Flats,”HDB InfoWEB, March 6, 2017, http://www.hdb.gov.sg/cs/infoweb/residential/buying-a-flat/new/types-of-flats; Housing & Development Board, “For Our Seniors,” HDB InfoWEB, March 8, 2017, http://www.hdb.gov.sg/cs/infoweb/residential/living-in-an-hdb-flat/for-our-seniors.

Council for Third Age [C3A], “Studio Apartments,” Schemes for Seniors, accessed June 27, 2017, http://www.c3a.org.sg/Benefits_details.do?id=127

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integrated hdb 2-room flexi flats case study: kampung admiralty

Context Mature estate well-equipped with amenities No of Storeys 11 Key Features public housing for seniors healthcare and wellness facilities hawker centre childcare centre

medical centre

eldercare

Envisioned as a â&#x20AC;&#x2DC;Vertical Kampungâ&#x20AC;&#x2122;, Kampung Admiralty employs three distinct strata to foster diversity of cross-programming. The ground level is freed up for activity generators. As a one-stop vertical retirement village, Kampung Admiralty houses a Peopleâ&#x20AC;&#x2122;s Plaza in the lower stratum, a Medical Centre in the mid stratum, and a Community Park with studio apartments for seniors in the upper stratum. The Community Park is a more intimately scaled, elevated village green where residents can actively come together to exercise, chat or tend community farms. It aims to foster diversity of cross-programming and frees up the ground level for activity generators. Seniors who live in Woodlands, or whose married children live there, will get priority for the 100 or so flats.

Residents are encouraged to take ownership of the various community spaces. The close proximity to healthcare, social, commercial and other amenities supports intergenerational bonding and promotes active aging in place. With a medical centre in the hub, residents need not go all the way to the hospital to consult a specialist.

Some innovative architectural interventions include co-locating child care with senior care facilities. Healthcare facilities are also integrated within the same development to ease patient load at hospitals. The huge amount of greenery incorporated into the hybrid building has also generated biodiversity and a therapeutic environment for healing.

childcare centre

37

5th Storey of Blk 676A of Kampung Admiralty

studio apartments

36 sqm

eldercare and childcare centre medical centre

45 sqm access corridor

community farm

hawker centre ground floor

supermarket

basement

carpark

38

kitchen bathroom living/ dining bedroom connection

Floor Plan of 2-room Flexi Flat at Kampung Admiralty

The eldercare centre and childcare centre are connected one to another via a com tion/ between the two spaces to promote intergenerational interaction.

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should we replicate the success of kampung admiralty?

It requires the collective effort of eight government agencies, such as MOH and NEA. Such a large-scale effort requires collaboration between many players. Cost is high and it is also not very scalable.

â&#x20AC;&#x2DC;From an economic standpoint, it is not easy to sustain such a model, which is highly dependent on its prime location next to a mass transport node, town or neighbourhood centre. The small number of seniors living in the apartment units of Kampung Admiralty alone cannot support the amenities, which have to rely on high foot traffic from the [mass rapid transit] to be commercially viable. If Kampung Admiralty were replicated elsewhere under a different site condition and the amenities remained concentrated in a single development, it would mean some parts of the neighbourhood would be underserved..â&#x20AC;&#x2122; Fung John Chye Director NUS Centre for Ageing Research in the Environment

mmon corridor. Perhaps more could have been done to create genuine interac-

The Edge(2018). As Singapore ages, companies begin to offer different forms of care facilities. Retrieved from https://www.theedgesingapore.com/singapore-ages-companies-begin-offer-different-forms-care-facilities Kampung Admiralty. Retrieved from https://www.architectmagazine.com/project-gallery/kampung-admiralty

3 AGEING-IN PLACE = AGEING WELL? examining the case of ‘ageing-in-place’ HOW TO ENABLE AGEING-IN-PLACE IN SINGAPORE? HOME AND CENTRE-BASED CARE: is it necessarily replacing nursing homes?

ACTIVE AGEING HUBS: the solution?

TECHNOLOGIES: how does it enable ageing-in-place?

AGEING-IN-PLACE: is staying in the same apartment what the seniors need?

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how to enable ageing-in-place in singapore?

Ageing-in-place means to age gracefully, safely and comfortably in the community that they live in, and have access to a range of aged care facilities that will facilitate active ageing.

Ageing-in-place shifts the provision of care to the home and community where the elderly is living in, thereby reducing public financial burden and alleviating the shortage of institutionalised placements.

According to HDB Sample Household Survey 2013, majority (81%) of elderly residents in HDB towns wanted to age-in-place. About 85% of elderly households had no intention to move within the next five years, They mainly felt that the present flat was comfortable, had an emotional attachment to it, or wanted their children to inherit the flat.

what is centre-based care?

Ageing-in-place, even with professional care at home, can be more cost-effective than ageing in an institution. The high costs involved in building and maintining nursing homes, as well as to provide for the elderly residents’ medical and non-medical needs have prompted stakeholders to look elsewhere. One of the alternatives was to provide the elderly with care in their own homes (Alliance for Home Health Quality and Innovation, 2012).

Provided within a communal setting, ‘centre-based care’ inludes social day care, dementia care and day rehabilitation.

what is home-based care?

‘Home-based care’ refers to home nursing, home therapy, and home personal care services delivered to the elderly care recipient’s home by non-profit and private providers. The philosophy of home care is to provide holistic and clinic-centric care. It seeks to maximise seniors’ functions while promoting, maintaining or restoring health, thereby enabling seniors to live in the community as long as possible.

enabling seniors to age-in-place even as needs increase Centre-based Care Services for seniors with mild to moderate care needs, with some family support (e.g. working caregiver)

Home-based Care Services for seniors with mild to high care needs, with some family support (e.g. frail caregiver, or FDW)

Nursing-Home Services for seniors with high care needs, with little or no family support

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home and centre based care: is it necessarily replacing nursing homes? increasing demand

high and unpredictable costs

Home and centre-based services have replaced nursing homes as the main mode of long-term care(LTC) in Singapore. According to the Ministry of Health, about 14,000 people used subsidised home and centre-based services in late 2017, up from 12,000 in 2016. The number of subsidised nursing home residents, meanwhile, has remained stable at around 10,000 over the past two years. According to government estimates, one in two seniors could become severely disabled at some point in their lives, being unable to perform at least three of six routine activities of daily living(ADL).

Under the Integrated Home and Daycare(IHDC) programme, people who usually use centre-based care but sometimes find themselves unable to leave home can delivered to their homes temporarily, while those who receive home-based care are encouraged to switch to centre-based services when they become mobile. A family looking after a severely disabled person at home under the Integrated Home and Daycare(IHDC) programme could pay $3,100 per month. Costs may deter even middle-income families from using formal long-term care services, especially since many find it cheaper to hire a domestic worker instead.

home and services

centre-nased

nursing homes 2016

2017

usage of home and centre-based services, as well as nursing homes

It might be too resource-intensive to send paid caregivers to the homes of the disabled seniors if all they require is personal care.’

Dr Ng Wai Chong Chief of Clinical Affairs Hua Mei Centre for Successful Ageing

insufficient supply

1 in 2 seniors unable to perform ADL

lack of regulation among private providers

The government has recognised the increasing demand for home and centre-based services. Despite government’s effort to ramp up supply for such services, demand still outstrips supply. For instance, Agency for Integrated Care received 7,800 referrals for day care services in 2015 when only 3500 spots are available.

MOH only regulates the providers that receive government subventions. Care quality can sometimes be compromised.

Should mishaps occur, actions are taken only against the individual who can be easily replaced by another one. Seniors are portrayed as a passive care reciver when he has so much more to offer.

home care places centre care places

2011 2017

2030

capacity of home and centre-based services

Eldershield Review Committee Report, p.50. Retrieved from https://www.moh.gov.sg/docs/librariesprovider6/resources/eldershield-review-committee-report.pdf MOH, direct communication, 2018; Eldershield Review Committee Report.

Liu, C., Eom, K., Matchar, D.B., Chong, W.F.& Chan A.W.M.(2016) ‘Community-based long-term care services: If we built it, will they come?’. Journal of Aging and Health 28, 307-323; p.31 Agency for Integrated Care. Introduction to Home Care. Retrieved from https://www.aic.sg/sites/aicassets/AssetGallery/HCIK_BOOKLET%2002_FA-5(Online).pdf

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active ageing hubs: the solution?

MOH has been collaborating with HDB to create purpose- built â&#x20AC;&#x2DC;Active Ageing Hubsâ&#x20AC;&#x2122; offering integrated eldercare services in new BTO estates. These one-stop centres provide seniors with a range of services, ranging from daycare and rehabilitation to assisted living services such as grocery shopping and housekeeping for frail senior . At least 10 future HDB estates will have these hubs by 2020.

home care services

Granted, centralisation of services can be more efficient and cost-effective for the service providers, However, with soaring rates of seniors living alone, caregiver crunch, active ageing hubs, which are only built at certain public housing blocks, might not be sufficient to address the issue. community and volunteer activites

morning exercise

day rehabilitation

senior day care

traditional chinese medicine

The Straits Times(2017). Active ageing hub opens in McNair Road. Retrieved from https://www.straitstimes.com/singapore/active-ageing-hub-opens-in-mcnair-road.

Agency for Integrated Care. Introduction to Home Care. Retrieved from https://www.aic.sg/sites/aicassets/AssetGallery/HCIK_BOOKLET%2002_FA-5(Online).pdf

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ageing-in-place: is staying in the same apartment what seniors need? fall risks According to Health Promotion Board Singapore, about one-third of elderly Singaporeans aged 60 and above have recurring falls. Many seniors who lived alone have reported incidents of falling at home, mostly at the living room. Injuries sustained during falls can result in head trauma and fractures. It can even prove to be fatal if the senior living alone is unable to call for help.

difficulty in carrying out activities of daily living Housekeeping and maintenance becomes increasingly difficult as one ages, resulting in hygiene issues. As seniors become frailer, they might find cooking a chore. Some seniors might also find it increasingly difficult to keep up with medication regime due to poor memory and eyesight, resulting in medication error and potential health problems.

the fear of dying alone/ kodukushi 1 in 3 seniors have recurring falls

potential senior isolation One of the inevitable aspects of ageing is the decline in physical mobility and death of one’s spouse. The number of seniors who live alone is expected to rise from 47,000 in 2016 to 92,000 by 2030, rendering the concept of ‘ageing-in-place’ to be less desirable as commonly perceived.

Notwithstanding the various efforts in encouraging seniors to be involved in social groups such as briskwalking, taichi, bird watching, karaoke and gardening, senior isolation might still occur, especially so when one is disabled. Many seniors often suffer from leg pain, and might not be able to walk for long distances.

Prolonged isolation from the society might cause the seniors to withdraw themselves from the society and wish to be left alone, resulting in a vicious cycle that exacerbates the situation. A wheelchair-bound widowee staying alone at 1-room rental flat in Bukit Merah that I talked to sits at the corridor, watching the passerbys everyday. It might

92,000

47,000

2016

2030

number of seniors living alone

The fear of dying alone is increasingly shared by the increasing number of seniors who live alone. To some, privacy is the least of their concerns and they do not mind having CCTVs or movement sensors for children or volunteers to monitor them in case mishaps occur. Some even reportedly sit in front of the CCTV all day long, waiting for bed time to come. Therefore, one can be ageing-in-place, but not necessarily with dignity.

‘Two of my neighbours died and people found out only because of the smell. I don’t want the same thing to happen to me.’

Mr Wee Yoke Tai Retired Cleaner Lives alone in a rental flat

the unique context of Singapore In Singapore, a crude generalisation, yet typical scenario goes like this: Right into a few years into the working world, a man gets married and began staying in a Buil-to-Order(BTO) flat with his wife. They labour hard with the aspiration of ‘upgrading’ from a HDB flat to a private property. Twenty years later, they did move into a condominium. As they hit their late 50s, their children have grown up and have moved out.

The couple then decided to move into a smaller flat that can be maintained more easily. Coupled with HDB’s policy on leasehold, it is not unusual for Singaporeans to relocate.

The unique social climate and political context in Singapore differentiated it from bigger countries, where seniors

Chumari, Alvin. Fall Prevention: A Serious Matter for the Elderly. Retrieved from https://www.healthxchange.sg/seniors/ageing-concerns/fall-prevention-elderly The Straits Times. 2016. ‘When I die, I want someone to know’: Fear of dying alone increases among elderly folk. Retrieved from https://www.straitstimes.com/singapore/when-i-die-iwant-someone-to-know-fear-of-dying-alone-increases-among-elderly-folk

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technologies: how does it enable ageing-in-place? smart elderly alert system Sensors placed in the flat to help monitor the movements of the elderly, and caregivers will be alerted should irregular movements be detected. It is non-intrusive, non-contact and low cost methodology, and provides timely alerts. Besides, it allows the elderly to live independently, and offers peace of mind to family members and caregivers.

1 SAVES TIME

smart health video consultation (VC) VC leverages video conferencing technology to allow patients to remotely consult their care team online. The system offers a level of immediacy when patients need care and in-person visits are not possible.

It saves the healthcare team’s time from travelling the patients’ homes, enabling them to care for more patients.

Patients need not spend hours of waiting time in long queues, too.

smart health telerehab Allows patients to undergo their rehabilitation exercises at a time and location of their choice, through the use of wearable sensors and remote monitoring by a therapist.

Support from healthcare professionals for patients and caregivers can also be done remotely via an Internet-based videoconferencing service that works on consumer devices and can support one-to-one and multi-user interactions.

2 EFFICIENT

assistive technology and robots in healthcare Industrial robotic arm can pick and pack a range of objects, including fragile items. Automated guided vehicles (AGV) can transport food, linen or documents, or move heavy items like beds. Robots that can help recovering stroke patients exercise, or keep early stage dementia patients occupied and alert them to take their medicine. Automated bathing machines and autonomous droids that can interact and monitor patient progress. A robot trainer that imitates human movements and teaches exercises to senior citizens individually or in groupsS. It helps to provide physical and cognitive therapy to seniors who have suffered strokes or have disorders such as Alzheimer’s or Parkinson’s.

Smart Nation Singapore. 2018. Retrieved from https://www.smartnation.sg/ Because IT’s in Healthcare(2018). Retrieved from https://www.ihis.com.sg/

The healthcare team can remotely link up with other care providers to discuss the patients’ needs and resolve emergency issues that require speedy decisions.

4 THE CASE FOR ASSISTED LIVING understanding assisted living HOW TO DEFINE INDEPENDENCE? HIEARACHY/ CLASSIFICATIONS OF ACTIVITIES OF DAILY LIVING SENIORSâ&#x20AC;&#x2122; DILEMMA: what if i can no longer manage myself independently?

ASSISTED LIVING: is this the housing solution for seniors requiring help with adl?

WHY ASSISTED LIVING WITHIN THE COMMUNITY?: addressing the gap of deinstitutionalisation and affordability IS ASSISTED LIVING NECESSARILY A SUCCESS?: potential problems ANY OF SUCH ASSISTED LIVING FACILITIES IN SINGAPORE?

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how to define independence?

Activities of daily living(ADL) is a means to measure to measure oneâ&#x20AC;&#x2122;s functional status and independence. It can be classified into basic activities of daily living(BADL) and instrumental activities of daily living(IADL).

BASIC ACTIVITIES OF DAILY LIVING (BADL)

Eating

Personal Hygiene

Continence Management

whether a person feeds themselves or needs assistance

bathing/ grooming/ nail and haircare

mental/physical ability to use the bathroom

Ambulating

Dressing

Toileting

ability to change from one position to the other and to walk indepedently

ability to select and wear proper clothes for different occasions

mental and physical ability to properly use the bathroom

INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL)

Managing Finances

Managing Transportation

Shopping and Meal Prep

paying bills/ managing financial assets

driving/ organise other means of transport

shopping for clothing or other items required for daily life

due to dementia or visual impairment

Home Maintenance

Managing Communication

Managing Medication

cleaning kitchens after eating keeping living spaces tidy

such as telephone and mail

take medications and taking them as directed due to dementia/visual impairment

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hiearachy/ classifications of activities of daily living instrumental activities of daily living (iadl) Instrumental Activities of Daily Living(IADL) are not essential for functional living but allows one to perform more complex skills. The pattern of loss among the specific IADLs are not as specific. IADL impairments are usually associated with mild cognitive impairment and early dementia.

basic activities of daily living (badl) Basic activities of daily living are activities which engage people on a day-to-day basis. These are everyday personal care activities that are fundamental to caring for oneself and maintaining independence. BADL impairments are usually associated with late dementia.

stages of decline

seniors’ dilemma: what if i can no longer manage myself independently? seniors’ concern with inability to perform ADL According to a survey conducted by Lien Foundation, the utmost concern across all age groups among the elderly would be the inability to perform ADLs. As one ages, one becomes increasingly worried about being becoming dependent, ‘burdening’ their family.

The fear of these seniors are not unfounded. With changing family structures resulting from a low birth rate, rising divorce rate and estranged familial relations, the number of seniors living alone is set to increase. They have no family to turn to, especially if they need help with ADL. With Singapore becoming a super-aged societ, the number of elderly above 65 with poor activities of daily living (ADL) is projected to increase from 32,000 in 2010 to 83,000 in 2030.

As one ages, his or her functional ability decreases. Seniors lose their ability to perform IADLs, such as cooking and shopping in the earlier stages of their decline while BADLs often weaken in the middle to later stages. A study conducted in the UK showed that seniors experienced most difficulty with cutting toenails, shopping and using steps and least with washing hands and face and feeding. Besides, older women are reported to experience more ADL limitations compared to older men(MCYS SIHLS 2009).

83,000 32,000 2010

2030

number of seniors requiring aid with ADL

Age 30-44 Inability to perform ADL

Out of Savings

Burden to the Family

Chronic Organ Failure

Memory Impairment

Top Five Concerns for Old Age

Age 45-59 Age 60-75

Lien Foundation(2016). Supporting Silver Aspirations in Singapore Morris, John M. (2013). “”Scaling functional status within the interRAI suite of assessment instruments” John”. BMC Geriatrics. 13. doi:10.1186/1471-2318-13-128.

Gerrard P.(2013). The hierarchy of the activities of daily living in the Katz index in residents of skilled nursing facilities Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22894986 Kingston, Andrew. 2012. Losing the Ability in Activities of Daily Living in the Oldest Old: A Hierarchic Disability Scale from the Newcastle 85+ Study. Retrieved from https://journals.plos. org/plosone/article?id=10.1371/journal.pone.0031665

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assisted living: is this the solution for seniors who require help with daily activities? what is assisted living?

Assisted living residences are designed for seniors who are no longer able to live on their own safely, yet do not require the skilled nursing care provided in nursing homes.

Assistance with ADLs are routinely provided. Meals are served waiter- style in a common dining room. Residents live in their own apartments, which frequently have a small pantry, small refrigerator and microwave. Staff is usually available 24 hours a day for additional safety. Some assisted living apartments have a wing dedicated specifically to dementia patients. Not to be confused with independent living, assisted living caters to seniors who are dependent on help for ADLs, yet are still cognitively capable.

why assisted living? encourages a more active lifestyle Traditionally, nursing homes are care homes for seniors under who are wheelchair-bound or bed-bound and need help with most daily tasks. They are likely to suffer from complex co-morbidities and require heavy nursing care. perhaps even nearing the end of their lives. However, increasingly, many seniors who do not yet require such intensive medical attention are sent to nursing homes due to lack of choices. Such an option is, more often than not, less than desirable. The seniors’ exposure to chronic illnesses and deaths experienced by their peers in nursing homes is likely to be more frequent than in an assisted living facility.

The seniors might even find life to be devoid of meaning and ‘waiting to die’. On the other hand, assisted living residents tend to be more socially active, benefitting their psychosocial wellbeing in the long run.

relatively affordable Many seniors living in nursing homes, in fact, do not require expensive and skilled nursing care, such as tube feeding and wound management. In an assisted living facility, staff who are not necessarily professional healthcare workers can help the seniors with ADLs, such as changing of diapers and medicine management. The relatively lower manpower costs compared to nursing homes can translate to lower operations costs.

In Singapore, assisted living facilities is only 10-20% cheaper than nursing homes due to lack of economies of scale.

Assisted living can potentially be a lot cheaper than nursing homes if it is implemented on a larger scale.

changing socioeconomic landscape With the prevalence of dual-income households and rising singlehood, traditional familial support, at least in the form of caregiving, is waning. The younger generation might not have enough time to look after them, not to mention their siblings are equally old and need help. Many young, middle-class working adults might not have issue giving financial support to their elderly, frail parents, which usually comes only in the form of hiring of maids or nursing homes. Such expedient measures usually lack a sense of community. With its promises and endeavours to replicate homelike environment, assisted living facilities are able to fill this gap, providing the seniors with much-needed care and companionship.

renders more dignity and autonomy to seniors Ideally, assisted living facilities allow residents to decide on their daily schedules. Unlike nursing homes, which are modelled after medical model, assisted living adopts social model of care, addressing beyond the residents’ physical needs. Besides, the programmes organised are usually more personalised compared to the offered at most senior activity centres, such as colouring, which can be demeaning.

Thompson, J. Malhotra, R., Love, S. Ostbye, T., Chan, A. & Matchar, D. (2014, January). Projecting the number of older Singaporeans wjth activity of daily living limitations requiring human assistance through 2030. Annals, Academy of Medicine Singapore, 43(1), 51-56.

Cheong, D. (2016, April 10). ‘When I die, I want someone to know’.: Fear of dying alone increases among elderly folk. The Straits Times Lien Foundation (2016). Supporting Singaporeans’ Apsirations for Aged Care http://www.lienfoundation.org/sites/default/files/Supporting%20Silver%20Aspirations%20in%20Singapore%2018Oct16.pdf

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why assisted living within the community: addressing the gap of deinstitutionalisation and affordability lack of economies of scale

cultural ethos

The few assisted living facilities available currently are nestled in nursing homes- St Bernadette’s Lifestyle Village and St Joseph’s Home, to name a few. They are usually smallscale, housing only 8 to 10 residents on one compound.

Due to the prevalent negative portrayal of nursing homes, the older generations are often somewhat averse to the notion of retirement villages. Some seniors also perceive the idea of having to queue for food a shameful thing to do.

After all, it boils down to individual pride and dignity.

financial capability of seniors Due to the lack of economies of scale, the facilities have no choice but to charge a premium to administer a decent level of care. For instance, Lentor Residences, known for its homelike environment, charges $5,000 per month.

According to Safe but Soulless commissioned by Lien Foundation, nearly 50 per cent of the 1,000 respondents were willing to live in assisted living facilities, and would fork out $1,386 to $1,745 a month to do so.

not-in-my-backyard (NIMBY) syndrome With the integration of megastorey, mega nursing homes within the public housing estates such as Ren Ci Nursing Home in Bukit Batok, concerns have been raised by neighbouring residents concerning the perceived loss of privacy and public spaces. They also regard nursing homes as being detrimental to the resale value of their properties. It is therefore predictable that the integration of assisted living facilities into public housing might evoke similar responses. Such a mentality could arguably be alleviated via a sharing of common spaces and facilities for the residents. For instance, Ren Ci Nursing Home allowed neighbouring HDB residents to use its multi-purpose hall and gymnasium after working hours.

lack of players and public funding Assisted living is not clearly defined. Even in the US, where such faciliies are relatively common, each state has their own definition and policies. In the face of silver tsunami, many developers have realised the demand for assisted living. Around two-thirds of Singapore’s 12000 nursing home beds are managed by VWOs.It is also not immediately obvious as to which party or organisation should shoulder the responsibility of providing assisted living facilities. As pointed out by Rosa Kornfield-Matte, a UN independent Expert on the enjoyment of all human rights by older persons), in the area of healthcare and caregiving, there are many volunteers involved in supporting the elderly.

However, caregiving should not be wholly dependent on volunteers and the state should be the main entity in the provision of care. While family plays and important role in caregiving, the state must be present to support the family.

On 7 March 2019, Ministry of National Development(MND) announced that the first assisted living pilot site will be launched in Bukit Batok next year. Through the collaborative effort between MND and MOH, it is hoped that developments comprising flats with senior-friendly features complemented by communal spaces like recreation cum dining rooms to ‘encourage interaction’. The government also forewarn that such assisted living facilities should not be used merely as a machine for profiteering. True to every other assisted living facilities, services should be provided on top of residential units. Nonetheless, coupled with the launching of the assisted living guide on 2 March 2019, private developers might be sncouraged to enter the assisted living market.

Channel News Asia (2016). MOH to pilot masterplan to enhance senior ageing at home. Retrieved from https://www.channelnewsasia.com/news/singapore/moh-to-pilot-masterplan-toenhance-senior-ageing-at-home-8110580 NTUC Health (2016). Active Ageing Hub. Retrieved from https://ntuchealth.sg/active-ageing-hub/ Sze Meng Khoo et al., “Nimby Syndrome in Singapore : A Study on Eldercare Facilities.,” 2013. Retrieved from https://repository.ntu.edu.sg/handle/10356/52132.

Residents Soften NIMBY Stance on Eldercare Centres,” TODAYonline, April 14, 2014. Retrieved from http://www.todayonline.com/singapore/residents-soften-nimby-stance-eldercare-centres Lee Kuan Yew School of Public Policy. (2017). Successful Ageing in Singapore: Urban Implications in a High-density City. Retrieved from https://lkyspp.nus.edu.sg/docs/default-source/ case-studies/entry-1792-successful_ageing_in_singapore_092017.pdf?sfvrsn=21d7950b_0.

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potential problems in assisted living

any of such assisted living facilities in singapore?

is assisted living yet another institution?

case study: bethany east

Lest we fall into the trap and repeat the narrative of nursing homes, the caveat remains that we should place more emphasis on assisted living within the community.

The caveat remains that over time, assisted living facilities become just one of the many institutions that are already in place.

Institutions, or even the hiring of maids, might breed unwarranted dependency, exerting harmful effects on the seniorsâ&#x20AC;&#x2122; physical abilities. Instead, they should be encouraged to be more active and independent, ultimately reducing the need for advanced nursing care and cost savings.

Located along Changi Road, Bethany East is a 7000 sq ft assisted living residence for retired priests. The teo-storey detached house houses a lift for easier access, a prayer room, and en-suite bathrooms for each bedroom.

It can accomodate up to eight priests, a short walk from Church of Our Lady of Perpetual Succour, enabling the residents to continue remaining active in the community.

Nurse manager and nursing aides are in charge of providing care for the seniors. The retired priests are able to carry on pastoral work. In the event that the priests are unable to continue serving in a parish, the priests will stay at the assisted living facilty.

Today, assisted living is regarded as an intermediary station between independent living and nursing home. But when Keren Brown Wilson, one of the originators of the concept, built her first assisted living home for the aged in the 1980s, she was trying to eliminate the need for nursing homes altogether.

relentless quest for efficiency However, assisted living, more than often than not, falls short of the ideal. For instance, the seniors should be allowed to dress themselves to maintain their capabilities and sense of independence. But most caregivers simply dress the elderly before actually trying to let the seniors dress themselves first.

Living Room at Bethany East

higher aspirations of the future cohort of seniors There is a ready market of third-age equity holders looking to downsize. They are diverse and harbour aspirations predisposed towards higher standards. By moving the seniors out of homes which typically house three-four bedroom properties, this would release much-needed family dwellings for the younger generation. But in most areas, there are simply not enough accomodation and existing home designs are not sufficiently desirable to most third-agers.

Nursing manager and nursing aides are in charge of taking care of the seniors

any of such assisted living facilities in singapore?

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case study: st bernadetteâ&#x20AC;&#x2122;s lifestyle village Located in a bungalow in upscale Bukit Timah neighbourhood, St Bernadetteâ&#x20AC;&#x2122;s Lifestyle Village is one of the very few assisted living facilities in Singapore. It features 8 single ensuite rooms, a common living area, dining area and outdoor area. It caters to seniors who need only some form of help everyday Given the small scale and the high quality of care, it is no surprise that the Village charges the residents $3650 per month, of which the lower-income seniors could not afford. Regardless, the Village is expanding. A three-storey dwelling at Adam Road has been retrofitted into a new assisted living facility with eight well-appointed, themed rooms. The expansion of the facilities indicate a strong demand for such facilities. Some features include 24 hours medical concierge service, en suite senior-friendly bathrooms, shared kitchen facilities and a therapeutic swimming pool. Unlike nursing homes, where kitchens are locked, the kitchen at the Village is open for the residents to whip up simple dishes. More importantly, they have their own personal space and toilets, too.

At the village, dignity and autonomy are respected at all times. The residents possess the freedom to plan their own schedule and go anywhere they wanted, accompanied by staff They can go on supervised trips to shopping malls.

The staff also help them to do banking if they are unable to do it themselves. Occasionally, residents even go on durian trips to Malaysia. However, such a model is not without its shortcomings. True to any group living arrangements, some residents admitted to having disagreements, but life was not dull. Pastoral care is an important component of the assisted living. two staff stay here permanently and are on roster as famililiarity breeds contempt.

Cooking Sessions

En-suite bathrooms are located right next to the bed to avoid the residents from soiling themselves. Some visitors from the US have commented on the size of the bedroom, however, in view of land scarcity in Singapore and the importance of proximity between the bed and bathroom, sizes of bedrooms might not be too much of a concern. After all, residents spend most of their time at the living area.

Rooms are more individually designed and themed at the newer facility at Adam Road. Hospital bed is required for safety. Efforts have been made to disguise the hospital bed in a bid to create a homelike environment.

Group and Individual Therapy

24 hour medical concierge

Group Games

In typical nursing homes, kitchens are out of bounds. At the Village, kitchen is open to all and residents are encouraged to whipped up simple meals for themselves to encourage continued independence. The kitchen at St B is more basic but the kitchen at Adam Road, as shown in the picture, is a full-fledged one.

The Straits Times(2019). Parliament: Caregiver allowance, assisted living options among suggestions by MPs in debate on ageing. Retrieved from https://www.straitstimes.com/politics/ parliament-caregiver-allowance-assisted-living-options-among-suggestions-by-mps-in-debate

any of such assisted living facilities in singapore?

57

case study: st bernadetteâ&#x20AC;&#x2122;s lifestyle village

Each room is equipped with their own toilet as shown in the photo. There is also a larger toilet near the living room for residents who require assistance with showering.

Sensors are installed in the room to detect when the residents use the toilet.

To avoid alert fatigue for caregivers, a common station with CCTV is featured at the nurse station overlooking the park.

Fence is installed at the stair landings to discourage the residents from using the stairs.

Dementia-friendly lifts are equipped with the necessary buttons should the seniors unable to recall which buttons to press.

There is a childcare centre located next to the Village.

Sometimes children come over for events.

5 CLASSIFICATIONS OF ASSISTED LIVING understanding the types of assisted living according to typologies TYPES OF CLASSIFICATIONS OF ASSISTED LIVING TYPES OF ASSISTED LIVING RESIDENCES(ALR): basic, enhanced, special ASSISTED LIVING IN DIFFERENT COUNTRIES CONTINUING CARE RETIREMENT COMMUNITIES (CCRC): overview CONTINUING CARE RETIREMENT COMMUNITIES (CCRC): estate-scale UNIVERSITY-BASED RETIREMENT COMMUNIES: estate-scale NATURALLY OCCURING RETIREMENT COMMUNITIES: estate-scale 4-5 STOREY APARTMENTS: building complex 3-STOREY APARTMENTS: building complex PODIUM AND TOWER TYPOLOGY SINGLE HOUSE

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types of classifications of assisted living

context

urban

suburban

rural

estate

building complexes

single house

home-care based

institutional

scale

care model

continuum of care

financial model

rent

entrance fee+ monthly service fee

deferred management fee

levels of care

independent living

assisted living

nursing/memory care

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lifestyle concepts

lifelong learning

integrated with neighbouring amenities

integenerational interactions

height

high-rise

mid-rise

low-rise

personality/ hobbies/ interest

ethnic group/ religion

socio-economic status

external service providers

in-house outpatient staff

own dedicated nursing facilities

target audience

medical care

staffing

presence of licensed nurse

State of New York Department of Health. Consumer Information Guide: Assisted Living Residence. Retrieved from https://www.health.ny.gov/publications/1505.pdf Sheryl Zimmerman, and Philip D. Sloane, MD, MPH2(2007). Definition and Classification of Assisted Living Nan Sook Park, Sheryl Zimmerman, Philip D. Sloane, MD, Ann L. Gruber-Baldini, and J. Kevin Eckert. An Empirical Typology of ResidentialCare/Assisted Living Based on a Four-State Study. Retrieved from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.576.6974&rep=rep1&type=pdf

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types of assisted living residences(alr): basic, enhanced, special physical ability declines Basic ALR

Enhanced ALR

Special Needs ALR

-24 hour supervision

residents who need assistance transferring/ ambulating, medication management and have chronic incontinence

residents with cognitive impairment/ dementia needs 24 hr supervision

-medically stable but might be visually or hearing impaired.

-do not require 24/7 skilled medical care ADL Stage 1 needs help

ADL Stage 2

ADL Stage 3

getting in/out of bed/ chair/ walking

no need help

IADL Stage 1

IADL Stage 2

IADL Stage 3

needs help no need help

INSTRUMENTAL ADL

Causes

fine motor coordination/ arthrtis

Mitigation/ Prevention

occupational therapy

Types of Care Staff

social worker

heart/ lung disease/ arthrtis

visual impairment/ dementia increased volume and button

social worker

social worker

visual impairment/ dementia low vision rehab

social worker

enrolled nurse

social work

ker

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types of assisted living residences(alr): basic, enhanced, special definition of assisted living of today lies between board-and-care home and nursing home board and care home

assisted living

(1940-1992)

housing and supportive services in a homelike environment, maximising function and autonomy

individual sleeping spaces full baths kitchens personal furnishings medical staff not always available

nursing home -24 hour supervision -nursing care must be available

types of ADL assistance provided in different assisted living residences assistance with walking, transferring, stair climbing and descending stairs

nursing care(vital signs, eye drops, injections) provided by agency and staff

if necessary, 24 hr skilled nursing/ medical care can be privately hired

specialised programmes and modifications with dementia or other special needs

Basic ALR Enhanced ALR Special ALR

BASIC ADL

muscoskeletal

dementia depression muscoskeletal

muscoskeletal/ stroke

stroke rehab/ exercises

occupational therapy/ psychotehrapy

occupational therapy

certified nursing certified nursing certified nursing assistant assistant assistant

dementia depression osteoarthrtis

advanced dementia diabetes/ rheumatism

urgency control occupational exercises therapy/ aerobic and resistance exercise accessible toilet

stroke/ fear of choking

speech therapy

social worker

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assisted living in different countries definitions of assisted living in different countries There is no singular definition of assisted living facilities. There are significant variants in state regulatory definitions. .

Region/ Alternative Names for Assisted Living

Common Manifestations of Assisted Living

UK

Self-contained flats with the usersâ&#x20AC;&#x2122; own front doors, and a legal right to occupy the property.

- extra care - very sheltered housing - frail elderly care

AUSTRALIA HammondCare hostel care low care

US continuing care retirement community life plan community Active Adult Community Homes

Available for renting, owning, or part owned/ part-rented.

Facilities may include laundry restaurant, dining room, domestic support, personal cares, lounges, 24-hour emergency support.

Warden might live on-site or visit to provide â&#x20AC;&#x2DC;floatingâ&#x20AC;&#x2122; support.

Permanent or respite residential care for people who are able to mobilise independently and do not require intensive skilled nursing care.

Residents receive assistance with all aspects of living including medication management and clinical care.

Extra services charge more than the standard fee. They offer a higher standard of accomodation, food services and lifestyle activities.

Provides a continuum of care and must offer independent living, assised living and nursing home care all in one campus. Older adults must move into a CCRC when they are healthy.

These various levels of shelter and care may be housed on different floors or wings of a single high-rise building or in physically adjacent buildings, such as garden apartments, cottages, duplexes, mid- and low-rise buildings, or spread out in a campus setting.

private, for-profit, metropolitan, freestanding

skilled nursing care

8 in 10 ALF are owned by private, for-profit organisations and are located within metropolitan regions, as well as freestanding.

4 in 10 residents live in ALF that provides skilled nursing care. Only 13% of all residents used this service.

large or extra-large communities

81% of residents live in large(26-100 beds) or extra large(over 100 beds) communities.

Half of ALF are small(4-10 beds).

35% of ALF are large or extra-large.

Department of Health and Human Services(2016). Residential Care Communities and Their Residents in 2010: A National Portrait. Retrieved from https://www.cdc.gov/nchs/data/nsrcf/ nsrcf_chartbook.pdf

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assisted living in different countries In general, assisted living facilities provide 24/7 awake staff, health-related services(excluding 24-hr nursing care), supportive services, recreational activities etc., to respond to residentsâ&#x20AC;&#x2122; scheduled and unscheduled needs. According to the HHS survey, in addition to room and board, nearly all facilities provided basic health monitoring, incontinence care, social and recreational activities, special diets, and laundry services.

Other services, such as occupational and physical therapy, social services counseling, and case management varied by size of facility.

Senior Living Types

Swedish Fokus Housing

central bathing facility after making an appointment

Humanitas Care

Senior Living Types

UK Sheltered Housing

meals are not normally provided

Dutch Care Cooperative Village Humanitas Care US Village Model

encouraged to do oneselves

U.K. Elderly Accomodation Counsel M. Masuda, 2003: Wakariyasui Kaigo Hoken Ho, Yuhikaku, Japan Institute of Health Economics and Policy in Japan U.S. Senior Housing and Care Glossary of Terms MatherLifeWays Institute of Aging

66

Senior Living Types

Typology

Density

Context

Japan Takuroujo (Home-like place for the elderly)

single house multiple houses satellite arrangement

small-scale about 10 seniors

within typical residential communities in suburban/ rural settings

UK Sheltered Housing Dutch Care Cooperative Village Swedish Fokus Housing for severely disabled

Indian Athashri

day care short-stay respite group living

ground-up privately managed

self-contained flats

communal areas such as gardens and lounges

estate-scale

serviced homes day centre support centre for seniors

local council/ housing association

10 to 15 special apartments are dispersed throughout one large apartment complex with 50 units

cluster housing

(Cluster Housing with Services) US Village Model

For/ Not-forProfit

Facilities

estate-scale integrated township

near the city

CCC polyclinic recreational

nonprofit, charitable

sheltered village squares

Humanitas Care Household Model (Unit Care in Japan)

Group Homes in Large Facilities

Dutch Lifetime Neighbourhood

Part or whole of district/village

integrated neighbourghood services

Dutch Apartments for Life (remain in same apartment until death)

city centre

Dutch Residential Care Zones (Woonzorgzone)

2

3

ageing estate

level site

large area

more than one in five people over retirement age living in the locality

level site, near public transport, shops, church and other facilities.

1

4 convenient location not more than five miles from a major centre of population.

typically between three and five hectares.

5 site-specific attractive features pleasant outlook, near park.

ideal sites for ccrc

67

Target Audience

Finance Model

Types of Units

Concept

Are workers present 24/7?

Managing Medication

Things to Note

age-within-community in a homely and familiar environment >65 who value independence and security

sale rent part-buy

24/ emergency help through alarm system

wheelchair-bound residents with accessibility needs

disabled tenants are geographically integrated

Yes

nterdependence higher-middle-income

sale lease

AR AL independence companionship

sale rent 6 to 15 private rooms/ unit

Yes. Scheduled around a regional care centre Individuals above 55

once a day for independent residents 4-8 times in 24 hrs for frailer residents

rent

Residents typically enter the apartments while still independent.

Mixing of residents requiring varying levels of care

care and support for young and old

common area circulation rooms services

typical layout of assisted living facilities

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continuing care retirement communties(ccrc): overview offers a continuum of care on the same compound Continuing care retirement communities (CCRC) are residential communities that offer housing and health- related services that allow residents to remain in the community for the rest of their lives. Many elderly do not want to move to congregate or assisted living and then have to relocate if they need skilled nursing. In addition to the residential unit. CCRCs typically offer access to coordinated social activities, dining services, housekeeping, scheduled transportation, emergency call monitoring, healthcare when and if the course of aging raises the need. Some CCRCs offer residents short-term care, such as rehabilitation after a hospital stay. These beds are often combined with beds reserved for long-term residents. Both are provided with round-the-clock nursing services.

CCRCs are commonly large-scale (over 100 units), rural, cater to a mix of residents, tailor to individual needs, and comprise a mix of tenures. In surburban locations, the typical CCRC are low-rise and site-specific. They have a larger centrally located building with the major services/ amenities and lodging for the frailest members of the society. core and cluster A core building contains most of the communal facilities and sometimes a residential care home. Residents live in their properties scattered around the core building. dispersed facilities

catering/ dining services

Facilities are spread throughout the scheme.

Communal facilities such as lounges and dining-rooms are located around the scheme catering for a small number of people.

weekly servicing/ housekeeping

buildings and layout high-rise preventive nursing care

scheduled transport - no need of a car urban

tower mid-rise

emergency call monitoring

guard patrols

suburban

building complexes

low-rise

24 hour staff care

gardening

key services

rural

estate

common typologies of CCRC

Joseph Rowntree Foundation. Planning for continuing care retirement communities: issues and good practice. Retrieved from http://www.jrf.org.uk/sites/default/files/jrf/migrated/ files/0156.pdf

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continuing care retirement communties(ccrc): overview offers a continuum of care on the same compound ccrc in the context of singapore? independent living 10-12 years

assisted living 1-2 years

nursing care

St Josephâ&#x20AC;&#x2122;s Home somewhat resembles a small-scale CCRC with nursing home and a pilot assisted living project within the same site. MOH has also been developing a continuum of care for seniors within selected housing estates. Tampines North Nursing Home where the design and connectivity of the eldercare facilities (that is, day care and residential care) have been integrated with the adjacent public housing development at Tampines GreenWeave, so that we have independent living, assisted living and nursing care all within the same area.

1-2 years

typical length of stay

cost prohibitiveness of ccrc Most CCRCs require residents to pay a one-off entry fee or a weekly fee to cover accommodation costs and a regular fee for the duration of stay. The monthly fee is set in the contract and typically increases annually to cover any increase in the cost of operations. In a CCRC, residents begin their stay in the independent living unit. If they are required to move to assisted living or skilled nursing, the monthly fee may increase due to the increased cost of care. This is not always the case. Some CCRCs charge a very high entrance fee with the promise that the monthly fee will not increase as the need for care increases. Whether the monthly fee increases as the need for care increases or not depends on the type of contract the resident signs.

limitations of ccrc in Singapore context Successful CCRCs require large plots of land, dedicated specifically to the seniors alone. Even in bigger countries where lands are aplenty, CCRCs are usually found in suburbs. It is therefore not very feasible for Singapore to implement the CCRC model. Furthermore, it is unecessary, given how most healthcare services are within the reach of public transport system.

The mejority of time spent in CCRC is that in the independent living unit, where one does not require much help.

Given how cost-prohibitive CCRC can be, the notion of moving into a CCRC might not appeal to the seniors in Singapore context.

Even in the US, where community governance is more popular than in Asia, sometimes independent living residents may not want to interact with or even see the residents of the care centre.

By far, CCRC is the most expensive senior living option.

Notwithstanding the high cost of CCRC, of which most low or even middle-income seniors could not afford this option, new residents must be capable of living independently upon entry t the community. Today, average ages at entry are generally in the 80 to 83 range, which has increased from the past decade. Even in the US, where CCRCs are the most popular, only 6 of ALF are part of CCRC.

Siok Peng, Lim(2017). Various programmes exist to help seniors age in place. Retrieved from https://www.straitstimes.com/forum/letters-in-print/various-programmes-exist-to-help-seniors-age-in-place Zebolsky, Gregory (28 July 2014). â&#x20AC;&#x153;An introduction to continuing care retirement communities. Retrieved from http://us.milliman.com/insight/2014/An-introduction-to-continuing-care-retirement-communities/

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continuing care retirement communities(ccrc): estate-scale case study: elphin lodge retirement estate, modderfontein, johannesburg

Context Near Edenvale Hospital Key Features assisted living units frail care facilities Types of Units 119 two-bedroom cottages 40 one-bedroom 64 two-bedroom apartments

Within close proximity to Edenvale Hospital, Elphin Lodge Retirement Estate houses seniors from assisted living to frail care. It offers a wide array of programmes and activity areas such as residential library, recreation centre, manicurist, beautician, podiatry, hairdressing, physiotherapy etc. It has only one service support, eliminating cross traffic between residents and staff. The first wing houses semi-frail residents and a recovery station for able-bodied residents who suffered a temporary medical condition.

The second andthird wing house frail care residents who rely on caregivers for health support and assistance with daily activities. Within this block, the units house private bedrooms with communal bathrooms.

Services emergency call system gardening service weekly servicing of apartments monitored 24/7 and guard patrols preventive nursing care physiotherapy podiatry laundrette transport to shops swimming pool residential units

residential units recreational/ medical semi-frail care frail care

Site Plan

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entrance+ nursing station

entrance+ nursing station

entrance+ nursing station

nursing care communal dining

communal tv lounge

communal bath

nursing care communal dining

communal tv lounge

communal bath

semi-nursing care communal dining

dining/ kitchen space

communal tv lounge

recovery area

multipurpose hall

physiotherapy/ podiatry clinic (blood pressure, tablets)

reception

kitchen

admin/ managersâ&#x20AC;&#x2122; offices

library/ reading space

social space

Site Plan of Recreational Facility Ryan George Caldeira (2012). URBAN AGEING: the social inclusion of senior citizens Retrieved from https://core.ac.uk/download/pdf/39671837.pdf

72 Within this block the units link to a communal space which consists of a TV lounge, kitchenette and small dining room.

To manage the condition of the semi-frail residents, the units offer 1 bedroom, an en-suite bathroom and a kitchenette.

bedroom

BR WC

bedroom

bedroom bathroom

lounge

dining area

lounge

dining area

kitchen

lounge kitchen

dining area kitchen entrance

yard

bedroom bathroom

Apartment Type A 1-bedded units 76 sqm

Cottage Type A 93 sqm

bedroom

bedroom bedroom

bedroom

bathroom

lounge

dining area

lounge

dining area

lounge

dining area

kitchen

kitchen

yard

Cottage Type B 101 sqm

bedroom

kitchen

bathroom

bedroom

Apartment Type B 2-bedded units 92 sqm

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vertical continuing care retirement communities: estate-scale case study: montgomery place, chicago, the us

Context 14-storey building located on prime real estate and a tight urban site in the heart of the well-established Hyde Park neighbourhood of Chicago.

Key Features 174 independent living apartments 8 dementia care apartments 26 nursing care apartments 12 assisted living apartments Amenities private suites private bathrooms scheduled transport(non-medical related) shared room

Montgomery Place is a complete CCRC including 174 independent living apartments and 12 household-concept assisted-living apartments which have been added as part of a repositioning project on the third floor.

It emphasises participation and visual connection between the seniors and the vistors/ passerbys by placing residential amenities at the very front of the building. As a demonstrative statement that the residents and their care programme are at the centre of Montogomery Place, the administrative offices were moved to a reclaimed portion of an existing underbuilding parking garage, to which light was providedby means of a large skylight well, providing additional and valuable aboce-ground portions of the building to dedicate to programme and social space.

14th storey 13th storey 12th storey 11th storey 10th storey 9th storey 8th storey 7th storey 6th storey 5th storey 4th storey 3rd storey 2nd storey 1st storey basement

independent-living

household-concept assisted living assisted living apartments household model of 12 short-term residents social spaces parking garage& admin offices

main dining

main kitchen

green house library

amigo parking

game room

activity room

mail room

east room

concierge cafe

wellnesscentre aquatics centre

exercise room

living room

chapel

beauty salon

First Floor Plan

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university-based retirement community: estate-scale

continuum of care

The subsequent generationâ&#x20AC;&#x2122;s greater quest for privacy and demand for larger units as well as smaller communal spaces, the concept of collegiality should be reintroduced. Many seniors strive to seek intellectual, cultural and vocational opportunities hitherto unattainable. The Kendal Corporation has pioneered this notion with five CCRCs adjacent to college campuses, including Dartmouth College, Cornell University and Oberlin College. Such CCRCs allow the elderly to audit classes, host study sessions in the library, and become involved with intergenerational think-tanks.

Retirement communities should be designed as living and learning centres. Residents harbour a greater desire to participate in managerial processes.

access to campus fitness centres

Integrated university and retirement campuses alongside ancilliary services, such as security, maintenance, dietary, transportation, housekeeping and healthcare have been built. Academic classes and cultural, sporting and social events will be open to all who wish to attend. The interplay and symbiotic relationship between the young learner and the mature learner will not impinge on the privacy of either.

Facilities that provide a therapeutic environment and rehabilitation such as health club has replaced nursing centre in the hierarchy of demands.

Theatre-style seating can be used for lectures and distance-learning opportunities with colleges and universities. Display cooking and customer participation is increasingly in vogue. Patrons should also be allowed to customise food orders to meet specific dietary needs or preference.

enroll in or audit college classes

intergenerational diversity

uorc in the context of singapore?

Many elderly Singaporeans have demonstrated the desire to stay relevant and keep oneself abreast with the rest of the society. Some seniors received a subsidy and used their SkillsFuture Credit to pay for vocational courses offered in various tertiary institutes in Singapore. It allows the seniors to fulfill their childhood dreams. National Silver Academy under the Action Plan for Successful Ageing has been offering lifelong learning courses for seniors. Some courses that have been proven to be popular include social media and the arts.

Grosse, Sara. (2017). New study to look at impact of lifelong learning on seniors. Retrieved from https://www.channelnewsasia.com/news/singapore/new-study-to-look-at-impact-of-lifelong-learning-on-seniors-7618266

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naturally occuring retirement community: estate-scale case study: classic residence, new york

Naturally Occuring Retirement Communities(NORC) are often high-rise housing blocks and clusters of landed homes that evolve organically into age-friendly communities. A NORC is denoted by any geographically defined community where more than 40% of the population is aged 60 or above and live in their own homes. NORCs tap on the combined power of public and private funding, housing partnerships, philanthropies, corporations, community stakeholders and residents to offer the services tenants need.

health classes

Not only does it keep costs low for retiree, it also allows the seniors to maintain the ties and relations they already have established throughout their decades of living there. They also do not have to acquaint themselves with a strange environment, which can be stressful for a senior. Most known CCRCs are found in urban areas.

Programming is unique to each community. Core services that are deemed necessary include case management, information and assistance providing referrals, helping folks with different entitlement and benefit applications, and health care management. For instance, New Yorkâ&#x20AC;&#x2122;s NORC Supportive Service collects baseline health data on NORC residents to identify the most needed health services.

limitations of norc

visiting healthcare professionals

courses/ workshops

Beyond the more successful examples of NORCs, Some lack a full-time staff of social workers or nurses stationed within the service area, which is key to providing daily help. Immediate medical attention is, more often than not, necessary for seniors with dementia. Besides, certain unhealthy NORCs do not have adequate access to transportation services and active community environments.

norc in the context of singapore?

transportation

In Singapore, mature estates such as Bedok, Whampoa and Marine Parade had been equipped with age-friendly features in view of its ageing population.

The addition of elderly-friendly features and services is more reactive than preemptive in nature. housekeeping

Masotti, P. J., Fick, R., Johnson-Masotti, A., & MacLeod, S. (2006). Healthy naturally occurring retirement communities: a low-cost approach to facilitating healthy aging. American journal of public health, 96(7), 1164-70. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1483864/

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4-5 storey apartments: building complex case study: npo group fuji, kanagawa, japan

Context a four-storey building surrounded by a residential neighbourhood in suburban Tokyo Key Features assisted living for seniors >65 multifunctional care including adult day service short-term care for 25 seniors group home for 6 youths experiencing physical and mental disabilities Services restaurant (faces main street) adult and day service (open to surrounding community) elderly caregiving resource centre (street level)

4th storey

assisted living apartments

3rd storey

assisted living apartments

2nd storey

group home for disabled

1st storey

child daycare + elderly care

Initiated by five housewives for local community residents who needed assistance with caring for seniors as well as children, Group Fuji adopts cooperative support system, where local residents care for each other. The assisted living residents each have a private room with small kitchen and private bathroom, maintaining their independence. These rooms are only a short distance away from living room and dining room shared by all residents on the floor.

Adult and child day services are open to surrounding community so that local residents of all ages are integrated into the care and service. The emphasis on inclusive care is expounded by supporting interactions between the different age groups. This is because the seniors prefer to be surrounded by other generations rather than living among a homogeneous group.

balcony

small kitchen

living room

kitchen

dining area

Third Floor of NPO Fuji

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2

1 INDEPENDENCE Each resident has a private room with small kitchen and private bathroom, maintaining their independence.

INTIATIVE

THE EXTENDED FAMILY

Residents are encouraged to cook, clean and bath themselves, but with regular assessments from care workers.

MULTIGENERATIONAL

A ‘YES’ CULTURE

The multifunctional care programs for seniors and child daycare services are located on the first floor.

Intergenerational activity with local school children in a household dining room

The ‘Ohana’ cafe open to surrounding neighbourhood community

Everyone has something useful to contribute, be it professional skills or simply spare time. Humanitas rewards each volunteer with a monthly stipend of 100 euros tax free.

6

5

4 If residents request something, staff should ‘start with yes’ and work out a reasonable solution.

Everyone should have a positive attitude towards the residents.

3

INTEGRATION The organisation operates a restaurant and a child day-care service, both of which are open to the public.

Household living room with resident rooms on either side

Residents attend a music class with a volunteer musician.

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3- storey apartments: building complex case study: belong atherton, lancashire, united kingdom

Context a three-storey building located in the centre of Victorian mill town Key Features six self-contained households of 12 residents each assisted living apartments care home household Facilities community rooms Internet cafe small shop bistro central, fully equipped catering kitchen

Belong Atherton houses six self-contained households of 12 residents each under one roof. Of the size households, the scheme manages three distinct layouts. Each revolves around a large open-plan communal centre that contains living, dining, and kitchen area.

Residents can find their way around easily and that staff members can easily and discreetly monitor the entire household.

Private bedrooms that include en-suite bathrooms open onto the central open-plan communal area or onto short lengths of corridor. Residents can find their way around the household easily and discreetly monitor the entire household.

assisted living apartments The balcony accessed from the household lounge is large enough for several people to sit comfortably.

care home household

dining bistro

hair salon

care home household

The main entrance is accessed either through gardens or directly off the street. Vehicular access is kept discreet but readily accessible.

Open-plan household lounge and dining area with access to garden beyond the domestic-style kitchen.

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1

2

3

SENSE OF COMMUNITY

FLEXIBILITY

FREEDOM OF CHOICE

Some residents, especially bedridden ones, enjoy listening to the activities of the living/ kitchen area from the privacy of their rooms.

The design layout and details allow for â&#x20AC;&#x2DC;future-proofingâ&#x20AC;&#x2122; should the needs of current and future residents change.

The kitchen is open and forms a lively hub around which all activities revolve. Dining, craft, and living areas are clearly separate, and long with other smaller alcoves and sitting spaces, allow residents to choose their preferred activities.

balcony

living/ dining

small recess with low ceiling

bedroom

bathroom

connection

other bedroom

Each layout revolves around a lare open-plan communal centre that contains living, dining and kitchen areas To emphasise independence, one- and two-bedroom apartments are accessed accessed externally with their own controlled door to common carpeted corridors and stairwells.

Two ensuite bathrooms can easily convert in the future to a one-bedroom apartment with a separate kitchen, bedroom and living space.

private spaces including living room semi-private space/ small recess corridor

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podium and tower typology case study: tanner hill, hong kong

Context adjacent to North Point MTR and within walking distance to malls Key Features four-level podium and three residential towers studio(including open kitchen) 1-bedroom 2-bedroom combined unit(2-bedroom and 3-bedroom) Facilities family medicine and Chinese medicine clinic home care re gymnasium senior citizen wellness centre

Tanner Hill is the first non-subsidised quality elderly housing project in Hong Kong. It is for lease only and not for sale. It provides a comprehensive range of services and amenities to enable active aging and aging-inplace.

home care

independent living units

gymnasium

residential care home day care, rehabilitation centre library, MPH wellness centre, clinic, gymnasium rehabilitation centre

carpark

Hong Kong Housing Society Elderly Housing Developments: Legislative Council Panel on Housing Special Meeting(2012). Hong Kong Housing Society

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single house UK sheltered accomodation Bungalows are especially common in seaside towns. Sheltered accomodation allows independence to be maintained and support to be provided if needed. It is usually housed in detached bungalows, engendering social disconnection.

Staff is also on-call 24/7, rendering a monitored level of care to the residents.

Occasionally, accessibility issues arise in two-storey cottages without elevator. It is not very profitable and land-efficient for developers to build bungalows. A typical accessible (wheelchair friendly) 2-bedroomed bungalow has a floor area of 72sqmwith an internal width of 7.4m. The plot size, with a parking space and a small rear garden is on average 220sqm. Adding the access roads and paths, this generates a development land take of 275sqm/plot giving a density of 36 units/ha.

Such sheltered accomodation housed in bungalows are declining in popularity in the UK as a result of the seniorsâ&#x20AC;&#x2122; evolving aspirations.

More specifically, in he context of Singapore, it is not economically sustainable to build such low-density accomodation for seniors. For instance, St Bernadette Lifestyle Village has to charge her residents $3,650 per month to remain viable, given the fact that it is housed in a bungalow and hence, could take in only eight seniors.

Severnside Housing, a sheltered accomodation in the UK

emergency call monitoring

communal garden

weekly servicing/ housekeeping

pets accepted

6 CONCEPTS OF ASSISTED LIVING RESIDENCIES understanding the types of assisted living according to typologies DUTCH LIFETIME NEIGHBOURHOOD DANISH COHOUSING MODEL HOMESHARE HOUSEHOLD MODEL JAPANESE TAKUROUJO JAPANSESE GOJIKARA MURA DUTCH CARE COOPERATIVE VILLAGE VILLAGE MODEL INTEGRATED SERVICE AREAS (ISA)

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dutch lifetime neighbourhood case study: weidevogelhof

Context part of 2,300 houses in a newly built suburb Key Features one-bedroom assisted living sheltered housing primary care at-home nursing care care hotel dementia care No of Buildings 9 Types of Units 119 two-bedroom cottages 40 one-bedroom 64 two-bedroom apartments Services emergency call system gardening service preventive nursing care weekly servicing of apartments monitored 24/7 and guard patrols

Image Credit: http://www.datarchitecten.nl/projecten/de_weidevogelhof/

Living an independent life in one’s own home, regardless of lies the core for the Dutch housing policy. The three elements of housing, at-home care and welfare services are therfore developed simultaneously. Individuals can stay at home as long as possible, or, if necessary, move into a care environment and stay within the same neighbourhood. Couples can stay close one to another when one is in need of care.

Given the socioeconomic profile of Weidevogelhof, most of the inhabitants live in affordable housing, who increasingly want to sell their homes and rent in order to free themselves from the demands associated with homeownership, such as maintenance. Others simply want to downsize and leave their large family home for the comfort of an apartment without stairs.

Weidevogelhof, a comprehensive ‘lifetime’ nieghbourhood with age-mix and a mixture of independent and care-supported livng, is integrated with 2300 other hoses in Keijzershof, a newly built suburb. Popular with young families, the development has sixteen fully self-contained apartments with access to roundthe-clock support scattered throughout the suburb.

True to the Dutch concept of ‘lifetime neighbourhood’, the specific services, ranging from assisted living to dementia care, are not aggregated. Rather, they are scattered across the site for true integration of community. The community is also encouraged to travel through, rather than around the site.

Individuals are given the opportunity to rent an apartment even if no care is required, allowing the residents to stay in their own apartment and in a familiar environment should they require care in the future. Each apartment has its own garden/ balcony. There are 41 one-bedroom assisted living apartments designed flexibly to enable reconfiguration into more households for dementia care in addition to the existing 10, each accommodating six people with dementia.

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Ground Floor

Second Floor

Third Floor

Care Hotel Household for Dementia Care

Pieter van Foreest

Apartments

Local Welfare

Speech Therapy, Pathology Service, Hairdresser

25 sheltered housing

independent living with ADL support for severely disabled residents

Fourth Floor

49 sheltered housing 3 household dementia care Child day centre Alzheimerâ&#x20AC;&#x2122;s garden

20 sheltered housing 40 assisted living Restaurant Beauty Salon Offices Pieter van Forest

24 sheltered housing 3 household dementia care Carehotel with 8 rooms Local Welfare Speech Therapy Pathology Service Hairdresser

35 cohousing apartments 15 apartments for mentally disabled residents 2 group homes for mentally disabled residents

23 sheltered housing 4 household dementia care General Practitioners Pharmacy Dentist Physical Therapy Obstetrician

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danish cohousing model ungated community for the grassroots, by the grassroots

buy groceries for neighbour

gardening Image Credit: http://www.jutlandstation.dk/not-without-my-neighboursthe-success-of-cohousing-in-denmark/ Since 1987, about 250 senior co-housing communities have been established.

The Danish definition of co-housing fulfills the following criteria:

car-pooling

1. The facility has a common house/ apartment.

2. The resident group has to constitute an independent social unit with its own board or residentsâ&#x20AC;&#x2122; committee.

3. A residential minimum age is in place, or a rule that prohibits children from living with them.

The resident might have to compromise on privacy at first. However, as a Danish survey has shown, the residents had adapted well to the cohousing environment.

The majority of Danish senior co-housing communities are established as singlestory row houses. Often the common house will be placed at the center of the facility, as here in Tanderparken, close to Aarhus.

Pedersen, Max(2015). Senior Cohousing Communities in Denmark. Retrieved from https://www.tandfonline.com/doi/pdf/10.1080/02763893.2015.989770?needAccess=true Soh, Emily. Social Sector-led Housing in Denmark and Japan. Retrieved from https://lkycic.sutd.edu.sg/wp-content/uploads/sites/7/2016/08/Housing-Note-9-Social-sector-elderly-housing-in-Denmark-and-Japan.pdf

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The common house is the social nexus of all facilities, establishing visual connection between the common house and surrounding houses. According to Danish survey, the frequency of usage of the common house varies greatly, where some use it everyday, while some others use it only several times per year. Most residents feel that residents should help each other out extensively in all practical matters, except for tasks that are traditionally performed by homecare staff, such as giving a neighbour a bath.

1

2

3

PRIVACY

CLOSE-KNITTED COMMUNITY

INITIATIVE/ GROUND-UP

Residents have access to shared spaces, including gardens and community kitchens. By forging interactions between seniors, isolation, detrimental to physical and mental health, can be reduced.

Many co-housing facilities are self-initiated by the seniors themselves, who then approach a housing organisation to help establish the facility.

Unlike many other assisted living units, which put residents in close quarters, Danish cohousing provides residents with their own house and apartment.

4

5

AFFORDABLE

SHARED RESPONSIBILITY

Under Boligtrivsel i Centrum, many cohousing facilities became established as rental social housing and are made affordable and less socially exclusive.

The absence of responisibility might lead to regression and decline. Residents prepare the meals themselves or tend the common garden.

6 AUTONOMY Resdents have the freedom and say on the way it is being run.

They operate by consensus and gather to make decisions.

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homeshare between the traditional â&#x20AC;&#x2DC;ageing-in-placeâ&#x20AC;&#x2122; and residential care

7 in 10 non-subletting households were unwilling to consider tenants even if they had spare rooms and found an ideal tenant.

Organised by non-profit organisations, Homeshare brings together two people who can help each other; usually an elderly householder and a younger homesharer. Homesharers and householders of similar interests would be matched via agencies. This scheme is in place in a bid to stave off loneliness from the seniors who otherwise would have to live alone. Homesharers are required to provide support to householders for, say, a minimum of 10 hours per week.

In Singapore, many seniors live in houses larger than they require and which may not be suitable. Some seniors are already averse to the notion of renting rooms(at market rate) to strangers. As such, mindset change will have to occur before Singaporeans become receptive to the notion of homeshare.

accomodation

companionship shopping cooking cleaning overnight security very low rental overnight security

transactional relationship between the home-sharers

1

2

OLDER HOUSEHOLDER

YOUNGER HOMESHARER

has a room to spare but needs some help to live independently in their own home in exchange for somewhere to stay at very low cost or rent free.

needs accommodation and is willing to give some help and friendship

householders are usually seniors who would otherwise have moved into assisted living facilities rather than living alone.

may help with daily tasks such as shopping, cooking, cleaning, companionship, overnight security, enabling reengagement with the local community and social activity.

Single parents, older people, busy professionals, pet owners value home help.

The companion provides an agreed amound of help around the home, around 10 hours per week, in exchange for accomodation. Companions tend to be interns, mature students or working professionals that commit to a 9 month or 1 year agreement. However, companions do not support with any personal care or manual handling tasks. These tasks are suited to a professional and trained carer.

The subscription is a monthly charge to both Householder and the Companion for the duration of the home-sharing period. Householder subscription fees include a complimentary physiotherapy / occupational therapy consultation, for persons aged above 65. Companion subscription includes invitation to Share my Home social groups hosted throughout the year.

Garland, Emma(2018). Learning from Intergenerational Housing Projects in the USA. Retrieved from https://www.wcmt.org.uk/sites/default/files/report-documents/Garland%20E%20 Report%202017%20Final.pdf Share My Home. Retrieved from https://www.sharemyhome.co.uk/faq

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household model person-centred approach where residents have a significant say in their lives

1 AUTONOMY/ PRIVACY Residents have a significant say in their daily lives, their care and their living environment. All ADLs occur within closely related private or semi-private zones that are discrete from other portions of the facility. The small scale of the household, with its open floor plan, virtually eliminates corridors and allows orientation and easy access for residents to all daily activities.

2 INTIMACY To foster a sense of ownership, this small-scale model typically only has 10 to 18 residents live in each residency(‘household’), creating a home and sanctuary where residents live meaningful lives. Individuals become more outgoing and confident. Residents share common living spaces with other residents, too. Each resident also has his own apartment with a bedroom, bathroom and kitchen.

Dining Room at Creekview

Living Room at Creekview

3 EMPOWERED STAFF/ SHARED RESPONSIBILITY The household staff signs up for the shift he/she wants, promoting a healthy work-life balance, which reduces staff turnover, forging stronger resident-employee bonds.

Staff are trained as more holistic caregivers. Nursing staff are authorised to prepare simple meals to help promote staff confidence.

4 PERSON-CENTRED It emphasises interpersonal relationships and personal decision-making. It allows residents the freedom to continue the lifestyle they have lived all their lives, there is an easier transition between levels of care, and no pressure to fit into a structured schedule. The care staff respect the choices of the residents’ decisions.

Creekview- Medicine Island

Cassandra Dowell. How the ‘Household Model’ Is Redefining Senior Living Design. Retrieved from http://innovation.seniorhousingnews.com/how-the-household-model-is-redefining-senior-living-design/ A New Care Model: The Household Model . Retrieved from https://wesleyplacedothan.org/2016/05/a-new-care-model-the-household-model/ Ortigara, Anna(2018). The Household Model: Creating a ‘Home’ in Nursing Homes. Retrieved from https://phinational.org/household-model-creates-real-home-people-living-nursinghomes/ Housing Model for Nursing Home Environments. Retrieved from https://www.pioneernetwork.net/wp-content/uploads/2016/10/Household-Models-for-Nursing-Home-Environments-Symposium-Paper.pdf

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japanese takuroujo home-like place for the elderly ‘Takuroujo’, which means home-like place for the elderly, is a community-based small local care complex subsidised by the government. These facilities, which can come in the form of single house, multiple-houses or satellite arrangement, are usually found in suburban or rural areas.

respite care

In line with Japan’s effort of residentialisation of elderly facilities and care services, ‘Takuroujo’ provides a homely atmosphere to the residents. ‘Takuroujos’ can be similar to the group homes in operation and setup, which deviate quite significantly nursing homes.

day service single house

multiple houses

converted from a big individual house with sufficient spaces to contain the services

consists of adjoining residential units.

satellite arrangement a group of homes located near a hospital or nursing home

classification of takuroujo delivery nursing

group living

2

1 HOMELY ATMOSPHERE

COMMUNITY NEEDS

Despite the lack of quality equipments, community-based small local care complex

Over time, takuroujos have been adapted to meet the community’s demands as well, such as residential place for disabled residents, daytime place for junior high school students.

Ohara, Kazouki(2006). New Trials of the Elderly Living in Japan. Retrieved from https://www.enhr.net/documents/2006%20Slovenia/W06_Ohara.pdf Lee Li Ming Programme in Ageing Urbanism. Social-Sector-led Elderly Housing in Denmark and Japan. Retrieved from https://lkycic.sutd.edu.sg/wp-content/uploads/sites/7/2016/08/ Housing-Note-9-Social-sector-elderly-housing-in-Denmark-and-Japan.pdf

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japanese gojikara mura multi-generational community Gojikara Mura aims to simulate a multigenerational community where seniors are able to continue their lifestyle before moving in. To achieve this, Gojikara Mura offers a range of services to cater to the seniors; family members and visitors as well as seniors themselves.

assisted living

2

1 AUTHENTICITY Vehicles are to be parked at the boundary of property and people are required to walk to the various buildings.

To simulate the larger community, multigenerational functions such as preschools are gradually added.

MULTIGENERATIONAL Nursing school and preschool in close proximity to elderly residences.

skilled nursing care

At the entrance, childrensâ&#x20AC;&#x2122; voices from the preschool are one of the first voices heard.

home care

3

4

INTERDEPENDENCY

DIVERSITY

To encourage interdependency, some non-critical areas are inaccessible and inconvenient to encourage residents and visitors to help one another.

It offers a range of services, such as skilled nursing care, assisted living, home care and adult day care for seniors. To cater to children and community by and large, child day care, nursery and community centres are incorporated, too.

Besides, meals are prepared by mothers whose children attend the preschool.

adult day care

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dutch care cooperative village care cooperative that aims to run without subsidies

twice-a-week daycare

2

1 FACILITIES WITHIN REACH The aim was to meet older peopleâ&#x20AC;&#x2122;s need for health and social care in their own village, instead of having to travel to a town.

support centre for seniors

CO-RESPONSIBILITY

It employs only 6-10 staff and uses a mix of professionals and volunteers.

Volunteers take part in a rota to cook meals for older disabled residents, provide other domestic help required and transport when necessary. They also help with weekly lunches or training people in using mobility scooters.

garden maintenance

4

3

meals cooked by volunteers

CO-PRODUCTION

COMMUNITY INVOLVEMENT

The cooperative and its 200 members work to preserve and develop care services and facilities. As a result, senior citizens, the chronically ill and disabled people can continue to live in their own village, even when demand for care increases.

Day care is available twice a week, giving relief to informal carers. Wheelchairs and motorised scooters are lent out as needed. Staff are recruited locally so that they can provide rapid response in emergencies. Garden maintenance is done by workers in sheltered employment.

Kingâ&#x20AC;&#x2122;s College London. (2013). Assisted Living Platform -The Long Term Care Revolution: A study of innovatory models to support older people with disabilities in the Netherlands. Retrieved from https://www.ifa-fiv.org/wp-content/uploads/2013/11/HLIN-Case-Study76-Netherlands.pdf Dutch Village Care Co-Ops. Retrieved from http://beingwell.plunkett.co.uk/inspirations/dutch-village-care-co-ops/

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village model community dwelling + non-professional services organised by ‘grassroots’

1

2

INTERDEPENDENCY

INITIATIVE

The Village concept is not a provider model and does not have license requirements.

Members are linked with one another via a network of volunteer and paid services.

Many volunteers assist with daily operations or delivery services.

Villages are initiated and governed by the residents they serve. Volunteering opportunities abound for members to help each other one-on-one, organize and lead a new activity or class, or become board members to help the overall operations.

transport

housekeeping

assistance with moving furnitures

3

4

AFFORDABILITY

‘KAMPUNG SPIRIT’

Most residents belong to the middle class who do not qualify for means testing. It is funded by the government and kept affordable. A high level of service is also striven for. Run by volunteers and paid staff, it is membership-driven, grassroots, nonprofit organizations.

The coordinator manages a vetted list of service providers and community partners to call when a villager needs help: home maintenance and repairs, technology help, health and wellness services, transportation, light housekeeping and shopping assistance. Service providers—from drivers to handymen—will often negotiate special prices when they’re contracted to work for an entire village.

home health care

Linda Abbit(2017). The Village Model: A Neighbourly Way to Age in Place. Retrieved from https://seniorplanet.org/the-village-model-a-neighborly-way-to-age-in-place/ Scharlach, Andrew & Graham, Carrie & Lehning, Amanda. (2011). The “Village” Model: A Consumer-Driven Approach for Aging in Place. The Gerontologist. 52. 418-27. 10.1093/geront/ gnr083.

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integrated service areas (isa) integrated service in Germany, the Netherlands, Switzerland and Denmark The Integrated Service Areas(ISA) began in 2009 with Germany, the Netherlands, Switzerland and Denmark identifying the types of housing and service arrangements. This group of architects, city planners, service providers and researchers looked for existing projects that met a series of criteria they developed. Cooperation in planning, implementation and evaluation of housing, care and service projects empower the seniors with dignity, independence and worth, well integrated into their communities.

2

1 barrier-free apartments with easily accessible public spaces

varied levels of assistance by provided by specialists and neighbours

3 various care options, emphasising smallscale home care

4 one or more social meeting spaces

criteria for ISA/ key provisional components

municipality

1 full participation of local stakeholders in shaping the types of housing and services

Cooperation between stakeholders

2

director/ initiator

citizensâ&#x20AC;&#x2122; association

provision

housing entreprises

finance housing social

cooperation, especially between professionals and government

partner

means of implementation

citizensâ&#x20AC;&#x2122; association welfare organisation

Integrated Service Areas(ISA) for Ageing-in-Place in Germany, Switzerland, the Netherlands and Denmark. Retrieved from http://www.ifa-fiv.org/wp-content/uploads/2013/12/Stolarz-Holger-Integrated-Service-Areas-ISA-for-Ageing-in-Place-in-Germany-Switzerland-the-Netherlands-and-Denmark.pdf Integrated Service Areas: An Innovative Approach to Housing, Services and Supports for Older Persons Ageing in Place (2014). Retrieved from https://onlinelibrary.wiley.com/doi/pdf/10.1002/casp.2175

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integrated service areas (isa) co-located and locally integrated services in small communities In Eching, Germany, the senior housing building (including both independent and assisted living floors) has a first-floor cafe that is open to the community, as well as meeting and activity rooms that are open to all citizens of the town.

There are intergenerational programmes there so that residents of the building can interact with others in the community. Social isolation can be a major risk factor for social isolation among elders. The fundamental building blocks of ISA consist of housing, social support and nursing care.

3

1

2

small scale and interlinked structure of decentralised nursing care within residential areas

from provision-oriented care to participation-oriented care

economically necessary serves the needs and wishes of older people

structural changes in the care of older people

housing integrated into the local community, where all generations live together

housing adaptation barrier-free housing communal housing

Components of ISA

social support multidisciplinary and coordinated

nursing care

counselling coordination help social integration mutual help

domestic care linked to the area forms of housing with care provision (group living) integration of nursing homes, short-term and day care

7 OTHER DESIGN CONSIDERATIONS other things to note for design of assisted living units OF WHAT SCALE? FLEXIBLE CONFIGURATIONS TYPICAL FLOOR PLANS OF ASSISTED LIVING UNITS AFFORDABILITY HOW TO EASE NIMBY SYNDROME: design elements to achieve deinstitutionaisation

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of what scale?

flexible configurations

According to a study published by Medical Journal of Australia, residents living long-term in clustered home-like aged care had a significantly higher quality of life compared to those in standard care. The criteria for clustered homelike facilities in this study included having an independent accessible outdoor area, allocation of care staff to specific living units, meals cooked within the units, self-service of meals by residents and residents’ participation in meal preparation.Residents in the home-like aged care environments also had a 68 per cent lower rate of being admitted to hospital and 73 per cent lower chance of admission to the emergency department. The researchers estimate the clustered model saved governments approximately $14,000 per resident per year in health and residential care costs. The criteria for clustered home-like facilities in this study included having an independent accessible outdoor area, allocation of care staff to specific living units, meals cooked within the units, self-service of meals by residents and residents’ participation in meal preparation. The residents living in the clustered home-like facilities were more likely to receive more than two-and-a-half direct care hours per day (77 per cent) than those in standard facilities (45 per cent), according to the study.

case study: attemsgasse, vienna

‘Not only are home-like residences providing better health outcomes, they are also cost effective.’

Dr Stephen Judd CEO of Hammondcare

Assisted living homes range in size from four bedrooms to large scale developments containing hundreds of double-occupancy bedrooms. Larger facilities are able to offer more routine screenings for cognitive impairments, as well as dental and mental health services. However, some individuals might choose to remain using the healthcare and dental services they have been using for years. On the other hand, a higher quality of individualised care is associated with the smaller resident-to-employee ratio. Small-scale residences garner strong appeal among the older folks, especially the professionals. Some seniors with dementia are easily overstimulated by a large group environment, according to Philip Sloane, the Goodwin Distinguished Professor of Family Medicine at the University of North Carolina.

Attemsgasse embraces the inter-generational narrative and the concept of adaptability. One of the buildings is designed for ‘senior citizens’ aged 50+, the other for the increasing number of ‘young urban professionals’ who also work from home. Rigidly defined functions such as dining room and bedroom are avoided. The generous two-room apartments in the building for the over 50s can be subdivided to provide space for the carer. Given that older people spend a considerable amount of time confined within the four walls, the integration of loggias into the living area is of particular importance.

Suzanne M Dyer, Enwu Liu, Emmanuel S Gnanamanickam, Rachel Milte, Tiffany Easton, Stephanie L Harrison, Clare E Bradley, Julie Ratcliffe, Maria Crotty(2018). Clustered domestic residential aged care in Australia: fewer hospitalisations and better quality of life. Retrieved from https://www. mja.com.au/system/files/2018-05/10.5694mja17.00861_0.pdf The Perfect Assisted Living Facility Size. Retrieved from http://seniorsmatter.com/the-perfect-assisted-living-facility-size/ Assisted Living: Back to the Future. Retrieved from https://newoldage.blogs.nytimes.com/2009/12/28/assisted-living-back-to-the-future/

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how to ease nimby syndrome: design elements to achieve deinstitutionalisation To alleviate the not-in-my-backyard (NIMBY) syndrome, assisted living facilities should be deinstitutionalised. Community spaces should involve the public by and large. Besides, inviting spaces can be created, beckoning the unsuspecting passerby to join in.

community spaces involving the public by and large

inviting spaces

Khoo Teck Puat Hospital allows the public to volunteer at its herbal garden. Unlike most rooftop gardens, the herbal garden here is well-utilised.

Goodlife! Makan, a community kitchen located at 52 Marine Terrace, is a recreational cooking, dining and activity centre for seniors. The open floor plan connects the elderly with residents/ passerbys with its porousness.

Image Courtesy: CPG Consultants

Image Courtesy: DP Architects

Kampung Admiralty allows the public to do gardening at its rooftop community garden.

Image Courtesy: The Straits Times

â&#x20AC;&#x2DC;Community Pocketâ&#x20AC;&#x2122;, located in a HDB void deck in Ang Mo Kio, is a launch pad to connect residents and create resources to support ageing in the community.

Image Courtesy: Collectively Ours

Independent Living Institute. Independent Living and Attendant care in Sweden: A Consumer Perspective. Retrieved from https://www.independentliving.org/docs1/ar1986spr.html#anchor4502360

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typical floor plans of assisted living units Over the years, the unit size of assisted living units increased. Many projects contain both smaller and larger studios, bedrooms or shared units to cater to a wider range of preferences and budget. A typical resident mix might be 75-80 percent single women, 10-15 percent single men, and 5-10 percent couples.

two bedroom/ one bath Some sponsors build units with two bedrooms for single residents, couples, siblings, and even unrelated individuals.

This unit is typically 60 to 75 sqm in size.

semiprivate This option is becoming less common but is still included in some projects due to its low costs. It is, however, an apt typology for dementia patients., who often require a shared living arrangement.

small studio The most common unit type in an assisted living facility is a small studio. It is usually about 30sqm.

alcove studio A slightly improved version is the alcove studio with a more separate sleeping area. It usually measure about 32sqm.

large one- bedroom American Association of Homes and Services(AAHSA) prototype research has decided that 51sqm as the optimum size of a full one-bedroom. The living and sleeping room are each more generously sized.

The alcove studio. Adapted from floor plan by Perkins Eastman Architects

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double master

affordability

Thiis layout is suited for two siblings or friends who share the same unit. It is usually found in higher-income markets.

adaptive reuse Eastern Village Cohousing in Silver Spring, Maryland, recycled a vacant 1950s office building and created 56 apartments.

single-room occupancy buildings Residents live in a single room and share a bathroom and kitchen. Often the result of the adaptive reuse of old hostels or single-family houses.

shared housing Shared housing enables two or more unrelated people occupy a house or apartment rogether. A homeowner is matched with someone seeking a residence, who then pays rent and shares the utility costs.

accessory units shared suite hotel unit This layout is modelled after three or four-bedroom apartment. Shared living arrangements have been experimented with, where each person has a private bedroom but shares a common living room, a tea kitchen and sometimes, a bathroom.

Accessory units are small homes constructed or installed on the lot of an existing house. It allows them to live independently while remaining near family or friends. Elder Cottage Housing Opportunities are trailer homes that can be attached to existing homes and removed when no longer needed. Prefabricated units are usually less expensive.

shared ownership Usually offered by non-profit housing associations, shared ownership allows the senior to purchase part of the property(usually between 25% and 75%) and the paying of subsidised rent on the remainder at a reduced rate. It allows one to get into home ownership in manageable stages. Shared ownership is usually limited to seniors who are at least 55 and are unable to afford to buy a suitable home in the open market. This policy might suit Singapore’s context, where the home ownership rate is more than 90%, and the notion of ‘renting’ for the remainder of one’s life might take some getting used to.

It could cost around $1,300 per pax to enjoy assisted living in a public housing setting.

Dr Belinda Wee Director Assisted Living Facilities Association

All Party Parliamentary Group. The Affordability of Retirement Housing. Retrieved from https://www.demos.co.uk/files/Demos_APPG_REPORT.pdf?1415895320

8 WHERE DO WE GO FROM HERE? possible ways forward for singapore WHY ASSISTED LIVING IN HDB? MIXED-USE TYPOLOGY: brief introduction MIXED-USE TYPOLOGY: examples MIXED-USE TYPOLOGY: why incorporate assisted living facilities onto the podium?

CENTRAL AREA: why incorporate assisted living facilities into highly urbanised areas?

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Image Credit: AsiaOne

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why assisted living in hdb?

possible ways forward

‘Assisted living is a social construct, not a medical construct,’ said Dr Ow. ‘So these units should be right within the housing blocks that the majority of Singaporeans call home.’

adaptive reuse of old buildings

Despite efforts from various parties to shed the negative portrayal of nursing homes and the like, trappings of institutionalisation still remains, partly due to not-in-mybackyard syndrome in Singapore. Even then, the issue of institutionalisation of such homes are not unique to Singapore alone. For one, Sweden has attempted to integrate severely disabled people into ordinary housing schemes to ‘normalise’ them into ‘mainstream society’. However, its successes remain debatable and unwarranted stereotypes toards such schemes still exist. After all, it takes time for mindset to change. Nonetheless, it is plausible that ‘institutions’ such as assisted living be incorporated into such schemes and take off successfully. Ultimately, in Singapore, HDB is more than just affordable housing for the masses; it is a social construct, too.

In land-scare Singapore, where high-rise seems to be the convenient answer to housing, it is only natural that assisted living grows vertical too for it to be economically sustainable. At retirement age, the productivity and income of seniors are no longer at their prime and they are often mindful of how their money is being spent. Low-rise-lowdensity retirement residences often translate to high fees that most seniors are unable, or unwilling, to fork out.

That said, some Singaporeans might have entertained the thought of staying in a landed property(e.g. bungalow/ terraced houses) out of novelty, or out of the simple desire to own a garden plot and for pets to roam freely. Such considerations should be taken into account. Swathes of gardening of outdoor spaces that the residents can claim as their own can be incorporated into high-rise living.

The increase in supply of resale HDB flats, higher number of deaths and slowing demand from couples have resulted in a surplus of disused flats, especially for blocks that are not under the SERS programme. To rejuvenate these old estates, adaptive reuse of old buildings in mature estates such as Bukit Merah, Tanglin Halt and Dakota Crescent to incorporate assisted living can take place. The young-old, housewives and young retirees can volunteer for a fee. Singles can also be allowed to co-share units with seniors.

retrofitting into existing Assisted living can be retrofitted into existing flats of middle-aged towns such as Bukit Batok, Tampines and Hougang to cater to the young-old. Granny flats can be retrofitted into existing flats. Seniors need not always rely on qualifed or professional caregivers for activities of daily living. Housewives and young retirees(young-old) can be given an additional platform to volunteer and reach out to seniors who require assistance with activities of daily living(ADL).

integrate into new BTO In younger estates such as Bidadari, Tengah and Sengkang, assisted living units can be integrated with nursing homes and are to be randomly mixed with ‘conventional’ units on all levels.

Perhaps a new typology of HDB could be invented, where a mix of smaller elderly and larger family -sized units co-exist harmoniously. Senior citizens could live in close proximity to their children and grandchildren for family support while maintaining their own independence.

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Image Credit: S,M,L,XL by Rem Koolhaas and Bruce Mau

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mixed-use typology: brief introduction renewed interest in mixed-use development With integrated development such as Punggol Waterway and its likes dominating Singapore’s architectural discourse and built environment, the concept of mixed-use buildings in Singapore is not novel and hearkens back to five decades ago. The renewed interest in mixed use development can be attributed to Singapore’s unprecedented population growth, which has tripled from 1.7 million to 5.6 million in 2016. To accomodate an ever-increasing population without compromising the quality of life, where at least 10% of the land is to be dedicated as green spaces, the authorities once again are searching for innovative solutions to counter the age-old problem. Megastructures is one of them, with several groundbreaking public flats such as Pinnacle@ Duxton and Kampung Admiralty realised in the past decade, challenging the status quo of cookie cutter HDBs.

how did mixed-use typologies come about in sg?

In ‘The Future of Asian Cities’, a prescient proclamation of what Singapore now aspires to become, local architects of the 1970s foresaw that Singapore is only going to become denser and proposed that work, play and living be brought together under one roof, with an efficient public transport system linking the functions together to shorten commute time. Envisioned as a continuous super-mega-structure, dwellings are stacked vertically and street level is reserved for daily activities. Such mixed use developments of the 1970s, however, stood apart in favour of functional zoning in the latter years. Alongside efforts to renew the urban fabric, architects began to perceive ways to resettle the population, one of which is to house the masses in new high-rise, high-density housing within the city centre. To sustain existing social activities, dense mixed-use developments, with residential blocks perching atop commercial podium, were developed. Social interactions were encouraged through podium atriums and innovative high-rise circulation strategies, serving as prototypes for the podium/ tower buildings commonly seen today.

inent high-rise commercial and residential buildings of the 1970s include Golden Mile Complex and People’s Park Complex, Tanjong Pagar Complex etc. Such buildings that preceded the typology of today’s property development share many similar characteristics. They are usually massive, multi-storey and mixed-use.

more about mixed-use typologies Many of these second-generation HDB buildings are halfway into their 99-year leases and are in danger, or have already joined the bandwagon of en-bloc. Under Land Titles Act, all owners in such buildings must approve conservation plan, compared to more than 80% approval for en bloc sale if building is over 10 years old.

For instance, Rochor Centre is among the pioneer blueprints of second-generation HDB buildings, distinct for its community-oriented design, with shops, houses and underground carpark all connected within four blocks. In a bid to integrate the seniors into the community, a void deck nursing home for the senior citizens, Rochore Kongsi for the Aged, was built. The 40-year-old high rise complex previously housed 567 households and 187 shops, all of which have since been cleared out to make way for a new expressway.

These buildings pioneered typologies for dense mixed-use development with social interaction encouraged through podium atriums and innovative high-rise circulation strategies, serving as prototypes for the podium/tower buildings commonly seen today.

These second-generation high-rise, high density public housing complexes, constructed between 1974 and 1977, are often found in the city centre. Some of Singapore’s prom-

Exactly Foundation(2017). What to Keep? Thoughts about Tearing Down a Housing Estate in Singapore.

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mixed-use typology: examples

Peopleâ&#x20AC;&#x2122;s Park Complex Year

1973

Location

shopping-cum-commercial belt along Eu Tong Sen St, Chinatown

No of Storeys

31-storey 25-storey residential blocks

Site Area

Key Architectural Features

Amenities on Rooftop

Future

Beauty World Complex 1983 Upper Bukit Timah Road

231 Bain Stree

5-storey shopping centre 20-storey residential block

4- and 5- st shopping pod 21-storey flats

10,358.7 sqm

The central city room inside the shopping space consists of two multi-storey interlocking atriums, of which the ground-level has many turn-over shops and kiosks.

day-care centre open-air play space

high vacancy rate many old-time tenants are not renewing their lease

Bras B

N/A kiosks and restaurants located around landscaped courtyards

food centre

high vacancy rate many old-time tenants are not renewing their lease

multiple atri es affording abundant n ventilation

playground fitness corner residentsâ&#x20AC;&#x2122; com

still operate cultural hub supplies

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Basah Complex 1979

et

torey office and dium s N/A

ia of varying sizg inhabitants with natural light and

r mmittee

es as an arts and for books and art

Tanjong Pagar Complex

1977 in the historical district

27

31,527 sqm GFA: 122,12sqm

Waterloo Centre 1978 between Queen Street and Waterloo Street

17

N/A

a combination of slab and point blocks features atria similar to those of Bras internal landscaped courtyards run the Basah Complex entire length of the complex

fitness station Happy Villa Elderly Community Home

the residents have effected various upgrading and community programmes over the years. it was given conservation status in 2008.

playground fitness corner St Vincentâ&#x20AC;&#x2122;s Home (sheltered home)

most of the shops are shuttered

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mixed-use typology: why incorporate assisted living facilities onto the podium?

central area: why incorporate assisted living facilities into highly urbanised areas?

safe platform for wandering

seniors’ preferences

Wandering is common, and even encouraged, among seniors. It indicates the seniors’ needs for external stimuli and active engaement with the environment. However, the design of many nursing homes render wandering in a safe, secured and interesting spatial environment virtually impossible. Elevated platforms, such as the top of podium block, environmental deck or rooftop gardens are safer for dementia patients to wander around.

Healthcare is a major concern for seniors, it therefore stands to reason that it would be a lot more convenient to the seniors if there are healthcare facilities nearby. As Singapore is a city-state that is relatively urbanised throughout the island, where virtually all parts of the island are wellserved with public transport, location does not make too much of a distance. Nonetheless, it is still preferable for seniors to live at highly urbamised areas that provide them with conveneient access to amenities.

tapping on existing programmes Such podium-tower typologies already house a variety of commercial activities and amenties on the first few floors, such as family and dental clinics. Senior activity centres, sheltered homes for the aged and even childcare centres are still operating within these podiums built in the 1970s.

Potential sharing and collaborations can be forged between these existing programmes and the new proposed programmes housed within the proposed assisted living facilities on the podium.

greater perceived privacy/ territoriality Many ground-level void decks are perceived to be too open. Admittedly, street-level interaction between the residents and the public should be encouraged, especially in line URA’s aspiration of injecting greater vibrancy into the CBD area after working hours. The feeling and perception of greater privacy can be bestowed on the residents when such interactions are encouraged on the rooftop level. Such a provision will also encourage more meaningful and intimate scale of social interaction.

As seen in many void decks in rental flats, many seniors prefer setting up their own chess table instead of using prebuilt ones. Many seniors prefer appropriating their spaces, partly due to the much required privacy, away from the surveillance of the authorities and the public. It is also possibly a means where the seniors assert their own autonomy as well.

intensification of mixed-usage in CBD areas According to URA’s Draft Masterplan 2019, more mixedused urban neighbourhoods that combine amenities, residential and commercial buildings will be brought in to liven up the neighbourhood, similar to what has been done in Tanjong Pagar.

Parts of the CBD such as Anson Road, Cecil Street and Tanjong Pagar will offer an increase in gross plot ratio (GPR) for the conversion of existing office developments to hotel and residential use, subject to certain qualifying conditions.

There have also been debates if such live-in population should be geared towards public or private housing. Should the live-in population be housed in public housing, to what extent must it be subsidised such that the market forces are not distorted, but at the same time does not benefit only a small segment of the population?

As such, pilot assisted living facilities, which encourages a senior live-in population, can be incorporated into the public housing blocks in central area. Not only does it benefit the seniors, the office workers stand to benefit as well. This is especially so if the assisted living facilities are equipped with medical facilities.

Keng Hua Chong, Mihye Cho(2018). Creative Ageing Cities: Place Design with Older People in Asian Cities Channel News Asia(2019). Familiar places made new, greener under URA’s draft master plan. Retrieved from https://www.channelnewsasia.com/news/singapore/new-ura-draft-masterplan-planning-11383928

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GLOSSARY Nursing Home/ Long-Term Care Traditionally, a medically based model of care for very frail seniors requiring 24- hour care.

Assisted Living Residences A catchall name for a wide variety of programs that balance housing with support of â&#x20AC;&#x2DC;activities of daily livingâ&#x20AC;&#x2122; (ADLs), such as bathing and dressing.

Dementia/ Alzheimerâ&#x20AC;&#x2122;s Care A specialised program and setting crafted to meet the special needs of people with cognitive impariment, that is, impairment of abilities related to thought, perception, and memory.

Independent/ Residential Living Apartments/ Congregate Housing Housing with services designed for the elderly such as one meal per day, housekeeping and activities.

Continuing Care Retirement Community A model of retirement living that provides a full spectrum of services and living accomodations, from independent living through assisted living and nursing care.

Active Adult Communities A variety of lifestyle choice models of living that may simply provide more carefree living with an appropriately designed residence linked to active recreation, entertainment, and continuing education.

Basic Activities of Daily Living (BADL) BADLs are activities fundamental to a funtional life. They are defined as mobility, washing, feeding, grooming, toileting and transferring.

Instrumental Activities of Daily Living (IADL) IADLs are activities not necessary to functional living but allow a person to perform more omplex skills and independent living.

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what do the seniors usually do in public?

VOID DECK- Khatib Cafe

VOID DECK- Teck Ghee SCC

VOID DECK- 23 Dover Crescent

VOID DECK- 839 Tampines Palmwalk

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what do the seniors usually do in public? people watching

bird-watching

intergenerational interaction

exercise

gardening

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what do the seniors usually do in public? reading newspaper

chess-playing

hanging out with maid

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what do the seniors usually do in public? chit-chatting

skilled craft (shoe mending etc)

busking

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what do the seniors usually do in public? wheelchair-bound elderly

VOID DECK- 840 Tampines

VOID DECK- 804 Yishun Ring Road

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news articles/ excerpts THE STRAITS TIMES MARCH 22, 2018

Philanthropists to set up facility for assisted living A group of five philanthropists from Singapore have come together to develop the first purpose-built assisted living facility here that will allow seniors with mobility issues to live independently, instead of in an institutionalised setting, such as a nursing home.

One of the five, Mr Laurence Lien, chairman of the Lien Foundation, spoke of plans for the facility during the inaugural Asean Philanthropy Dialogue yesterday.

The facility, which has 50 rooms, will be located in the north-eastern part of Singapore and is expected to be completed by 2021. Mr Lien did not name the other givers, except to say that they were all members of the privately founded Asia Philanthropy Circle. He also did not reveal how much they gave.

Mr Lien said there was a growing need for assisted living facilities in a rapidly ageing society where many seniors may not have children or do not live with them.

“Developers are not sure if assisted living facilities are commercially viable, and if they are not sure, they wouldn’t go ahead,” he said. “But we can take the risk and spur the industry.”

In January, Health Minister Gan Kim Yong said his

ministry was studying models for assisted living. At these facilities, residents can live on their own but have access to nursing and personal care services, such as help with dressing or going to the toilet.

Assisted living differs from a nursing home in that residents have more autonomy, Mr Lien said. He said other details of the development, such as how much it will cost residents, are not available yet.

The Asia Philanthropy Circle was founded in 2015 by Mr Lien, Mr Stanley Tan and Ms Cherie Nursalim to bring together philanthropists to collaborate and address social problems. Mr Tan is the former chairman of the National Volunteer and Philanthropy Centre, while Ms Nursalim is the vice-chairman of the Giti Group, which has interests in manufacturing and property.

At yesterday’s dialogue organised by the Circle, the issue of trust between governments in the Asean region and philanthropists was one of the topics discussed.

“We usually do our own thing and governments will do their own thing,” said Mr Lien, the grandson of the late banker Lien Ying Chow. “Governments may not trust the motivations of philanthropists.”

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THE STRAITS TIMES MARCH 8, 2019

Assisted living pilot site in public housing planned for Bukit Batok The Ministry of National Development (MND) plans to launch its assisted living pilot site in public housing at Bukit Batok next year, and also explore similar retirement housing models for private residential sites.

be simply a property play. We do not want them to take the site, build something and sell the units. With assisted living, this has to be a package of services plus residential units combined.

This comes as more seniors are looking for alternative residential options like assisted living, National Development Minister Lawrence Wong said in Parliament yesterday.

“We will need to craft the appropriate rules and safeguards to ensure this happens. We are working on them and will provide details when we are ready,” Mr Wong said.

"Assisted living means 'home and care' combined, so that is why MND and Ministry of Health must come together to offer assisted living. It's not something one ministry can do.

When you go for assisted living, you are not just buying a flat, but a package of care services tied to that assisted living flat... Typically, in such assisted living apartments, there will be more communal and shared spaces for residents to interact with each other... and the individual units will be smaller," he said.

On monetisation and housing options available to seniors, Mr Wong said the lease buyback scheme (LBS) is now available to all HDB flat owners, with the extension of LBS to five-room and larger flats.

As the assisted living model is new, he said focus group discussions will be conducted to seek views on the proposed concept for assisted living in public housing. He added that similar retirement housing models for private residential sites are also being explored.

“We are studying potential sites to pilot these assisted living typologies which include... the option of converting vacant school sites into retirement homes.

“The key here is that when we put out these sites for private developers or private players to bid, we do not want it to

He noted that the response has been positive. In the first two months of the year, 160 households from five-room and larger flats had applied for the scheme, he said.

“I think more seniors are aware of the LBS and various monetisation options, but we will continue to do more to raise public awareness.”

But he added that he also understood the scheme may not be an option suitable for everyone.

“Some may wish to right-size to a two-room flexi flat. The options are available. Member of Parliament Saktiandi Supaat (Bishan-Toa Payoh GRC) asked if MND can facilitate the sale of flats if seniors face difficulties, be it due to market sentiments or the Ethnic Integration Policy.

THE STRAITS TIMES FEB 14, 2019

THE STRAITS TIMES MARCH 8, 2019

Suggestions from MPs to help seniors, caregivers

More help for hawkers to turn to centralised dishwashing

Ms Joan Pereira (Tanjong Pagar GRC) suggested providing more assisted living options in both Housing Board and private housing developments. "We can either utilise available void-deck space or transform several combined HDB flats into a senior group home with assisted living facilities," she said.

A new Bukit Batok hawker centre will be co-located with an assisted living residential flats pilot in Bukit Batok Town, in the area bound by Bukit Batok West Avenues 6 and 9, and Bukit Batok Street 41, she said.

"When completed, this new hawker centre will provide an affordable food option to residents."

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THE STRAITS TIMES MARCH 1, 2019

Guidelines to set standards of care in assisted living facilities launched SINGAPORE - Poor nutrition, inadequately trained staff, substandard hygiene and poorly maintained facilities.

These are among the issues common in assisted living facilities in the United States that prompted Dr Belinda Wee, who is with HCA Hospice Care, to help create standards for the industry in Singapore.

She roped in more than 40 professionals in fields such as healthcare, social work, architecture and technology to put together a guide for operators who want to establish a minimum quality of care for seniors residing in assisted living facilities.

Dr Wee is the founder of Assisted Living Facilities Association (Alfa), a non-profit organisation that advocates assisted living as a model of care for seniors.

The Alfa Good Practice Guide: Dignity And Discerned Autonomy Assisted Living Care Tool was launched on Friday (March 1) at Crossings Cafe in Waterloo Street.

The guidelines not only provide the minimum standard of day-to-day care that the elderly should receive in an assisted living facility, but also cover the operational and financial aspects of running such facilities for the operators.

Assisted living options have been explored in Singapore in recent years as an alternative to nursing homes for seniors who do not require intensive medical and nursing care, but need help with daily living activities, such as preparing meals, showering and dressing.

One example is the integrated HDB project, Kampung Admiralty, which houses 100 flats for the elderly, with a range of social, healthcare and communal facilities, including an active ageing hub and a two-storey medical centre providing specialist outpatient care.

In a project run by the Agency for Integrated Care, seniors living in rental flats in neighbourhoods such as Bedok, Bukit Merah and MacPherson also have access to care workers at senior activity centres in the void decks of their blocks. The care teams at these centres help the elderly residents with personal care needs, such as bathing and housekeeping, and also monitor their health and provide emotional support.

By 2030, almost one in three people in Singapore will need some form of eldercare service. One in four will be aged 65 and above. At the launch on Friday (March 1), Dr Chiang Hai Ding, a former MP and a member of PAP Seniors Group, said: “Many seniors go into nursing homes prematurely, that is, before they need to.

“Nursing homes provide long-term medical care to those with disability or disease. For as long as possible, when we don’t need 24/7 medical care, we should stay at home and in the community.

“When we need help to live, group homes that provide social care offer a safe alternative to ageing in place, and a better and more economical alternative to nursing homes, “ said Dr Chiang, 80.

Ms Joan Pereira, an MP for Tanjong Pagar GRC, suggested in Parliament last month providing more assisted living options in both HDB and private housing developments, such as transforming several combined HDB flats into a senior group home with assisted living facilities.

Dr Paulin Straughan, sociology professor at Singapore Management University, said: “How do you provide a safe and comfortable space for older adults who have disabilities and need help but still maintain their privacy and dignity? I think assisted living as a model of care answers that need - you don’t feel like your identity is stripped from you just because you are old and disabled.” At St Bernadette Lifestyle Village, a private assisted living facility, the need for supervision to ensure the safety of its aged residents is balanced with a respect for their privacy. The facility in Adam Road, set up by Dr Wee, has closed-circuit television cameras only in the common areas, and not in the individual bedrooms of the elderly residents. Instead, there are motion sensors so that staff can track the movement and activity of the residents in their rooms.

One of the facility’s elderly residents, retired Chinese teacher Tong Ying Xian, 80, said: “This facility suits me, because I like my independence.

“I have the freedom to go around the house. I chat with the other seniors when I feel like it, and if I get tired, I just go into my room and immediately I have my own privacy.”

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excerpts of informal interviews

My informal chit-chatting sessions with the seniors have never been short of interesting and thought-provoking, Most, if not all of them always have life stories or experiences that they are ever willing to impart to the younger generations. Curiously, some of them are not keen on befriending services. perhaps out of pride and dignity as an elder member of the society. They also seem to be content with just simple meals and a roof over the head, but this could be perceived as resignment to the vagaries of life rather than actual contentment in the status quo.

Mr Ngaw, Retiree, Cassia Crescent, Hokkien-speaking.

Ms Lee, Cancer Survivor, Jurong East, English speaking

on senior isolation Born in 1943, he has retired for 6 to 7 years. He holds a dystopic view of â&#x20AC;&#x2DC;just waiting to dieâ&#x20AC;&#x2122;. He was sitting alone at the void deck at the point of interview. His everyday routine is to go to the kopitiam. He does not necessarily enjoy chit-chatting with friends, as they might end up gossiping.

If possible, he would want to live alone. That said, he does greet his friends who happen to pass by the void deck.He is content with sitting here everyday at the void deck. He sleeps at 5pm and wakes up at 4am.

on group homes and policies He stays at a 1-room rental flat at Cassia Crescent and finds it too troublesome to stay at group homes. It has been one year since he moved to Cassia Crescent. He has about 20 friends who moved from his previous flat to his current place. He had been witnessing people passing on. He wanted to go to Macritchie Road but the flats are too old so his friends suggested that he choose Cassia Crescent instead.

Many flats are left empty as the authorities might not necessarily approve if seniors apply. He disapproves of Lease Buyback Scheme. He is content with just a roof over the head. He spends about $26 on rental fee and $20 on miscellaneous fees. He receives $95 for electricity subsidy every 3 months. He uses meal delivery services, too.

on activities of daily living He cannot walk for too long and often suffer from leg pain.

He needs pit stops in between during a long journey. To avoid unnecesary gossip, he does not want to hire a maid.

He sweeps and mops the floor himself.

on senior activity centres and nursing homes In 2005, he suffered from a stroke. Beside this, he only has high blood pressure. He was admitted to Tan Tock Seng Hospital, who then connected him to Thye Hua Kuan. He moved out after 1.5 months as they just exercise everyday and finds it too boring. He finds the activities organised at Thye Hua Kuan, which is located at the void deck of his flat, to be too draining. When his brother migrated, he wanted to send him to a nursing home but he declined and applied for the previous flat he stayed at instead.

on exercising She was exercising at one of the HDB fitness stations at Jurong East. In recent years, she has witnessed more elderly exercising at fitness stations within the HDB precincts.

That said, many of the fitness stations are catered for youth instead of elderly. As a result, she had to transverse across flats for the fitness station.

on retirement village As a cancer survivor, Ms Lee lives day by day and does not plan too far ahead. She has lost her mobility and is unable to do heavy labour. When asked if retirement village is a feasible option, she replied that financial capability to support oneself, is, to most senior citizens, of utmost concern.

Besides, many seniors are able to afford helpers due to government subsidies.

on what could be done Homecraft, being carried out at most CCs, is a good way of keeping the elderly occupied, especially the lonely seniors who do not know where to go and resort to sleeping at void decks and McDonalds.

Currently, kopitiam and the library are the only places where the elderly people can feel more at ease. She applauded Church of the St Mary of the Angelsâ&#x20AC;&#x2122; efforts of opening up a canteen for the elderly. She also proposed that multigenerational complexes be built for elderly people to sit down for games, play chess. She finds the TV and chairs to be useful for socialising. Many seniors cannot even afford to work. Ultimately, more has to be done as community centres ultimately still charge the elderly.

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Mdm Mok, Wheelchair-Bound Widow, Bukit Merah, Mandarin and Cantonese speaking

Shopowner of Kai Joo Departmental and Optical, Tanjong Pagar Plaza

Born in 1943, Ms Mok is a sprightly woman brimming with energy despite being wheelchair-bound. She visits the senior activity centre organised by NTUC Health almost every Sunday. She has lived at Bukit Merah for eight years .

The shop was sold to them in 1994. The estate is 43 years old. The seniors here usually ‘do nothing’. It is very hot even at the cooling area. He proposed that fans be installed for the seniors. The wasted podium space has no shelter.

There are many wheelchair-bound seniors in this estate.

Occasionally, there are buskers outside. He estimated that more than 500 people are old folks aged above 60.

on group homes and nursing homes She prefers living alone over living with others other than her husband, who passed away four years ago. She also declined HDB’s offer of pairing her up with a new roommate. She counted herself fortunate that she could still stay put in her flat. She has witnessed conflicts that arose as a result of communal living. She is averse to the notion of nursing homes, as she has relatives who has to wash her own clothes. Nursing homes also charge additional fees if she would prefer to have her clothes washed. She finds the nursing home fees, which easily hit several hundred dollars, to be unaffordable.

on activities of daily living She does her household chores herself, including sweeping and mopping the floor. Her four brothers live at Paya Lebar, Ang Mo Kio, Joo Seng and Sembawang respectively.

The brothers have their own families. She has turned down suggestions from volunteers about the offer to be involved in befrienders’ programmes. A married friend of her offered to buy meal for her using her own coupon.

on senior isolation She pays her own rent. She is happy where she is, and enjoys people-watching at the corridor outside a flat everyday. She likes chit-chatting with her friends, some of whom are also wheelchair-bound, who pass by.

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Dr Belinda Wee, Co-Founder of Good Shephard Loft on how assisted living facilities should be run

on assisted living facilities

Long-term care facilities should not be regulated the same way acute hospitals are regulated as it would be resource-draining. Continuum of care should be the way forward and one facility should not provide only one type of care, notwithstanding staffing issues that might potentially arise. This is to allow for seamless transition of care as care needs of seniors increase. Seniors should be encouraged to move into such villages when they are still in their 50s before they lose their cognitive abilities so that they are able to assimilate into the senior living community more easily. Besides, they will be more receptive to the notion of retirement village, too. Currently, the situation is that most seniors would not move in until their children or family members force them to do so due to emergency issues, cognitive problems or even fall risks. Therein lies the challenge as it is not easy to encourage people to move in when they are still relatively more independent. Transition phase(e.g. from independent living to assisted living) must be recognised by someone. Otherwise, seniors become very vulenerable if not detected at an earlier stage. To avoid undesirable situations from arising, trained caregivers need to be supervised, too. In view of space constraints in Singapore, building codes and guidelines can be fitted to Singapore context after studying overseas example.

Every individual room should be retrofitted with a toilet to bestow dignity and to enable the seniors to get to toilet fast to reduce soiling issue. Eight to ten seniors form one unit and one of the reasons is that URA allows them to sublet to eight people. Besides, one staff can take care of eight seniors without too high a care need. Sensors can be put to good use at assisted living facilites housed in a three-storey bungalow so that staff do not have to be stationed on different levels. Pull chord might not be very feasible as it might be too late when to call for help when emergency situation arises. At times, pull chord is abused by seniors with dementia. Staff should be able to supervise the seniors face-to-face at an assisted living facility. Some seniors with sundowning at night will need assurance at night. They do not need to move into nursing home as assisted living facilities will suffice. Senior entreprise can be on one level.

Programmes such as cafe and tuition centre can be incorporated. Seniors should be encouraged to rent instead of purchasing property even if it means selling the property to monetise. A change in mindset is required. Palliative care should also be enabled in at the comfort of oneâ&#x20AC;&#x2122;s own home. Singapore also needs a robust home-care system to take care of them for a lifetime. Service delivery should be the same for everyone regardless of pricing and difference in estate prices, i.e. regardless of whether a person stays in bungalow or HDB flat.

Some residents who display care resistance do not want to receive help that they actually require. We should also limit buyers to be aged above 55.

on why assisted living has yet to kick off on a large scale Singaporeansâ&#x20AC;&#x2122; willingness to pay for assisted living facilities(ALF) remains to be a moot point. Many Singaporeans want to know the costs of such services as well. Currently, there is still too much uncertainties and are quite averse to discuess about being bedridden and death. Assisted living facilities can run on a membership fees model. A lot of hardware and software have yet to be organised properly.

Affordability remains to be an issue. Singapore has no lack of hardware, but it has to be organised properly. What is sorely lacking is perhaps the organisation of programmes.

Studio apartments at Kampung Admiralty is already provided for, but the crux of the issue lies in the delivery of services and programmes. For instance, club membership idea can be proposed. When seniors buy senior apartments, they should buy service pacakages as well. The current assisted living facilities and nursing home can already be retirement village. Many Singaporeans have the mindset that the government will provide and hence, there has been a lack of ground-up initiative.

on lease buyback scheme Many Singaporeans do not understand lease buyback scheme. They are concerned if they hav nothing to bequest the children once they take up the lease buyback scheme.

on St Bernadette Lifestyle Village The residents of St Bernadette are civil servants living off pensions and buy into the notion of assisted living. For one, St Bernadette Lifestyle Village was given the license to provide home care, however the facility faced hurdles when applying for staff. Most residents are plagued with some degree of dementia. Some are teachers, some are healthcare professionals. Some patients are also resistant to receive help.

on activities of daily living Instrumental activities of daily living(IADL) should be placed more emphasis. The first IADL to be lost is usually the ability to clean the house and to cook themselves. The seniors might have forgotten the recipe and simply do not have energy to maintain the house.

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Social Worker, Nursing Home on hiring of maids and nursing homes Some seniors have their own resources to hire maids whilst some depend on their family members to hire maids.

Maids do not necessarily know how to properly take care of the elderly. If the maid is the sole caretaker, she might feel burned out. Maids are sometimes unfairly blamed, too.

There are two types of nursing homes, one provides longterm care(four months), the other provides short-term care(only a few days to a few weeks). In nursing homes, a team of certified and dedicated nurses are readily available round-the-clock.

on how assisted living should be run The facilities must be elderly-friendly. Ideally, assisted living facitilities should be located nearby NH and hospital.

For instance, Khoo Teck Puat Hospital is situated next to a nursing home, so that they can pool resources together.

It is recommended that family members who want to send relatives for assisted living need to be certifed by doctors.

Perhaps they need more intensive care.

As for the lease system, what happnes after 20 years leasehold? Do we extend the lease if the person outlives the leasehold? What if the senior’s medical needs intensify? Is assisted living facilities still a viable option after 20 years?

on moving house The government should encourage people to buy their own house. Many people move house for social reasons, to be near their friends, or for financial reason to downgrade to a smaller house or run away from loan sharks.

on group homes Sometimes, it can be stressful for seniors to adapt to new environment. Roommates might not get along. Ageing-inplace in a familiar setting is good.

on senior isolation In general, people should be given a choice. Even if the family wants the perceived good for the elderly, the seniors might just want to be left alone and not be around other seniors. It is important to honour the individual’s wishes.

on studio apartments Studio apartments do not provide nursing care. It is only a place for elderly to rest. Some seniors are not capable of making their own decision. Family makes decision on their behalf and sometimes, it is not a decision that they want.

on the feasibility/ practicality of assisted living A certain number of seniors is required to justify the setting up of assisted living facilities. ALF is not for everyone. To a large extent, it depends on the seniors’ medical condition, mobility and mental facilities. There is a wide range of AL, some are more furnished while others, less. Some have oncall nursing care. Continuing care retirement community is a good idea, but cost will always remain a factor. For assisted living to take off, cost is always an issue and not meant for everybody. Individuals must go through vetting before he qualifies for subsidies. It very much depends on the individual’s financial situation and medical condition. If they can gather people together with elderly-friendly facilities and affordable healthcare, assisted living might become more feasible. Occasionally, operation costs of assisted living is too high, translating into high fees. After all, many seniors are particular about how they use money, which gives them a sense of security.

Fall is something that elderly cannot cope with. There have been several dementia cases in the nursing home. Besides, every seniors experience very different conditions. Some need urinary catheter, some have dietary problems such as puree.

on retirement village Retirement village is a good idea only if the elderly is well equipped with money and enjoys being surrounded by community.

on intergenerational interaction Some seniors like to walk their grandchildren to school in the morning but would want their own free time in the afternoon. The young-old tend to be more educated and want more say with what they want in their lives. Most seniors like to interact with children and it is good for children to interact with seniors and to acquaint the young with the aging process as well as communicating with the older generation. It gives the older generation mental stimulus. Some older generation are very open to new things like handphone. If young generation exercise patience and teach older generation, it will benefit both generations.

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5. Ministry of Community Development, Youth and Sports(2009). Adding Life to Years!: Happy, Healthy, Active Seniors.

6. Jeffrey W. Anderzhon, David Hughes, Stephen Judd, Emi Kiyota, Monique Wijnties. (2012). Design for Aging: International Case Studies of Building and Program.

7. Bradford Perkins, J. David Hoglund, Douglas King, Eric Cohen. Building Type Basics for Senior Living.

8. Atul Gawande(2015). Being Mortal.

9. Lorraine Farrelly(2014). Designing for Elderly.

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12. Lien Foundation (2018). Care Where You Are: Enabling Singaporeans to Age Well in Community.

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14. Heng, Chye Kiang(2017). 50 Years of Urban Planning in Singapore.

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Cheong Chi Yan | gracecheong812@gmail.com | +65 83982038