Singapore’s approach to Long-Term Care (LTC) focuses on integrated care and active care management and coordination, aiming to reduce unnecessary utilization of institutional care. The approach is nested with an overarching Action Plan for Successful Ageing, as part of a policy shift towards a population health approach. Singapore’s LTC policies are based on the principle of ‘Many helping hands’ that calls for individuals, families, communities, civil society, the private sector, and government to all play a role in ensuring the wellbeing of older people. The system is designed with the aims of maximising prevention, promoting individual and family responsibility and reduce inefficiencies, with LTC as part of a wider integrated system covering public health, primary care, acute care, rehabilitation and long-term and palliative care. Sources: Asian Development Bank (2021) Singapore’s Long-Term Care System. Adapting to Population Ageing.

In 2021 there are 5.4 million people living in Singapore, of whom 3.9 million are residents (comprising 3.5 million Singapore citizens and 488,700 permanent residents).

Singapore’s population is ageing rapidly, in the population aged 65 and over was 639,000 (15.9%) out of its 4 million resident population. This is expected to rise to 23.8% of the population of residents by 2030.

Sources: Department of Statistics Singapore

The Ministry of Health is responsible for governance over the entirety of the health and LTC systems, including setting policy direction, projection of national-level service demand, health and LTC financing, regulatory frameworks, standards, oversight, and coordination of related bodies. There is an Ageing planning Office with responsibility for setting policy direction and implementation for successful ageing across sectors.

In 2018 the Agency for Integrated Care (AIC) was created, within the Ministry of Health, with responsibility for coordinating the delivery of Long-Term Care, enhancing service development and building capacity across health and social care. The AIC is responsible for integrating and coordinating health and care services, case assessment framework and case finding, monitoring and evaluation, case management, referral services, strengthening primary care and community care services and quality of services.

Sources:

Asian Development Bank (2021) Leadership and Governance in Long-Term Care Systems in Asia and the Pacific. ADB Brief. http://dx.doi.org/10.22617/BRF210448-2

Asian Development Bank (2020) Singapore’s Long-Term Care system. Adapting to population aging. ADB.

Nursing homes in Singapore fall into three categories: public (~31%), private (~40%) and charitable/ not-for-profit (NFP) (~29%). There are a total of 77 nursing homes and 16,221 beds. Substantial government subsidies and donor funding financially assist most of the public and NFP homes, but they also require co-payment from clients. The Ministry of Health subsidy scheme does not cover private nursing homes, for which direct out-of-pocket expenses must be covered by clients (Udod et al., 2021).

Financing for LTC and support to older adults exists within an overall health-care financing that, in turn, is linked to the way in which social care and pension funding is organized. There are three complementary insurance schemes for disability cover: ElderShield and ElderShield Plus, and CareShield. ElderShield is a severe disability insurance scheme under which all citizens and permanent residents born before 1979 who have a MediSave account are automatically covered from 40 years of age (opt-out is possible). To be eligible for the scheme, individuals must be unable to carry out at least three out of six basic activities of daily living. ElderShield Plus offers higher monthly payouts or payouts for a longer period or a combination of both. CareShield Life is a compulsory insurance policy introduced in 2020 that provides payouts for people who are severely disabled. Everyone born between 1980 and 1990 is enrolled automatically and younger cohorts will be enrolled as they turn 30. Another funding scheme introduced in 2020, ElderFund, provides financial support for low income, severely disabled Singaporeans. Additional subsidies and schemes exist to finance LTC. Some schemes focus on financial support to informal caregivers and home-based care (source: Asian Development Bank).

LTC in the community is mostly provided informally by family and surrogate carers. Formal community services (e.g. day care) and residential care are largely provided through Voluntary Welfare Organisations or Social Service Agencies. In 2019, Singapore had 7,600 day care places, 10,300 home care places, 1,986 community hospital beds and 16,059 nursing home beds. Of the available nursing home beds, 75% were supplied through the Social Service Agencies and the government and 25% through private providers (source: https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Care integration is high on the policy agenda in Singapore. For example, to facilitate integrated delivery of support and services, Singapore has consolidated aging, health, and LTC under the Ministry of Health (MOH) with inter-ministerial remits, where relevant.

The Agency for Integrated Care has taken on the role of a National Care Integrator since 2009. It is the agency’s role to match people with LTC needs with available services. The agency further is ‘responsible for supporting community care service partners in manpower development, quality improvement, programme development, and crisis management’.

In 2012, a Regional Health System model was introduced by the Ministry of Health to support the provision of ‘seamless integrated care based on geographic location’. This model facilitates local collaboration and transitions between care settings and has been reported to strengthen management capabilities and continuity of care. Key actors are designated anchor public acute hospitals as well as ‘primary, chronic health and social care’ services in the different geographic areas.

Singapore relies heavily on community-based care, however older adults who cannot receive care appropriate for their needs at home are able to seek accommodation in a Long-Term Care Facilities (LTCFs). Singapore has over 16,000 LTCF places as of 2019 of which 40% are run by the government, 37% by non-profit organisations and 23% by the private sector (Irving and Bloom, 2020).

Public and non-profit run long term care facilities in Singapore are particularly vulnerable to infectious diseases due to their infrastructure: most facilities resemble dormitory-style housing shared by  between roughly 6 and 12 residents living in close proximity, with communal facilities. There is more variation in the layout of private nursing homes: some have dormitory-style living conditions that have as many as 30 residents; others have single or double private rooms. Most public and non-profit LTCFs have substantial subsidies from the government (Goh et al., 2022).

References:

Goh, H.S.; Tan, V.; Lee, C.-N.; Zhang, H.; Devi, M.K. (2022) Nursing Home’s Measures during the COVID-19 Pandemic: A Critical Reflection. Int. J. Environ. Res. Public Health, 19, 75. https://doi.org/10.3390/ijerph19010075

Irving and Bloom (2020) COVID-19, Older Adults and Long-Term Care in the Asia Pacific. Report prepared for HelpAge International Asia Pacific. https://ageingasia.org/wp-content/uploads/2020/12/COVID_LTC_Report-Final-20-November-2020.pdf

Singaporean LTC relies heavily on home-based and community care services and aims to reduce unnecessary utilization of institutional care (source: https://www.adb.org/sites/default/files/publication/637416/singapore-care-system-population-aging.pdf). In 2019, there were 7,600 day care places, 10,300 home care places and 1,986 community hospital beds in Singapore (source: Analysis of variable COVID-19 mortality among older people in Asia Pacific, by forms of long-term care (ageingasia.org).

There are different types of day care services in Singapore. These include: ‘senior care centres, day rehabilitation centres, general and enhanced dementia day care and day hospices’. Home care services for bed-bound older people living in their own homes include ‘medical, nursing, therapy, personal care and hospice’ are. In addition, there are meals-on-wheels services and Medical Escort and Transport Services available. Community hospitals offer short-term (2-4 weeks) rehabilitative inpatient care for people who experienced acute medical care needs. It is their role to facilitate transition back into the community (source: https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

The country operates with shortages of workers in LTC sector, which poses challenges to staffing facilities (source: Responding to COVID-19 in Residential Care: The Singapore Experience – Resources to support community and institutional Long-Term Care responses to COVID-19 (ltccovid.org).

Singapore took the threat of COVID-19 seriously early on and was able to draw on an already existing Disease Outbreak Response System framework, which had been refined based on the experiences from the Severe Acute Respiratory Syndrome (SARS) of 2003 and the H1N1 influenza pandemic of 2009 (Graham and Wong, 2020).

Following the 2003 outbreak, the government established 900 rapid response public health preparedness clinics (PHPCs) across the country, ear-marked for improved response to pandemics and outbreaks. The PHPCs serve as an intermediary between the community and hospitals, screening all patients with flu-like or pneumonia symptoms into low-risk and high-risk groups. The high risk group is referred to an infectious disease hospital for further assessment and management (Kuguyo et al., 2020).

Nursing homes in Singapore started to prepare for COVID-19 early. A case study of a large charitable nursing home’s measures shows that, as soon as news were reported from China, in January, the Nursing home’s Nursing Director and Infection Control Nurse started to work with staff to establish a command centre, setting up a screening counter, reviewing national pandemic guidelines and liaising with the Ministry of Health and the Agency for Integrated Care, and coordinating mask-fitting for all 400 staff (Goh et al., 2022)

References:

Kuguyo O., Kengne A.P., and Dandara C. (2020) Singapore COVID-19 Pandemic Response as a Successful Model Framework for Low-Resource Health Care Settings in Africa OMICS: A Journal of Integrative Biology.Aug 2020.470-478. https://doi.org/10.1089/omi.2020.0077

In August 2021 there had only been 42 COVID-19 related deaths in Singapore, with a small share of those in care homes. When there was a smaller number of deaths and individual reporting of cases, it was possible to identify deaths of people who lived in care homes. However, since Singapore pivoted to an endemic COVID-19 strategy, once a high (over 80%) vaccination rate had been achieved, the number of deaths has increased rapidly, with many outbreaks in care homes. No separate data is published for care homes (Feng Tan and Feng Tan, 2021).

The Ministry of Health’s dashboard reports that there have been 882 deaths linked to COVID-19 on 11th February 2022.

References:

Feng Tan L. and Feng Tan M. (2021) Pandemic to endemic: New strategies needed to limit the impact of COVID-19 in long-term care facilities. Journal of the American Geriatrics Society.  70(1): 72-73. https://doi.org/10.1111/jgs.17556

Singapore has put in place a multi-pronged strategy with an emphasis on epidemiological surveillance, case finding, testing, mandatory reporting, contact tracing and containment.

The country has a Disease Outbreak Response System Condition (DORSCON) framework. The severity of an outbreak and associated actions are highlighted through a colour-coded system

Source:

The long-term care sector in Singapore was first advised on January 23, 2020, against traveling to Wuhan (China) (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

The following response does not describe a national COVID taskforce, but instead one set up by a nursing home in Singapore in the early stages of the pandemic.

In their recently published study, Udod et al. (2021) describe pandemic measures reported by a nursing home in Singapore. This home set up a nursing taskforce committee and command centre as soon as news of the COVID-19 outbreak was reported in China in January 2020. This taskforce was responsible for reviewing the latest government guidelines and liaising with key stakeholders (such as the Ministry of Health), managing a surveillance system for staff and visitor traffic, and mobilising the necessary resources. Non-nursing administrative staff were assigned to help the taskforce with resource allocation (in the face of supply shortages), data collection, and other administrative tasks. This meant that when cases when widespread community transmission caused cases to spike in May of that year, the nursing home had already established organisational guidelines and vital infrastructure to be able to cope (Udod et al., 2021).

The Regional Health System model, and the collaborative relationships that were formed through this model prior to the COVID-19 pandemic, was reported to have contributed to the ‘allocation and sharing of infection control resources and training, and the safe transfer and management of patients between acute and community care settings’ (Source: https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Singapore recognised the limitations of their lean workforce in residential LTC and the need to protect it. ‘The implementation of split zones and full contact precautions’ protected facilities from acute staff shortages.

To ensure the functioning of split zones, housing was organised for LTC workers who shared accommodation with staff assigned to different zones, workers in different (health and LTC) care settings, or in dormitories that did not allow for safe distancing. Many care workers working in nursing homes lived in hotels and serviced apartments, others lived on-site (adhering to split zone arrangements) between April 7 and June 1, 2020, during the Circuit Break period. The government paid for meal delivery and dedicated transportation between home and work. Health and LTC workers that were moved into temporary accommodations received $500 to facilitate the transition.

In addition to public recognition, the workforces received care packages and message of support from care facilities and could access ‘professional counselling and emotional support services’ (source: https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

If a resident in a nursing home receives a positive COVID-19 test, a COVID-19 Incident Response Team (CIRT) is called in immediately by the AIC. These response teams consist of ‘representatives from the nursing home, the supporting regional hospital, the Ministry of Health, the Agency for Integrated Care, National Public Health Laboratory as well as the National Centre for Infectious Diseases. The response teams work on containing the number of positive cases, stepping up infection control, carrying out swabbing and testing operations, contact tracing, heightening vigilance (health monitoring of staff and residents), communicate with residents’ relatives and media, develop a service continuity plan and maintain adherence to the IPC measures, ensure workforce recovery after quarantine (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

A study conducted by Udod et al. (2021) (for which research was carried out in one nursing home in Singapore – so it is possible that this was not the experience of all LTC facilities in the state) reported that staff training and up-skilling – including competencies in pandemic management – was delivered by a nurse educator, who was also responsible for developing online training infrastructures in order for content to be available online.  Well-developed online training infrastructure and resources were then also made available to other nursing homes.

References:

Udod, S., Goh, H. S., Tan, V., Lee, C.-N., Zhang, H., & Devi, K. (2021). Nursing Home’s Measures during the COVID-19 Pandemic: A Critical Reflection. International Journal of Environmental Research and Public Health 2022, Vol. 19, Page 75, 19(1), 75. https://doi.org/10.3390/IJERPH19010075

As the DORSCON level reached orange in February 2020, elective surgical procedures and non-essential health/dental services were suspended. Hospitals continued to discharge residents to nursing homes throughout the Circuit Breaker period. The referrals were coordinated by the Agency for Integrated Care. At first, residents could be discharged if they did not have an acute respiratory infection and COVID-19 related symptoms. Those with an acute respiratory infection or pneumonia were required to provide a negative test. In May the policy changed as knowledge of asymptomatic COVID-19 increased. From then onwards, all patients discharged from hospital to nursing homes had to be tested (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

In comparison to other countries, there were only very few cases in nursing homes in Singapore. All of the residents with COVID-19 were transferred to acute hospitals.

Nursing homes introduced mandatory split zones to reduce the number of contacts for residents and staff. The zones cannot house more than 100 residents, a fixed set of staff and need to have dedicated entry and exist points. Communication between staff in different zones should take place remotely via text messages, phone or video conference. Shared spaces, such as pantries and lifts should have staggered access that allows for cleaning between the use from different zones. Medical staff needing to move across split zones are recorded for contact tracing and have to adhere to increased infection prevention and control measures (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

In-person visits to nursing homes were suspended for just over two months during the Circuit Breaker Period (April to June 2020). In July 2020, nursing home residents could ‘receive one of two designated visitors for 30 minutes each day.’ Visitors were asked to make appointments so that nursing homes could manage the number of people present (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Following an increase in infection rates in September 2021 there has been a total ban on visiting in acute hospitals and care homes, with exceptions for critically ill residents. This ban was in place until 21st November 2021. Since then, visits are now only allowed when both the care home resident and the visitor are fully vaccinated (unless either of them is not medically eligible for vaccination). Only one designated visitor is allowed per visit and visits have to be under 30 minutes long. Visits are to be suspected when there is an active COVID-19 cluster in the home. Care homes are asked to continue to support alternative methods of communication.

In April 2020 Singapore started routine testing of residents who showed COVID-19 relevant symptoms. At the end of April 2020 routine testing of all staff and residents began. Testing and follow-up treatment for those with positive results identified through this surveillance mechanism were provided for free by the government.

In addition, the Ministry of Health and the Agency for Integrated Care have ‘worked with the regional hospitals to train nurses in care facilities and nurses in three home care providers in testing and to support the development of ‘mass swabbing workflows’. The Agency for Integrated Care took on the coordination of sending the samples to the National Public Health Laboratory (https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf).

Already in 2018, Singapore introduced National Infection Prevention and Control Guidelines for Long Term Care Facilities. In addition, the Agency for Integrated Care provided webinars to review practices outlined with care providers and to provide up-to-date guidelines. In addition, the Ministry of Health issues current advisories.

The Agency for Integrated Care also drew on the national stockpile to ensure that all nursing homes, irrespective of provider, had sufficient levels of PPE. The supply of PPE was provided based on ‘the facilities’ staff size and level of precaution required of specific care services’.

Source:

https://ltccovid.org/wp-content/uploads/2020/08/The-COVID-19-Long-Term-Care-situation-in-Singapore-27July-2020.pdf.

Covid-19 Vaccinations have been voluntary for the whole healthcare sector (and country), but Care Providers proactively educate their staff and regularly report vaccination rates.  As of Mid-February, already 73% of healthcare workers had been vaccinated with at least 1 dose (the vaccination campaign started around Mid-Jan, so the coverage is likely much higher now) (https://www.moh.gov.sg/news-highlights/details/progress-of-covid-19-vaccination-programme/).

On the 3rd September 2021, the Expert Committee on Covid-19 Vaccination recommended that people aged 60 and over, as well as those who live in aged care facilities, should receive a booster dose of an mRNA vaccine six to nine months after the completion of vaccination with two doses.

The Agency for Integrated Care supports people who are housebound and need to be vaccinated at home or who need escorting or transported to vaccination centres.