Neha Sinha – India’s Growing Aged Care Sector

Transcript

Ash de Neef: Well, Neha thank you so much for joining us on the program today.

Neha Sinha: Thank you so much for having me.

Ash de Neef: Well it’s our pleasure. You’re actually our first guest from India and you’ve got quite a extensive background as a clinical psychologist and as a co-founder of an aged care company in India. Can you walk us through some of your journey and how you got to where you are now?

Neha Sinha: Yeah, sure. I think when I started off this venture and we actually thought about Epoch Elder Care and this was when I met Camille who the founder, this is in 2011. And when we met, we were actually trying to just do something very light. A light model of engagement for elders. This is what our initial thought was.
And we actually started off as a home care company. We just wanted to provide something called intellectual companionship. That was literally our main offering when we started off like that in 2012. And we had about two or 300 elders who we used to visit, let’s say a couple of times a week. Go spend time with them, play a game, take them out for a coffee, go watch a movie, literally just spending time and being a grandchild to them.
So this is what actually we started off doing, but it’s very different from who we are today. And one of the things that I quickly realized was as a person it really matters to me, if I’m able to solve someone’s problem or not. And when I used to visit one of these homes, let’s say an elder who has dementia or a chronic condition.
And I was like, they needed help. And I was like, okay, what can I do? Then there’s nothing that I could offer at that time. That kind of really set both of us thinking. And then we decided to actually shut down that arm of the business and pivot and move into residential care and do something very, very different, almost go to the other end of the spectrum to do specialized care.
And I think the journey has been amazing in the sense that I didn’t really have a clear vision that in 10 years, I want to be like the CEO of a big company. It should have X number of homes, it should do well – so many team members. It all happened in a flow. And I never ever thought that I would be an entrepreneur, but I guess when you’re really passionate about something, you just end up being one.

Ash de Neef: What were the sort of things that you wanted to really handle differently when you guys founded Epoch Care?

Neha Sinha: I think the most important thing is in specialised care. Just understanding what geriatrics is all about because gerontology and geriatric care in India is not something which people are aware about. And people, I literally have to give them an analogy to understand that for children, there are pediatrics. They are there for a reason because the needs of children and babies are different.
Similarly, as you age a general physician who looks after you and me, is not probably that well equipped to look after an elder. So the fact that everything needs to be specialized, starting from a counselor, to a nurse, to a physiotherapist or nutritionist, all of these need to have some form of understanding of what aging looks like.
That was one of the biggest gaps that I had in myself as well and I upskilled, and read up and, All of those things. So yeah, that, that would be definitely the top, most priority.

Ash de Neef: You write lots of articles online, whether that’s on the Epoch Care website or published as a guest post or another site and something you’ve talked about is mental health among seniors.
Why do you think it’s not receiving much attention?

Neha Sinha: As a psychologist, i’ve always felt this, that anything to do with mental health or mental faculties is very misunderstood. And there is a lack of awareness because. A lot of people think that the person has a control over it. There’s very little understanding about the biological basis of mental health so it’s like you’re depressed or you’re hallucinating, come on, do something concentrate on your work, or look up some hobbies, go meet some friends.
It’s almost like I have control over these symptoms. And it is also one of the misconceptions also like it’s a sign of weakness. In fact, most people don’t understand or don’t see it as a physical illness so if somebody has diabetes. You’re not going to say that you’re doing it on purpose.
Your blood sugar is running high, you’re doing it on purpose. You should concentrate on getting your blood sugar down. But that is the reaction that a lot of people give to mental health concerns. And therefore people don’t realize how debilitating it can become and that you can actually lead a very crippled life
if you have a mental health condition and then it goes untreated. It happens across all age groups not just elders.

Ash de Neef: How do you guys, how do you deal with that challenge at Epoch Care?

Neha Sinha: One of the things that we do a lot is talk about the work we do in the sense, not explain the services we offer, but why we do what we do.
So spreading awareness. So when we have someone who is looking for a space for their parent. And in India, what happens is it’s never the elder who is the decision maker. Especially at an age role which is 80-85+. It’s actually the child or children, or even relatives who comes and speaks to us and takes the decision almost on their behalf.
Yeah. So that happens. And infact a lot of elders who move into a care home, probably are not even aware that they are in a professionally run care home because culturally it’s not something which comes naturally, which is acceptable. Which is in their mind would be the right thing to do.
So we also work around that. And we choose to not orient elders in the sense that we let them be in the world they are in, because it would be very distressing to reinforce the fact that you’re actually in a care home. Because most of them, after a couple of months, just think that we are family members and they are living in their old house and things like that.
Coming back to how do we deal with mental health conditions is largely again de-stigmatizing mental health. And how do we do it is just explaining that a person with a mental health condition can lead a perfectly normal life. It’s all about how you manage their life. How do you equip them? So our care plan for dementia is very person centered of course, but it also focuses on keeping the person as independent as possible.
And another different aspect culturally in India is that elders, typically elders who come from well off families or backgrounds are always surrounded by a lot of resources. So they come from large homes where they probably have domestic help, and they’ve not really done any personal chores for a while. And that adds to their dependency.
And when they come here, e try to build in small things into their schedule. Let’s say folding their clothes or doing a small kitchen activity or even dusting their room and things like that. So all of this, these things can easily be done. It adds a feeling of purpose for an elder. And that is how we plan our days.

Ash de Neef: And going back to something you said before about trying to replicate a family environment, you shape the space. So it feels more like a family environment. Are there small groups of residents living in a smaller area? How does that work?

Neha Sinha: So basically the size of our independent homes are between, let’s say 15 to twenty-five rooms.
We don’t want to, on-purpose create larger facilities, which are, let’s say 40, 50, or 60 rooms and so on. Because one of our care philosophies is that we don’t want the homes to feel institutional. And that’s also to do with the stigma and the taboo around sending your parents away to an institution or a nursing home.
So the physical infrastructure of the home, the way it’s designed, I actually call it a imperfect homes. Which means that it’s not a hotel or a hospital, it’s a home. So it’s okay if the resident’s room is a little messy or the lounge on the corner has a newspaper open. Or the cushion is a little crumpled because elders who have stayed in their home,, they didn’t really have completely perfect settings.
And that is one of the things that automatically not relate to if everything looks too perfect. So that is one of the things that we do a lot. We also do a lot of handmade decor instead of buying stuff from the market. So a lot of our team members sit around with elders and do craft work and all our door decors so the name of the residents on the doors.
They’re all handmade stuff. And they change according to whatever the theme is. So let’s say it was Valentine’s day. So we made hearts and in March, there’s something called Holy, which is the festival of colors. So we would do accordingly and things like that. So meal timings or the way we do activities are in small groups and it’s, the meals would be served in a table in a small, a, not as a buffet but you know how you would lay down the table and just eat it at home.
So there are all these elements. They be put together to really replicate an environment. And the last thing I would like to add is before we take someone in the also try and visit. The elders home and see if we can replicate their room inside the room over here. So get their favorite, let’s say armchair or their favorite mug or the favorite clock. Whatever they relate to, pictures. And we try and see if we can make it a familiar space for them.

Ash de Neef: That’s a great idea. I can see that being extremely rewarding. If you can make them feel comfortable from day one, as they move into the facility. One of the main differences I feel between Australia and India and feel free to correct me if I’m wrong.
But in this aged care space would be the family probably operates a bit differently in India to how it does in Australia. And my assumption is that a lot of older adults will continue to live with their family and be cared for by their family. Is there a stigma amongst the population about aged care being not a proper way to care for your elders?

Neha Sinha: Yeah, absolutely. And it will continue to be this way, Ash, because culturally in India an elder is always an individual responsibility. It’s not the responsibility of the community or the government or any larger group for that matter. It’s always the child who is responsible for them, like in most Asian countries.
So yes, there is definitely a lot of stigma and a lot of guilt that we have seen when children reach out for professional care, not only just residential care, but even home care. The fact that, I am not able to bathe my mom and I’m actually getting someone from outside to do this job, I’m not a good child.
So those kinds of things are very much prevalent. I think more than 80% of our elders would continue to stay at with their families or even in their homes not move to a retirement community, forget about a care home. But what is happening right now is obviously India is a very, very evolving nation. And just the simple fact that more and more women are joining the workforce and family structures have broken down, there are our nuclear families right now.
And even if you do live in a joint family, everyone, including grandchildren are so busy, they lead busy lives and you can’t really blame them. So everyone just has so much to do nowadays. So ironically, what we’ve seen is children don’t take this decision to send their parent to a care home.
But most elders who stay with their families end up being even more isolated.At least in a retirement community or a care home you do come out of the room. There is a program, there is a structure for you to socially engage. But in a home, you probably just alone the whole day and you’re with domestic help at home.
You obviously don’t have an intellectual connect. So hence larger cities. So obviously in metropolitan cities where there are more corporate staff or sorry, more corporate people whose parents are there and they are more aware for them. It’s easier to take this decision to seek professional care.
But more traditional setups, they would still try and do it themselves.

Ash de Neef: But it sounds like a challenge that you’d be facing every day. And as somebody new comes into your facility, you’d be having conversations with families and trying to assure them that they’re making a good decision that their elders are in safe hands. Do you have any sort of follow-up procedures or do you keep in touch with the family in a special way to make them feel a bit more comfortable?

Neha Sinha: Well, yes that’s very interesting question, actually. So making the family part of the decision. And also part of the care plan. And one of our goals for the nursing team is to ensure that the elder is more connected to their family members than they were before.
So for example, Indians who are overseas and their parents were alone. They would struggle to get on an iPad or do a FaceTime and things like that. But once they are here, we make sure that we can connect to them everyday, send a video about them. They can do a video call at any point and things like that -send them a weekly note.
We keep families posted very closely about what’s happening because also in India, trust is not… so trust and integrity, go hand in hand. And both of these things are not taken for granted. You don’t really see trust come on very easily, or people with integrity function that way.
We try our best to ensure that we literally explain and inform family members about day-to-day updates. There’s a formal weekly update which goes on, but we form, let’s say a WhatsApp group and send their daily picture and daily video also care plans are collaborative. So if we have to take a decision about, a change in, let’s say a meal plan or change in something more serious, like a surgery or a hospital appointment, then we try and get the family members on a call, explain to them what’s happening, take their opinion and things like that.
So this is after they move in. Before they move in, it’s actually a series of conversations that typically happen, not just with the main family member, but sometimes it’s also extended family members. Sometimes it’s relatives. Sometimes it’s just like anyone who has a say. I like to joke about it, it’s like a wedding in India.
When you have a wedding in India, you typically consult like a lot of people about the alliance. So our admissions in charge – she would literally spend time speaking and counseling with all these family members and explaining to them. Sometimes they come and spend the day, they have a meal with us, all sorts of things just to make them feel comfortable.

Ash de Neef: Wow. That’s really interesting compared to Australia where it’s a bit more hands off. It sounds like it’s a much more intensive process to get everybody involved. And that probably translates into a lot more work for the staff, for the carers and for your team.
Is that such just the reality of operating in aged care in India?

Neha Sinha: Yeah. And especially in a dementia care home, because like I explained children, feel guilty when they know that their parents are not taking the decision. And also have to explain to them that if you explain to your parents that you have dementia, I can’t look after you.
You need to go to home or it’s not going to happen. So it’s a two-headed sword.
So the guilt is much more,that “oh my God. I am taking this decision on behalf of my father. He doesn’t even know why I’m moving him out.” So yeah, it gets quite intense.

Ash de Neef: Yeah. I can imagine. And something that I could see, perhaps being another challenge in India as well, because it’s such a diverse country, right?
You have many different cultures and languages and how do you encompass all this diversity in a residential care facility?

Neha Sinha: Yeah. That’s true. I think the diversity, we take it as a huge positive that kind of helps us break the monotony in several ways. We take it in a manner that helps us create diverse engagement plans or, food festivals or celebrations and things like that. And everyone comes together and sort of enjoys the various cultural aspects know.
For carers I personally feel what really is important is knowing the elder as a person. And for that, you don’t really need to be from the same background. You just need to have genuine interest in understanding who this person is.
And that is one of our core philosophies at Epoch, is that we focus on the person as much as the clinical condition. Most of our elders obviously who move in with us, have some form of medical chronic condition ,dementia, Parkinson’s or nursing needs. So it’s very easy to view them as a patient more than as a person.
So we actually spend a lot of time with families to understand their past history, understanding their childhood, understanding where they were born. What was the first school like? Who were their siblings? What were their interests back in their twenties? Just understanding the love stories. All of those things, which have essentially shaped them as a person.
And once we understand this, we actually capture it in the form of a mini bio and it goes out into the walls. Like we have a resident wall of stories. So every resident has a little bio just explaining, capturing who this is as a person.
And for the admission, we all sit down together and understand, okay, who is this new family member who is coming in?

Ash de Neef: For example if you have a resident who doesn’t speak Hindi or English and they might speak Tamil or Punjab or another language, do you have to have staff that cover a large selection of different languages so they can communicate with the elder?

Neha Sinha: So 90% of our elders do have a working knowledge of Hindi and English both. It’s actually English, which can sometimes become a challenge for our care assistants, nursing assistants, because they are mostly trained in Hindi. And they sometimes make an effort to understand English. So that means English in Hindi is good, then it works.
But of course the comfort with mother tongue is an added advantage. If we do happen to have a staff who has come from that part of the country, then it’s a huge advantage. And we make sure that person gets allocated to this elder. I think it also depends on where you are in India. So the North, mostly we are in Gurugram which is, like a satellite city from Delhi.
So there Hindi is basically the core language. And then we are also in the west, which is also again Hindi, but if you go down to the South or you got to the extreme east, then we would probably hire team members who speak those langauges.

Ash de Neef: Now you said that you’re in a satellite city of Delhi. I’ve just got the map up now.
Can you remind me of what it’s called the city?

Neha Sinha: Gurugram.

Ash de Neef: So this is quite a corporate city, right? This is built up around industry and enterprise. What does aged care look like in more rural areas? Is there any sort of formalized government involvement in aged care or any sort of organizations that run similar services or is it more just left to the families in rural areas?

Neha Sinha: Is definitely left to the families at the moment. See what happens is aged care is viewed as a health concern, but as you would understand it’s much more than just physical or medical health. It’s actually so many aspects of what aging looks like, and how you care for elders.
So in rural areas, the focus, so let’s say primary health center and, smaller districts would basically cater to the physical health of elders. But again, nothing specialized. It’s not that there’s a geriatric physician out there. And it’s almost like in smaller cities and villages, it is a sense of community who is responsible and they, take turns in looking after each of those children and caring for each of those parents.
So that’s how it doesn’t really escalate into an issue. It becomes an issue in urban areas where you don’t really, knock on the neighbor’s door and say, “Hey, can you look after my mum? And I’m just going out for an errand.” You don’t do that in those settings anymore.
But that still is very prevalent in rural areas. The government, unfortunately, is not very proactive in formalizing a structure, whether it is in terms of policy or formalizing or standardizing care facilities, skilling and training.
I mean there are a ton of things that need to be done. There is a national policy, but very few people follow them. The industry has evolved, definitely. But the role of the government is something which we are not very happy with.

Ash de Neef: Yeah. I think that’s probably a common sentiment around the world is how the government is relating to industry.
So what do you think are the lasting changes that you would like to make through your work in aged care.

Neha Sinha: So dementia is definitely one of the things that I talk a lot about – something, of course I specialized in. The reason why I always bring up dementia in every forum that I speak is because it’s really very misunderstood in India.
There’s a term called [Hindi term]. Which basically means that someone who’s about 60 is supposed to behave a little – it’s okay for the 60 year old to be a little weird. Let’s just say it like that. But that’s not true.
It’s probably because the person has early onset of dementia and needs help. But what we’ve done is we have normalized impairment when we have normalized any such symptom or deviation.
And not got the attention that it requires. And just to explain to people that this is not a psychiatric condition, this is not becoming mad. And no, not just not all 100 year old elders talk incorrectly. It’s like once you’re 60 or 70 and 60 is too young now, but once you’re 70-75?
So that is one of the things that I, really want to leave an impression in the thought processes of especially in youngsters. So like we have an elder who is a hundred year old. We are getting her vaccinated today. One thought process is that she’s already a hundred. Why are you doing this to her?
The other, that it is all about the quality of life. If she does get the infection and there is discomfort, even if it is for a month or two, I want to prevent it. So the whole concept of focusing on quality of life, irrespective of what the condition of the elder is also something that I’m very passionate about. In helping people understand that there is a lot of things that you can do even if somebody is 98 or 99.

Ash de Neef: Yeah, we’re running out of time and we’ve covered so much stuff, but I wanted to ask you now, what are you optimistic about in the coming years? What do you think are going to be the most exciting changes?

Neha Sinha: Aged Care is definitely a sunrise industry. It’s just the start. And we started, nine years back. If we went to a forum or a conference for elder care, there would hardly be like 8-10 people, 8-10 organizations participating. And today, there are a couple of hundred people. So that’s a huge difference and like super proud to see how the industry in India has started evolving.
It’s very fragmented, but it’s very collaborative because there is no sort of competitiveness, which is kicked in at the moment because we know that the gap between demand and supply is so huge that, everyone has to do their bit and still fall short. And to give you a sense that today, elders comprise almost 10%, 8-10% of our population.
And by 2050 is going to be 19%. And that’s, like a huge increase in terms of let’s say care homes or beds, which are available. So it’s forecasted that India would have 173 million elders in the next couple of years. So the number of beds that you have today is less than a lakh.

Ash de Neef: Sorry, this word always confuses me. The lakh is something I know this is a word that’s really common in India, but we don’t have this in Australia.
It’s like 10,000. Is it? I lakh.

Neha Sinha: 0.1 million.

Ash de Neef: Okay. A hundred thousand. Awesome. I always get confused by that. So there’s a hundred thousand beds and there’s going to be 168 million elders. Is that what you said?

Neha Sinha: 173 million by 2026. And that’s the, that you’re looking at. Yeah. Yeah. So there’s literally no comparison. It needs a 10 or 12 X increase every decade to match up to that.
So it’s very exciting because I see the changes in attitude. I see that people are sitting up and realizing the pandemic. In that sense has really one done one thing and made people realize that elders can’t be just left alone. Because all the while in India you always thought that your neighbour could come or I could fly down, or I could drive down. But once India went into lockdown for three months and nobody could go anywhere. And all elders who stayed by themselves and the family, their domestic help didn’t show up. And they’re all used to these resources being around them. All sorts of people coming home and helping them out and that suddenly stopped.
So now people are realizing that, okay, we can’t take it for granted. We need to take a decision about seeking professional care. So I think globally, it’s very interesting. I think technology is one of the things that would play a very important role in shaping aged care services.
I think a good amount of research and dementia, early diagnosis. All of these things have now – you’re beginning to see literally the light at the end of the tunnel. I’m sure that in a couple of decades from now, we will be able to focus more on preventive care and not curative. That needs to be a phenomena.
In fact, that’s the only thing that can improve the quality of life and ensure that they are also seen as a productive and important part of the society and not just, dependent and helpless section of the society. So yeah.

Ash de Neef: Yeah, lots to look forward to the it’s. It is great that as you said, you’re right at the start of this new wave and it’s going to change and it’s all happening now.
Is there anything else you wanted to chat about today before we leave it there?

Neha Sinha: No, I think it’s been wonderful. chatting with you. I’m very happy to share whatever little knowledge or experience that I’ve had.

Ash de Neef: It’s been fantastic Neha. Thanks so much for your time.

Neha Sinha: Thank you Ash. Thank you so much.