The Caregiver Ecosystem

The caregiver eco-system (CES) aims to provide resources in the physical, socio emotional and financial aspects, through community, professional, and technological support to relieve caregiver stress, enhance their well-being and self-efficacy, and improve the quality of care that the caregiver can offer to their care recipient


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The caregiver eco-system (CES) aims to provide resources in the physical, socio emotional and financial aspects, through community, professional, and technological support to relieve caregiver stress, enhance their well-being and self-efficacy, and improve the quality of care that the caregiver can offer to their care recipient. According to a 2013 national survey on informal caregiving in Singapore, two main caregiving challenges were identified to be financial inadequacy and the dual roles of caregivers. Taking these two challenges into account, the CES requires government incentives to provide monetary support for familial caregivers, work-friendly arrangements to support caregiver's dual roles, cost-effective solutions that leverage on technology and community resources, and the availability of respite care, (as illustrated in blue, the base of Figure 1). The CES models after the key themes in the 2019 Singapore Caregiver Action Plan (2019 CAP) , which focuses on the following -caregiver respite services, workplace support, care navigation, financial support and caregiver empowerment and training (highlighted in yellow of the CES figure). The maroon boxes are the values that the CES promotes. The CES aims to provide support for three main groups of caregivers. They are the adult children caregivers who are mostly economically active adults, the foreign domestic helpers (FDW) who are paid caregivers, and the aged spouse caregivers who may require more physical and practical help due to their older age. The three groups of caregivers in the middle of Figure 1 rely on the various sources of essential support illustrated in the blue base of Figure 1, and the caregivers can receive enhanced support with the development of the various thrusts, listed in the white boxes at the upper half of Figure 1.

FDWs caregivers
In Singapore, FDWs provide caregiving support to adult children and aged spouse caregivers, in the form of paid informal caregiving for their family members. FDWs can look after care recipients effectively if they receive proper caregiver training and other resources from the community, to lead them to the right medical services or other professional services when more critical need arises.

Adult Children Caregivers
For economically active adult caregivers, workplace support is crucial in helping them balance between caregiving needs and work commitments. A suggestion is to allow flexi-work arrangements in terms of timing, load and location e.g., work from home on some days, work less hours on some days and start work at an earlier or later time. The remuneration of the employee can be adjusted accordingly, for such cases. Government agencies and ministries can lead by example and the government can incentivise private companies to provide flexi-work arrangements. A current initiative is the work-life grant, which aims to incentivise and sustain companies in practicing flexible work arrangements for all employees.

Respite Care
Adult children and aged spouse who require a break from caregiving can turn to respite care support. Due to the lack of available beds in nursing homes and the current system which requires early and advance booking, caregivers cannot find respite. The lack of respite can worsen caregiver burden and distress, especially if the caregiver is burn out.
To meet caregivers' need for respite, nursing homes can allocate a small percentage of beds that are meant for respite purposes only and allow regular scheduling on a rotational basis, so that cargeivers can plan their break and holidays. For instance, care recipient A uses the respite service every Monday while care recipient B uses the respite services on the first week of every month. Nonetheless, the perennial issues of bed crunch and lack of manpower are obstacles that need to be tackled. The issue of bed crunch can also be addressed if we consider using existing spaces at the senior activity centers for night respite services. This would mean that the license for the operator needs to be converted to residential care and abide by residential care rules and regulations. Alternatively, we can consider extending operating hours of senior activity centers till 10pm for example and provide partial night respite care. Extended operating hours is especially useful for care recipients who suffer from insomnia. Adult caregivers who have to look after care recipients with insomnia will not be able to sustain work in the day. Evening respite support will then allow adult caregivers who has the option to start work later, to also end work later, since the care recipient can stay at the center till a later time. As some care recipients may not want to stay away from home, home respite care services in which the care provider lives in with the care recipients for certain days, can also be offered, and especially for advance care recipients. The government will need to support such short-term care services with overseas deployments who are granted short term work passes.

Caregiver Training, Empowerment and Navigation
Caregiver training and empowerment are important in equipping the three groups of caregivers to look after their care recipients. Caregivers in Singapore can benefit from the government subsidized caregiver training programs. The quality of the caregiver training program can be standardized and customized for different kinds of care recipients e.g., high dependency care recipient who require tube feeding, care recipient with severe dementia. The socioemotional needs of the caregiver can also be met through a caregiver support program, that links distressed caregivers to a counsellor. Singapore can also explore setting up locality-based caregiver support groups, which are more accessible than the current ones, which are usually held at a centre. As a start, Agency of Integrated Care (AIC) in Singapore can support such initiatives by funding staff to initiate such groups, who in turn will train peer leaders to run them for the long term.
In tandem with caregiver training and empowerment is care navigation. AIC has stepped up efforts in setting up centers, providing hot-lines and offering app services for caregivers to find resources and information. As the aged spouse may not be aware of such services especially if they do not surf the net to look for such information, the clinic assistants in the neighborhood clinics can serve as ambassadors to inform seniors of the hot-line. Such practical resources and financial support from the government would then promote caregiver self-efficacy.

Financial Support
The government has set up several grants and financial aids for care recipients and caregivers, however not every care recipient qualifies for the financial aids. The financial aids are also often insufficient to support both the care recipient and the caregiver, especially if the caregiver is an adult child and has to stop work or reduce work commitment to look after a family member. Tax rebates will not be useful especially if the adult children cannot continue work or are not working full-time due to caregiving commitments. In such scenarios, the government can consider letting the care recipient use his or her retirement fund from the CPF savings to finance caregiving. The government can also consider paying the caregiver through a co-payment scheme that uses the care recipient's CPF savings and a government-subsidized private insurance plan to pay the family caregiver. As a start, the Singapore government is offering $200 monthly Home Caregiving Grant. The government can consider providing caregiver allowances (in place of other grants and subsidies for the employment of a FDW) to family members who stopped work to become full-time caregivers. In addition, the government can also consider giving out groceries and transportation vouchers to offset daily expenses.

Technology
For older adults who live alone or do not have a caregiver to look after them for most of the day, technology can monitor and alert caregivers or others for help. Sensory detection technology are less obtrusive than CCTVs and can detect a range of anomalies, such as a significant rise in temperature that signals fire, motion sensors that detect older adults leaving the house or prolonged inactivity, reminders for medicine taking and sensors that detect if older adults did not take their medication. Caregivers or medical help can be alerted and mobilized. In less critical scenarios, technology can detect other anomalies such as disruptive sleep and frequent toileting, to serve as early warning signals to seek medical attention. Technology offers cost effective solutions if there is a critical mass utilizing it. Infrastructure cost would then be lower when technology can be shared by a critical mass. Therefore, the government will need to ensure that technology is not monopolized by individual companies. The government will also need to ensure standardization and uniformity, and regulate technology usage to protect the users.

Volunteers and community support
The pool of community resources available can supplement technology as a cost-effective solution for care recipients and caregivers. Apps and tele-centers can link care recipients to volunteers, neighbors, social workers and other community support such as grassroots organisations and community interest groups. Befrienders can check in or regularly monitor the care recipients. Befrienders can provide socioemotional support. If depressive symptoms are observed, befrienders can link the care recipient to a counselor. If ailments or disturbing changes in behavior are observed, befrienders can link the care recipient to medical professionals. Senior activity centres in Singapore will be transiting into the Active Ageing Clubs (AAC) model. Through the AAC model, the clubs will serve as activity centres and also provide befriending service to reach out to lonely and distressed seniors in the designated geographical boundaries. For caregivers or recipients who require practical help such as medical escort, to pack lunch or to buy groceries, they can seek help from volunteers through apps. Caregiver can show appreciation to volunteers and the government can offer benefits (e.g. vouchers) to volunteers to motivate them to continue contributing their time and assistance. The value herein is the building of social capital.

Active Ageing
Beyond ageing in place, the CES also promotes active ageing by having organisations and interest groups hold events and activities in the community, for the care recipients and caregivers to join in. For instance, SportsSG organizes exercises that sprout in many neighborhoods in Singapore, Tsao's Community for Successful Ageing (COMSA) has a club for seniors, in which older adults provide assistance to other older adults in the community in areas such as befriending, exercise partnering and food delivery. Hospitals in Singapore that offer social prescribing links patients to participate in in-house activities that promote wellbeing, such as gardening, exercising, singing, and reading. They are then linked to community care providers before discharge to partner community resources, such as the Community Network for Seniors to continue with the social activities. These are examples in which health care and social care can integrate to support the care recipient and caregivers.

Functional Maintenance
Lastly, the CES promotes functional maintenance of the care recipient through initiatives such as the use of technology to assist in the activities of daily living of care recipients (e.g. soft food mixer), caregiving support from the senior activity centers and by training FDWs to do rehabilitation exercises with care recipients.

Conclusion
Singapore has a rapidly ageing population. According to the Singapore's Department of Statistics (SDS), there will be one older adult above 65 years, in every five people in Singapore by 2030. The upward trend of older adults living alone presents a double jeopardy. SDS estimated that the number of older adults who live alone will increase from 35,000 in 2012 to 83,000 in 2030. These figures have yet to include older adults who live with their family but are left alone for most parts of the day when their adult children are working. Evidently, caregiving support is a pressing need, both in terms of time urgency and in terms of the magnitude of caregiving demand. It is therefore crucial to explore establishing the CES, by getting buy-ins from the various stakeholders to pilot the CES in a district in Singapore, and then revise the CES, before rolling it out national wide.