Ageing in place and the future of nursing homes

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/ EdgeProp Singapore
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August 14, 2020 6:00 AM SGT
The number of elderly living alone — a strong proxy indicator of people who could need institutional care at some point — grew steadily from 27,900 in 2010 to 47,400 in 2016, says C&W (Picture: The Edge Singapore)
In Singapore, 581,680 of the resident population are aged 65 and above, according to the Department of Statistics. They accounted for 14.4% of Singapore’s resident population in 2019. The number is a 76% jump from 330,132 a decade ago, and more than double the 235,296 in 2000.
By 2030, the number of those aged 65 and over is projected to increase to 900,000, which means one in four Singaporeans would be in that age group, up from one in seven today.
The old age support ratio (those aged 20 to 64 years per resident aged 65 and above) stood at 4.5 in 2019. The Ministry of Health (MOH) is projecting that the figure could more than halve to 2 to 1 by 2030. Singapore’s life expectancy is already one of the highest in the world at 83.66 years in 2020, while our fertility rate is among the world’s lowest at 1.14 in 2019, and an average of 1.2 for the past decade.
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Given the rise in ageing population, it is clear that eldercare facilities need to be improved to ensure that seniors can age comfortably and with dignity. Today, there are 77 nursing homes, a mix of public, private and not-for-profit facilities, with a total of 16,059 beds. These provide long-term residential care for seniors who have limited or no family support and require dedicated assistance.

Shift away from ‘dormitory style’

Due to real estate constraints and the government’s push towards greater standardisation and cost efficiencies, the prevalent nursing home model in Singapore is that of “medicalised, dormitory-style nursing homes”, said Cushman & Wakefield (C&W) in a 2018 report.
Last year, the National University of Singapore (NUS), in collaboration with MOH, URA and other stakeholders, embarked on an ongoing study to recommend design principles and typologies for future nursing homes based on “person-centric care models, with facilities that are integrated with the community”.
HDB plans to expand the number of public retirement villages such as Kampong Admiralty to other housing precincts. (Picture: Albert Chua/The Edge Singapore)
According to Associate Professor Fung John Chye — from the Centre for Ageing Research in the Environment at NUS School of Design and Environment — who is leading the study: “This is probably the first interdisciplinary design-led study of its kind for nursing homes in Singapore. We considered many different dimensions — how design needs to integrate with the care aspect, the social aspect, and how the community plays a crucial role.”
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Some of the initial findings were translated into early design concepts by two architectural firms — Farm Architects in partnership with Stuck Design, and Silver Thomas Hanley International.
One area the study is looking into is the density of beds. According to Tiah Nan Chyuan, director at Farm Architects, typical nursing homes in Singapore tend to come with about 16 beds per room. Throughout the study, the architects looked at the feasibility of eight-, four- and even single-bed options for future nursing homes.
The team at Farm presented an early design that incorporated a cluster of four rooms connected to a common living area, with four beds in each room. “This type of design mimics the home environment but it also comes with some trade-offs,” says Tiah. For example, while it provides a comfortable and spacious common area, it could result in a smaller living space. Thus, a big part of the design is the ability to customise the space around their beds to retain as much individuality as possible, he adds.
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Room for interaction

Encouraging socialisation among nursing home residents was a key design feature the team also sought to improve. As part of the research project, Tiah observed that most nursing homes enforce a schedule on residents who can congregate only in a few large common spaces. While this model is one of the best ways to monitor their senior residents, it restricts individuality and can be a jarring experience for new residents, says Tiah.
“In our focus group sessions and workshops with healthcare operators of nursing homes, their residents and staff, as well as grassroots communities near nursing homes, having the ability to maintain one’s independence in a nursing home was cited as one of the most important aspects to consider. People perceive a loss of family and community connections when you go to a nursing home, and you become dependent on others as everything is taken care of by the institution,” says Fung.
Thus, Farm recommended social corridors for future nursing homes which come with a mix of small and large social spaces spread across different floors. “We designed these corridors to encourage more movement and casual interaction opportunities, while considering limitations such as a high wheelchair reliance,” says Tiah.
This extends into dedicated care corridors for healthcare workers and nursing-home staff. “We observed that the corridors in most nursing homes today feel a lot like hospitals, with clinical equipment and supplies appearing in common community areas,” says Tiah. His team was inspired by similar service corridors in hotels which separate service areas and equipment from guest areas, but still provide quick and easy access for staff to reach guests.
“Unlike a hospital ward where one may stay for a few days and move on, those in nursing homes tend to stay there much longer,” says Fung. Therefore, creating a home-like atmosphere and environment becomes more important, which supports the person-centric care model of nursing homes, he adds.

Person-centric care, government subsidies

Person-centric care is about delivering care that enables individuals to continue to maintain their sense of self and personhood in terms of autonomy, privacy and dignity, says Fung, adding that another outcome of the study is to propose and chart out what person-centric care entails for nursing homes in Singapore as there exist varied understanding and practices of the model here.
“Designing nursing homes is an interesting challenge, and finding a suitable design typology is an ongoing process. Some of the issues we face will take some time to overcome, including social, economic and cultural norms,” says Tiah.
Kampong Admiralty is the first development in Singapore that integrates housing for the elderly with a range of social, healthcare and communal facilities. (Picture: Albert Chua/The Edge Singapore)
“People also tend to view the nursing home more as a medical facility and thus are less inclined to want to walk into a nursing home voluntarily, unless they are visiting a family member or a relative or are volunteering at the home. We need to continually address these challenges in transforming the nursing home and changing our social perception and understanding of its role and place within our neighbourhoods and communities,” says Fung.
The government plays an active part in supporting nursing homes. According to the MOH website, “patients who meet the means test criteria are referred by the Agency for Integrated Care (AIC) to volunteer welfare organisation (VWO) nursing homes which receive MOH subsidies. The VWOs provide additional support if the patient requires further financial and social assistance”.
In addition, since April 2003, MOH has extended subsidies to patients who meet the “means test criteria” and are admitted to accredited private nursing homes. These homes set aside a proportion of their beds for patients eligible for MOH subsidies and referred by AIC. The ministry says this allows for greater private-sector participation in the provision of MOH-subsidised care.

Nascent private-sector investment

According to C&W, the extent of private-sector involvement in Singapore’s nursing home market has been relatively low compared to VWOs and government-supported organisations. Of the 77 nursing homes today, 23 are public and another 23 are not-for-profit nursing homes, which have a total of 12,201 beds or 76% of the total beds. The 31 private nursing homes account for the remaining 3,858 beds (24%). “The proportion of beds belonging to private nursing homes has shrunk over the years, from 34% in 2010 to 24% in 2019,” notes C&W.
A reason for the private sector’s low overall involvement could lie in the supply of public land tenders for private nursing home developments over the past few years. The main supply of new nursing homes comes under the Build-Own-Lease (BOL) framework, where the government builds and owns the nursing home while it tenders out the operating rights to nursing home operators, explains C&W. “The aim is to ensure quality aged care at affordable prices.”
Only a handful land parcels zoned for nursing homes have been released for public tender in the past decade. The last government land tender was launched in 2016, and it was a 43,056 sq ft, 30-year leasehold site along Venus Drive, off Upper Thomson Road. The site was sold to Allium Healthcare Holdings, a subsidiary of investment holding company GK Goh Holdings, at a top bid of $24.3 million or $403 psf on the land area.
The site has since been developed into Allium Care Suites, a purpose-built premium nursing home comprising single and double rooms with en suite facilities. The 129-bed, four-storey nursing home targets the middle- and upper-income resident population in the neighbouring, predominantly private residential estates.
The Venus Drive nursing home site has been developed into Allium Care Suites, a purpose-built premium nursing home comprising single and double rooms with ensuite facilities. (Picture: Samuel Isaac Chua/The Edge Singapore)
Prior to the public tender for the Venus Drive site in 2016, the last time the government released a nursing home site for development was in 2004 when it launched a 23,681 sq ft, 30-year leasehold site at Simei Street 3. Orange Valley Nursing Homes was awarded the site after submitting a top bid of $4.5 million or $190 psf on the land area. In 2017, Singapore Press Holdings acquired Orange Valley for $164 million as the media and property group sought to expand its property holdings into healthcare.
“Given the shift to BOL [to regulate the supply of nursing homes], there has been a dearth of nursing home land released through public tenders,” says C&W. Other factors hindering the expansion of private nursing-home development are the cost of land, given the short lease (30 years), and the cost of operating a nursing home without government subsidies. Hence, it may not be cost-effective to build. Some people may even find it more cost-effective to hire domestic helpers to take care of the elderly folks at home, C&W points out.
Doubling eldercare facilities
Senior Minister of State for Sustainability and the Environment, Dr Amy Khor (who was Senior Minister of State for Health until July 2020), in a speech on March 5, 2020, says the number of home and day-care places to support seniors ageing-in-place has increased by 70% since 2015. Bed capacity at nursing homes has also increased by 30% over the same timeframe. “We now have sufficient capacity nationwide,” she adds. “Besides expanding capacity, we are also enhancing the scope of services, to better address the spectrum of care needs.”
Khor adds that over the next four years, the ministry will “progressively level up and fund at least double the number of eldercare centres to provide an expanded suite of baseline support services for all seniors nationwide”.
The government is encouraging seniors to age in place, and is rolling out a new HDB housing type called assisted living flats to expand the housing options for seniors. Khor says: “These new assisted living flats are meant to provide seniors with a housing option for independent living, with care available if needed.”
Unlike two-room flexi-flats, which are also targeted at seniors, the new assisted living flats will be sold with a mandatory service package that provides 24/7 emergency response and the assistance of an on-site community manager. The first set of these flats will be launched in Bukit Batok later this year, and will be reserved for seniors aged 65 and above.
“In addition, we will set aside some units where priority will be given to seniors with care needs,” says Khor, adding that plans for a private assisted living pilot are also underway.
The HDB developed Kampong Admiralty as the first integrated housing for the elderly with a range of social, healthcare, communal, commercial and retail facilities. It was completed in 2017 and features 100 flats, a two-storey medical centre, and a hawker centre. HDB plans to have more public retirement villages similar to the one at Kampong Admiralty in other housing precincts.
Changing needs
Given Singapore’s rapidly ageing population, C&W anticipates strong demand for nursing homes in the future. “The existing nursing homes will continue to enjoy high occupancy and demand,” says the consultant. “But this might not translate to stronger pricing power as the government maintains a keen watch on this sector.”
Given the country’s ageing population, C&W anticipates strong demand for nursing homes in the future, including those managed by volunteer welfare organisations such as Renci Nursing Home in Ang Mo Kio. (Picture: Samuel Isaac Chua/The Edge Singapore)
Looking ahead, demographic changes in Singapore dictate a revision of how nursing homes are perceived, says Fung. “Nursing homes, even the current ones, will have to support three major age groups: the Pioneer Generation who are the predominant current users of nursing homes; the young-old, or the Merdeka Generation who may in five to 10 years’ time consider using nursing home facilities; and the future old or the Millennial Generation who may need to use the nursing home in 30 years’ time.”
Nursing homes that are being developed today will need to be flexible and adaptable in order to respond to future changing needs, adds Fung. “In the future, nursing homes will continue to play an important role, but this role will have to evolve and transform. I hope that in 20 to 30 years’ time, each community can have some kind of nursing or care hub within the HDB neighbourhood to look after the elderly in its midst.”