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THE NEED FOR HOME CARE
 
SMA has formed a committee in association with community healthcare and other professional groups to look into the need for home healthcare. With the greying of the population and the increasing number of home-bound patients, the provision of such services would not only improve the quality of the home-bound patients but would also lessen the need for hospitalisation and nursing home care. While most doctors are familiar with the term house-call, which basically is a medical consultation at the patient’s home, home healthcare is continued and continuing care at the patient’s home punctuated  by hospitalisation only when more complex medical and nursing care is needed. 

A study done by Paul Chan et al(1) in 1984 showed that two-thirds of 954 house-calls done by 30 general practitioners over a 4 month period was for the elderly.  Repeat home visits were needed for half of these patients because they were home-bound with chronic problems. Only ten percent of  all patients needed hospitalisation after consultation. The average GP did about 7 to 8 house-calls per month 13 years ago as shown in this study. This is in contrast to an average of 1 to 2 house-calls per month noted during a recent audit of 20 GP enrolled in the private practitioners’ stream of the Master of Medicine (Family Medicine) programme. If this were to reflect the norm, then the decreasing number of house-calls is a matter of professional concern.

A better organised ambulance service may lessen the need for house-calls by doctors for true medical emergencies. There exists however a greater medical need for healthcare to be organised around the patients’ home for the frail and chronic sick elderly.  It is estimated that about 5% of all elderly ie. about 11,000 presently require substantial help with basic self care tasks(2). Attention must  be paid to the training, structure and funding of such services.

Training needs to be formalised for the healthcare team.  The School of Post-graduate Medical Studies has recently introduced a course leading to the Diploma in Geriatric Medicine (D.G.M.). This will provide appropriate training to complement the small number of specialist geriatricians we have. SMA has convinced the Institute of Technical Education (ITE) to develop Home Care Assistants training in parallel  with the technical level of healthcare aide already developed for hospital and clinics.  We are also working closely with other professional associations such as the Singapore Nurses Association so that healthcare teams can be forged. A home care conference would be organised as part of our National Medical Convention next year to facilitate dialogue. Appropriate contributions of all members of the home care team are important as more than medical care of the patient is involved.
 

The structure of the home care delivery has also to evolve.  There are at least three possible models.  One model is based on an extension of in-patient services of hospitals with departments of home care set up within the hospital structure. A second model is based on independent mobile clinics affiliated to hospitals much like the Hua Mei Mobile Clinic set up by the Tsao Foundation. A third model is based on primary care clinics in housing estates.   Interested General Practitioners could be encouraged to set up home care services within their clinics’ infrastructure with links to community and hospital services for the elderly. 

However, these three models are not mutually exclusive.  What is important is there should be close links with community and in-patient facilities such that the over-all care is cost-effective considering both the community and the episodic in-patient components. There is at present no external funding for home care. If effective home care can decrease the need for patients to be admitted to nursing homes and hospitals, then the monies used to subvent such services can be used to fund home care.  Without financial support, it is unlikely that home care can be developed on a nation-wide scale.

The home is the next frontier of healthcare delivery. We are familiar with delivering care from hospitals and clinics for in-patient and ambulatory patients. The medical profession must now actively explore all aspects of delivering continued and continuing care to home-bound patients.  

REFERENCES
1.  P Chan et al. Singapore Family Physician 1985; 11 (1): 9-15.
2.  National Survey of Senior Citizens in Singapore 1995.