Week 3_Lectures.pdf

CC0007 Science and Technology for Humanity Healthcare Challenges at Societal Level Prof Pang Weng Sun, NTU © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Views of Healthcare In healthcare, we can look at specific diseases: Study their causes, ef...

CC0007 Science and Technology for Humanity Healthcare Challenges at Societal Level Prof Pang Weng Sun, NTU © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Views of Healthcare In healthcare, we can look at specific diseases: Study their causes, effects on humans, find ways to investigate, treat those affected, manage the complications, if any, and think about how to prevent them or mitigate their effects. ▪ Examples: Ischaemic heart disease, cancers, metabolic diseases © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Views of Healthcare We can also look at specific groups of people, the kinds of diseases they get and how to diagnose and treat them: Age groups, e.g., children, women, elderly Defined groups, e.g., those living in a particular environment, occupational groups, racial groups (heredity, diet, cultural practices, social norms) © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Healthcare at Societal Level “Population Health” ▪ The health outcomes of a group of individuals, including the distribution of such outcomes within the group. These groups are often geographic populations such as nations or communities, but can also be other groups such as employees, ethnic groups, disabled persons, prisoners, or any other defined group. (Institute of Healthcare Improvement, USA) Applying this locally: ▪ People living in a geographical area within Singapore ▪ Age or occupational related groups, e.g., school children, taxi drivers, retirees Implications to healthcare funding: ▪ How healthcare budgets should be allocated to meet needs (…not wants) Institute for Healthcare Improvement. (n.d.). Population health. Retrieved July 13, 2022 from https://www.ihi.org/Topics/Population-Health © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Useful Resource: Statistics Singapore © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Some Trends From These Statistics Increasing number of elderly population: Percentage of resident population aged 65 and above increased from 9% in 2010 to 16% in 2021 Old age support ratio (number of people aged 20–64 per resident aged 65 and above) fell from 10.5 in 1990 to 7.4 in 2010 to 4.0 in 2021 Number of people living alone increased from 9.9% in 2011 to 15.6% in 2021 (not limited to elderly) Statistics Singapore. (n.d.). Latest data on Singapore’s population. Retrieved July 13, 2022 from https://www.singstat.gov.sg/find-data/search-by-theme/population/population-and-population-structure/latest-data © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Changing Demographics and Implications What does increasing number of elderly really mean? ▪ More elderly = more people with frailty? ▪ More well elderly and a changing workforce? Longer durations of chronic disease? ▪ More people with co-morbidities and end-organ failures? ▪ Better disease control with longer disability free (or less severe) lives? Changing workforce? ▪ More retirees and greater dependence on society for support? ▪ Shifting retirement age, extended employment, new careers? New shifts in health and social care? ▪ Redefining ageing… © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Solutions-Oriented Approach Rather than Problem-Oriented Approach? Increasing number of elderly Costs of supporting the elderly ▪ Increasing number of active and ▪ Keeping older people economically productive older people who can productive in creative ways (it still contribute to the larger society doesn’t always have to be work!) Environmental modifications to A burden to the young support care of the elderly ▪ Create mutual support amongst ▪ Creating new environments that older populations—self sufficiency, allow older people to continue active, with some help meaningful and productive lives Healthcare burden of older population ▪ Creating meaningful career opportunities for younger people (including “young olds"!) © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Common Health Issues: View From Two Angles Medical Functional Cataracts Visual impairment Chronic heart and Decreased effort lung diseases tolerance Osteoporosis, Chronic pain, fragility fractures, impaired hand function, osteoarthritis impaired mobility Neurological Memory impairment, diseases increasing dependence Cognitive impairment on caregivers Depression Disturbed behaviour Multiple medications Sleep disturbance Malignancies Adverse effects © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Functional Assessment Scales Clinical Frailty Score (CFS) 1 Very fit 2 Well Barthel Index 3 Managing well Activities of Daily Living (ADL) 4 Vulnerable 5 Mildly frail Instrumental Activities of Daily 6 Moderately frail Living (IADL) 7 Severely frail Abbreviated Mental Test (AMT) 8 Very severely frail 9 Terminally ill Geriatric Depression Scale (GDS) Rockwood, K., Song, X., MacKnight, C., Bergman, H., Hogan, D. B., McDowell, I. & Mitnitski, A. (2005). A global clinical measure of fitness and frailty in elderly people. Canadian Medical Association Journal, 173(5), 489–495. https://doi.org/10.1503/cmaj.050051 © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  History on Aged Care in Singapore (From the 1980s) Report on the problems of the aged, 1984 (“Howe Yoon Chong Report”) Need to set aside individual savings and government funding for aged care Homes for the Aged Act 1988 Regulation of aged care homes Aged care homes, nursing homes, chronic sick unit Home nursing Home Nursing Foundation Senior Citizens’ Health Care Centre (SCHCC) Growth, rebuilding and restructuring of hospitals © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Community Services for the Elderly: 1980–90s Acute Intermediate Long-term Hospitals Community hospitals Nursing homes Day rehabilitation Sheltered homes Home care Hospices Hospice care Day care Home care Home hospice © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Challenges in Managing Frail Elderly Different disease patterns and responses to treatment Complex chronic disease; combinations of diseases Physical and mental conditions Increasing need for subacute/rehab care Evolving social structure: ▪ Fewer children to support ▪ Smaller nuclear family ▪ decrease in informal caregivers decrease in societal capability in caring for the frail elderly ▪ Caregiver stress © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Geriatric Syndromes (“Giants of Geriatrics”) In 1965, Bernard Isaacs - UK geriatrician coined the following terms: Immobility Instability (subjected to falls) Incontinence Impaired intellect/memory Inanition (diet issues) In 2017, John Morley, US geriatrician further added: Sarcopenia, frailty, cognitive impairment, anorexia of ageing—harbingers of falls, hip fractures, depression, delirium © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Care Integration With many settings to look after the continuum of illness for one patient, care can be fragmented. High risk of care fragmentation for frail elderly, whose health needs traverse across different/multiple sectors by different care providers. Integrative care model offers care that is patient-centred, recognising that health and social outcomes are interdependent. © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Example: Mr A (80-year-old retiree) has hypertension, diabetes and high cholesterol for many years. He used to be active and independent. Due to arthritis in his knees, he stopped exercising and his control of blood sugar is also poor. He feels more socially isolated now that he can’t go out with friends like he used to. What kind of problems may we anticipate? Risk of stroke and heart disease from high risk factors Diabetic complications that may affect function—visual, sensory, infections Pain and functional decline, falls Depression, caregiver stress © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  A Greater Challenge/New Approach: Anticipatory Care 1. What are the existing problems? 2. What other problems do we anticipate in the coming future? Medical issues Functional issues Social issues Progression of Decline in physical Potential care crisis disease or mental function and placement issues Likelihood of new Disease progression/ Potential ethical or disease disuse or legal issues deconditioning Prolonged effects Elder mistreatment of treatment or abuse © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Team Approach Specialists Physiotherapist Family physician Occupational therapist Prosthetist Nurse Orthotist Nurse clinician Speech therapist Advanced nurse Dietician practitioner Case managers Pharmacist Operations team Medical social worker Patient, family Psychologist and caregivers © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  The Straits Times Report Poon, C. H. (2017, January 19). Public healthcare gets new look. The Straits Times. https://www.straitstimes.com/singapore/health/public-healthcare-sector-to-be-reorganised-into-3-integrated-clusters-new © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Healthcare Cluster Integration of health Acute and social services hospital Medical Community centres hospital Patient Day centres GPs and family Home care Nursing Polyclinics Home Hospices Community based care © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Healthcare Facilities WHC CH KTPH YCH SKGH CH AMKH BVH CGH NTFGH TTSH SACH JCH RCCH NUH AH SLH CH SGH OCH © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Healthcare: Moving Forward Beyond Hospital to Community Managing regional health Transforming primary care Developing aged care in the community Beyond Quality to Value Ensuring appropriate care Making healthcare manpower more efficient through innovation Beyond Healthcare to Health Ageing actively Moving upstream to health; war on diabetes Better Health Better Care Better Life © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Who are the Elderly? Grouped by age “Young olds” 65–74 75–84 > 85 Well and Elderly with chronic Frail elderly independent elderly illness and disabilities Grouped by health and functional status © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Ageing and Disease What do we do at each step to prevent decline? High blood pressure Diabetes mellitus Hyperlipidaemia Stroke disease Heart disease Recurrent strokes Heart failure Infections “Well” elderly Functional decline “Frail” elderly © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Eldercare Landscape Well elderly Chronic illness Advance illness End of life Education and Research Keep well and Control disease, Manage complex Symptom control, independent prevent complications illnesses and dignity and disability care transitions Community GP RH CH DRC NH Hospice Home care Social landscape – elderly persons, families, social support services, environment HOP GRM clinics Acute care of Geriatric Transitional and the elderly evaluation and home care Passion for Life Specialty clinics management and programmes Geriatric Long-term care collaborations Subacute, rehab Palliative care Advance Care Planning © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Care of the Elderly Well elderly Chronic illness Advance illness End of life “Healthy ageing” “Successful ageing” Individual Longevity Education and Research Genetic factors Keep well and Control disease, Diet, exercise, lifestyle Manage complex Symptom control, independent prevent complications illnesses and dignity Community, society and disability care transitions Family and community interactions Community GP RH CH DRC NH Hospice Home care Intergenerational relationships Housing, Social landscape – elderly community persons, families, social living support services, environment Workplace, retirement, finances HOP GRM Clinics Acute Care of Geriatric Transitional and the Elderly Evaluation and home care Passion for life Health Specialty clinics promotion and education Management and programmes Geriatric Long-term care Health for older persons Subacute, Rehab Collaborations Mini medical school Palliative care Advance Care Planning © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Care of the Elderly Well elderly Chronic illness Advance illness End of life Disease management and “restorative medicine” Acute and chronic diseases BP, DM, lipids, malignancies Education and Research Functional impairment Keep well and Control disease, Manage complex Symptom control, independent prevent complications illnesses and dignity and disability Elderly, care transitions in particular: Memory deficits, dementia Community GP RH CH DRC NHDepression Hospice Home care Social landscape – elderly persons, families, social support Falls,services, osteoporosis, fractures environment Incontinence HOP GRM clinics Acute Care of Chronic Geriatric pain Transitional and the Elderly Evaluation and Home Care Passion for life Specialty clinics Polypharmacy Management and programmes Geriatric Rehabilitation Long Term Care Collaborations ‘Restorative’ Subacute, Rehabmedicine (jointCare and Palliative other organ replacements) Advance Care Planning © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Care of the Elderly Well elderly Chronic illness Advance illness End of life Complex illnesses Acute, subacute, intermediate, long term care Utilisation of multiple health Education and Research services Care Keep transitions well and Control disease, Manage complex Symptom control, independent prevent complications illnesses and dignity Care co-ordination and disability care transitions Healthcare funding, costs, Community benefits GP RH CH DRC NH Hospice Home care Social landscape – elderly persons, families, social support services, environment “Advance care HOP GRM Clinics Acute care of Geriatric Transitional and management” the elderly evaluation and home Care Passion for Life Specialty clinics management and programmes Geriatric Long-term care collaborations Subacute, rehab Palliative care Advance Care Planning © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Care of the Elderly Well elderly Chronic illness Advance illness End of life Palliative care End-of-life issues Education and Research Keep well and Control disease, Manage complex Symptom control, independent prevent complications illnesses and dignity and disability care transitions Community GP RH CH DRC NH Hospice Home care Social landscape – elderly persons, families, social support services, environment HOP Advance GRM care Clinics planning Acute care of Geriatric Transitional and Preferences at end of lifethe elderly evaluation and home care Passion for Life Specialty clinics management and programmes Geriatric Long-term care collaborations Subacute, rehab Palliative care Advance Care Planning © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Funding of Healthcare: Government, Insurance, Self, Welfare Medisave Compulsory savings in Central Provident Fund (CPF) Medishield, Medishield Life Catastrophic medical insurance Medifund For low-income group Eldershield Long-term disability insurance Other government schemes PG, CHAS, IDAPE, CTG, FDW, SMEF © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Newer Trends © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Stages of Advance Care Planning (ACP) Over the Lifetime of Adults General ACP Discussion: Nominate substitute Disease decision maker(s) and Specific-ACP: consider when a serious Determine what goals neurological injury would of treatment should be change goals of treatment. followed if complications result in “bad” outcomes. Preferred Plan of Care - Cardiac-DS ACP: - Renal-DS Establish a specific plan - COPD-DS of care expressed in the preferred plan of care form. Healthy adults/ Adults with progressive, Adults whom it would not be Early chronic disease life-limiting illness, suffering a surprise if they died in the frequent complications next 12 months Agency for Integrated Care, Singapore. Adapted from Respecting Choices, Gundersen Health System, Wisconsin, USA. © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Publications (2015 and 2016) © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Publications (2018) Lien Foundation 2018 © 2022 Nanyang Technological University, Singapore. All Rights Reserved. © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  CC0007 Science and Technology for Humanity Health Economy, Silver Economy Assoc Prof Goh Kim Huat, NTU © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Silver Tsunami Singapore 2010 2020 2030 9% 15.2% 25% aged 65 aged 65 aged 65 and above and above and above © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Distribution of Residents Older than 65 in 2001 243,650 Number of People Changi Bay Central Area Western Southern Islands Islands 2001 Singapore Land Authority and Department of Statistics. (n.d.). Resident population by planning area/subzone and age group [Map]. OneMap. Retrieved June 29, 2022 from https://popquery.onemap.gov.sg/ © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Distribution of Residents Older than 65 in 2011 352,650 Number of People Changi Bay Central Area Western Southern Islands Islands 2011 Singapore Land Authority and Department of Statistics. (n.d.). Resident population by planning area/subzone and age group [Map]. OneMap. Retrieved June 29, 2022 from https://popquery.onemap.gov.sg/ © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Distribution of Residents Older than 65 in 2021 639,020 Number of People Changi Bay Central Area Western Southern Islands Islands 2021 Singapore Land Authority and Department of Statistics. (n.d.). Resident population by planning area/subzone and age group [Map]. OneMap. Retrieved June 29, 2022 from https://popquery.onemap.gov.sg/ © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Impacts of Ageing on the Economy Production Consumption © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Production Economics Labour Entrepreneurship Technology Output Land Capital © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Technology as the Silver Lining? Change in GDP per capita All countries except OECD OECD countries from 1990 to 2015 Change in the ratio of old to young workers from 1990 to 2015 Adapted from Acemoglu, D. & Restrepo, P. (2017). Secular stagnation? The effect of aging on economic growth in the age of automation. American Economic Review, 107(5), 174–79. https://doi.org/10.1257/aer.p20171101 © 2022 Nanyang Technological University, Singapore. All Rights Reserved.  Consumption Public goods: Produced by government Public healthcare Social security and needs Environment accessibility Defence Private goods: Produced by commercial entities Services: Private healthcare Social/lifestyle needs Products: Durables: Electrical appliances, mobility aids, etc. Consumables: Nutrition © 2022 Nanyang Technological University, Singapore. All Rights Reserved. © 2022 Nanyang Technological University, Singapore. All Rights Reserved.