CADENZA Symposium 2009

“Primary Care & Older Persons – Key to Medial & Social Integration”

Michael Lai, JPChief Executive Officer St. James’ Settlement

Experience of HK NGOs in primary care : success, obstacles and future plans.

Quotation : Supporting the Elderly Strengthening elderly care is one of our core areas in building a caring community. To encourage our senior citizens to lead an enriched life, the Elderly Commission has tried, in the form of “cross-sectoral collaboration and inter-generational integration”, to encourage self-help and mutual help among elders at the community level through “Neighbourhood Active Ageing Project” in the past two years. (The 2009-10 Budget)

“Study of the Needs of Elderly People in H.K. for Residential Care and Community Support Services.”

Deloitte & Touche – November, 1997

Recommended : • The continuum of care model should be

developed for community support services; • Increasing the availability of medical and health

professional support in the community;• Integration of services (e.g. day care/home help) –

single entry; and case management;

< Primary health care support is essential to the new service model !>

“Interface between Medical and Health Sectors and Social Service Sector in provision of Long Term Care Services for Frail Elders.”

(September, 2001)

• Reaffirmed “Ageing in place” – in particular enabling more elders to continue to live at home ;

• Therefore requiring closer co-operation between the two sectors in terms of knowledge and skill;

Some Obstacles to Integration

1. “Compartmentization” – Defined rules and regulation; Different Funding Sources (e.g. renting of HA properties).

2. Inadequate skills and knowledge; (can be overcome by training)

3. Trust and credibility; 4. Sharing of Records and Resources.

(Records to be shared)

All along, NGOs are striving to meet the needs of community dwellers. Role of NGO in Elderly Health Services ：

1. Need Identification & Referral e.g. SJS program ：老人心理衛生輔導服務 (Psycho geriatric Assessment Clinic)

3. Health Prevention e.g. Medical Check-up ,dental service, health talks

2. Liaison Service e.g. Inviting CGAT outreach clinic in DCC 、 DECC

4. Psychosocial Support e.g. Mutual groups & counseling in DECC

A step forward?

New born of EHCSS in 2001, HA & NGOs had collaborated to serve frail elderly living

in some districts.

Result : Reduce in hospital admission, better case management among medical & social professionals. Good knowledge transfer In handling frail elderly.

What’s happening? Silo What’s happening? Silo Effect?Effect?

NGO Community Hospitals

Why are we doing so poorly?

The Institute of Medicine (IOM) 2001 “Quality Chasm” report says:

“The current care systems CANNOT do the job.”

“Asking clinicians to simply try harder will NOT work.”

“Changing care systems will.”

Source : “crossing the Quality Chasm : 2001”

The Growing Burden of Non-communicable Disease

Rapidly aging population

Increased environmental risks—smoking, changed diet, increasing inactivity, air pollution

Double jeopardy: still fighting infectious disease and malnutrition while experiencing impacts of chronic disease

Sources : W.H.O. Innovative Care for Chronic Conditions, 2002Sources : W.H.O. Innovative Care for Chronic Conditions, 2002

The Chronic Care Model (CCM)

Developed at Group Health by Wagner & colleagues in 1996

A systems model to facilitate the delivery of chronic care in primary care settings

Chronic care is defined very broadly – any condition that requires ongoing activities with responses from both patients and care providers

Traditionally applied to chronic medical conditions, but has been applied in mental health problems, addiction

, and health behavior change

Useful in both planning & improving service delivery

Sometimes called the planned care model

Widely adopted in U.S. & internationally

Source :

Informed,Activated

Patient

ProductiveInteractions

Prepared,Proactive

Practice Team

DeliverySystemDesign

DecisionSupport

ClinicalInformation

SystemsSelf-

Management

Support

Health SystemCommunity

Resources and Policies

Health Care Organization

Improved Outcomes

The Chronic Care Model (CCM)

Source : Developed by Mac Call Institute (ACP-ASIM Journals and Book)

15

Why integrate care?

Primary Care

Community Mental Health

Center

PC

CM

HC

Home & Community based social

services?

Alcohol & substance

abuse care?

Source : Impact Implementation Care, University of Washington.

紅棉單張

17

Team Members ( 紅棉計劃 )

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Functional and Clinical Outcomes:Outcome reference from US

80% remission in 2 yrs (40% for usual care)Higher role functioning

DeliverySystemDesign:

PCP, nurse and care manager all

involved.Monthly contact

with pts by phone via care manager

Decision Support:

Psychiatrist review and advice on tx

adjust

ClinicalInformation

SystemsPt roster with tx

summaries, feedback to care

team

Self-Management

Support:office nurse provided

info on treatment options, readiness

intervention, tx effectiveness assessment

Health System:Sai Wan Ho Health Center

CommunitySt. James’ Settlement

Ongoing Depression Treatment

Weight loss program

Sharing of Medical Records.

Conclusion ：

Future Role in NGOs

1. Consolidation ： Care management, Professional teams, Evidence Based Care

2. New thinking, flexibility

3. Further meet the needs for the deprived groupse.g. Health Bank, Community Nurse Clinic

Thank you