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R.A. Merchant1

1. Division of Geriatric Medicine, Department of Medicine, National University Hospital, Singapore.

Corresponding Author: Associate Professor, Reshma A Merchant, Division of Geriatric Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore 119228, Email: reshmaa@nuhs.edu.sg, Telephone number: +65 6779 5555, ORCID iD: 0000-0002-9032-0184

J Frailty Aging 2020;
Published online July 15, 2020, http://dx.doi.org/10.14283/jfa.2020.39



Dear Editor,
Older adults at home, intermediate and long-term care (ILTC) setting including nursing home and hospice care are vulnerable to COVID-19 infection with increased morbidity and mortality. Singapore is one of the fastest aging countries in Asia where 14.4% of population is above 65 years old and this will double by 2030 (1). About 16000 older adults live in long-term care facilities and many more attend different types of day care facilities (2). Many of the residents are frail, with underlying dementia and / or multimorbidity and often present atypically causing a delay in diagnosis. In many countries, COVID-19 has spread amongst nursing home residents with mortality ranging from 24% in Hungary to 82% in Canada (3). It is known that 56% of residents may test positive while in pre-symptomatic stage, and many countries have put in initiatives to decrease the risk of spread in care homes (4). COVID-19 pandemic has highlighted the importance of communication and collaboration amongst ILTC providers which in many countries are run by non-governmental organization’s, healthcare providers, regional and national healthcare leaders.
In Singapore, the healthcare system has been organised into three integrated regional health system (RHS) clusters including Singapore Health Services (SingHealth), National Healthcare Group (NHG) and National University Health System (NUHS). Each of the clusters are responsible for the population health of the selected region, bringing together care, and enhancing capabilities of primary care and community service providers, and to anchor care in the community as a team. The Agency for Integrated Care (AIC), a centralized agency under the Ministry of Health (MOH) is responsible for the overall development of community care and/or ILTC services and works closely with the different RHS to maintain standards and quality of ILTC sectors (5). During COVID-19 pandemic, AIC has been working closely with MOH, RHS and community care providers in strengthening the pre-existing network to implement measures to slow the spread of the disease, and maintain the physical and mental wellbeing of older adults and caregivers. AIC serves as a command centre to guide and provide support for the various ILTC’s including provision of information and resources.
AIC and MOH, supported by different RHS work with nursing homes, centre-based and home care providers to implement and reinforce COVID-19 measures including infection prevention and containment, access to a steady supply of Personal Protective Equipment, safe distancing measures, split-zone arrangements and suspension of visits for nursing homes, alternative accommodation and transport arrangements for resident-facing staff, and surveillance testing for residents/ clients and staff. Special attention is also being given to additional funding requirement arising from COVID-19 prevention measures, staff appreciation and setting up telehealth and / or televisit infrastructure. A COVID-19 incident response team advising on heightened precautionary measures, surveillance testing, crisis communication and ensuring business continuity has been set up by AIC to support service providers with confirmed COVID-19 cases. The containment of small numbers of outbreaks has been made possible by above measures which also includes education, information sharing and learning from different ILTC providers on success measures.
While it has been difficult to do blanket screening in many countries, Singapore has been successful in screening their ILTC residents and those providing care where only four residents and one staff were found to be positive. The RHS community nurses have been on the ground to boost capacity and enhance capability of ILTC staff.
To support seniors and caregivers at home, various programs have been rolled out including online courses, television, and radio shows. In addition to various caregiver resources and AIC hotline, the Silver Generation Ambassadors (SGA) as outreach team under AIC have been reaching out to vulnerable seniors, providing them with support in coping with COVID-19 situation including reminding them to stay at home, providing education on safe distancing and hygiene, connecting them with relevant support including meals provision and food distribution. SGA also helps seniors to run simple errands like buying food supplies, medication and access and set up digital tools. For seniors without phones or those who are uncontactable, special arrangements have been made to conduct short physical visits with precautionary measures.
In addition, we have safe transfer of older adults from acute hospital to ILTC, where they need to be swabbed and proven to be COVID-19 negative regardless of admission diagnosis.
The above proactive measures and strong collaboration of RHS, AIC, MOH and various ministries in Singapore has been effective in reducing the outbreak in ILTC setting and can serve as a standardised care model which can be implemented and adapted by other countries.


Conflict of interest statement: nil.



1. https://www.tablebuilder.singstat.gov.sg/publicfacing/createDataTable.action?refId=14914.
2. S.-L.Wee PLKY. Timely Lessons From A Pandemic On The Benefits Of Person Centric Care In Long Term Care Facilities. The Journal of Frailty and Aging.doi: 10.14283/jfa.2020.28.
3. Adelina Comas-Herrera JZ, Charles Litwin, Amy T. Hsu, Natasha Lane , Jose-Luis Fernández. Mortality associated with COVID-19 outbreaks in care homes: early international evidence. Article in LTCcovidorg, International Long-Term Care Policy Network, CPEC-LSE, 21 May 2020.
4. Arons MM, Hatfield KM, Reddy SC, Kimball A, James A, Jacobs JR, et al. Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility. N Engl J Med. 2020;382(22):2081-90.
5. Agency of Integrated Care. https:///www.aic.sg/