1 Love in the Service of Hope CADENZA Symposium 2009 Primary Care & Older Persons – Key to Medical and Social Integration 9 th October 2009 Primary Care.

1 Love in the Service of Hope

CADENZA Symposium 2009CADENZA Symposium 2009Primary Care & Older Persons – Primary Care & Older Persons –

Key to Medical and Social IntegrationKey to Medical and Social Integration99thth October 2009 October 2009

Primary Care for Elderly:

The Need for Integrated Medical and Social Care

Chan Mei Kit, Maggie

Director, Social Work Services

Caritas – Hong Kong



Ageing and

The Need of Care Service

Two possible Developments: 1.First Scenario

If aged people have health problem, they will have more years spent in poor health.

Statistics indicate that the utilization rate of health care services rises exponentially for people aged 65 and above.


Source: Strategic Service Plan of Hospital Authority (2009 – 2012)


2.Second Scenario

Increase in life expectancy will be associated with an improvement in the health of the elderly.

Elderly aged between 65 and 75 are still healthy.

The oldest age group (above 75) has difficulties in caring themselves.

The use of care service (especially intensive care service) will be postponed to a later age.


Self-rated Health

　Proportion (%)

Age Excellent Very Good Good Fair Poor Unknown/Missing

75 and above

0.9 6.5 27.9 44.2 19.5 1

65 – 74 1.3 9.9 24.6 50.8 13.3 0.1

All Persons

aged 15

and above 2.7 20 36 35.5 5.7 0.2

Source:　Population　Health　Survey　2003　-　2004


Extent of Limitation in

Accomplishing Moderate Activities 　 Proportion (%)

Age No, Not limited at all

Yes, limited a little

Yes, limited a lot

Unknown/Missing

75　and　above 39.3 39.5 19.7 1.4

65　–　74 60.0 31.0 8.7 0.3

All　Persons　aged　15　and　above

84.1 12.6 3.0 0.3

Source:　Population　Health　Survey　2003　-　2004


Conclusion

1. Morbidity and the health condition of the elderly are the influencing factors on the demand of care service and the level/intensity of care service.

2. It is important to promote/improve heath condition of the elderly and enhance their ability to live independently.


Conclusion

3. The provision of integrated medical and social care service is essential to support the elderly living in the community.

4. More effort made to develop preventive health care and rehabilitative service will improve health and avoid disabilities of the elderly, thus diminishing the need for hospital care and intensive care service.

(Reference: Ageing and Its Consequences for the Socio-medical System Council of Europe, 1995)


Preparation for the Demographic Shift

1. Practitioners of Welfare and Health Sector Effort has been made by NGOs to promote co

mmunity-based primary care service for the elderly through our networks of ：

Neighbourhood Elderly Centres District Elderly Community Centres Enhanced Home and Community Care Service Other community-based service centres (Caritas)


2. The Elderly

Increase of awareness of the elderly on the need to maintain their health conditions to prepare for positive ageing.


3. The Community

The public is aware

of the issue and

advocates for

a healthy city.


Collaborative Projects 1. Aged Support Community Network and

Community Volunteer Service8 NGOs collaborated with HA (HK West Cluster)

2. Hong Kong East Community Network7 NGOs collaborated with Eastern Hospital

3. Fall Prevention Project and Education Project on Hepatitis DiseaseNGOs in Shamshuipo collaborated with CMC


4. Elderly Suicide Prevention Programme and Psychogeriatric Support Purchased Service

NGOs with Castle Peak Hospital

5. Outreach Service for High Risk Elderly and

Care Plans for Elderly

NGOs collaborated with Tai Po Hospital


6. Fall Prevention Project Caritas collaborated with the Chinese University to

organize the project at 12 Centres

防跌測試


Achievements

Through collaboration, we have succeeded in:

1. Providing community based and one stop service in response to the health status and care needs of elderly of different segment with objectives to:


enable early detection and follow up service provide preventive and rehabilitation service provide Integrated and seamless care service

for elderly discharged from hospitals


2. Outreaching to elderly in the community, especially the deprived

義工量血壓


3. Setting up formal or informal networks among NGOs, SWD, DH and HA to coordinate integrated service in districts:

District Coordinating Committees convened by SWD

Collaborative networks convened by HA Cluster/ NGOs

Some are project-based networks


4. Promoting elders’ participation and their awareness

Empowering the

elderly to sustain

their health and

to provide peer

support to promote

health education.

跌倒風險測試


5. Engaging the community

Mobilizing support from carers/family, volunteers, community leaders to provide community support.


6. Strengthening NGO’s service quality for elderly

Soliciting support from HA including training of staff, consultation service, advice on infectious disease control, sharing of information and direct referrals.

7. Mobilization of community resources for health programmes

Support from District Council, Community Investment and Inclusion Fund, donation and NGOs’ resources have been sought.


Difficulties in Sustaining Collaboration

1. Development of integrated service is piecemeal and fragmented due to lack of long term planning.

2. Rely on the initiatives of the front-line practitioners but without support from policy makers.

3. Formal collaborative networks are lacking in some districts.


4. Resources provided are on short-term or on project-basis.

5. Insufficient nurses and therapists to provide primary care and rehabilitativeservice.


Recommendations

1. The need for Long Term Planning for

Integrated Care Service

The Government should take the lead to formulate a long term plan on integrated care service including primary care service for elderly.


Through the planning process, we can:

conduct needs assessment and project future demand of social and health care services;

develop a community based model to deliver primary care and community care services by engaging NGOs, medical sector, the elderly, carers and the community;


set up formal networks in districts for service interfacing;

develop strategy on training of medical and health care workers to meet rising demand of services;

identify and allocate resources to implement the recommendations.


2. The need for Evidence-based Service Planning

A database on the population aged 55 and above, including indicators of health, morbidity, socio-economic status, family and household characteristics should be developed to enhance future service planning and review.


3. The need to adopt information technology to promote primary

health

care


4. The need to engage our users and the community in formulating the long term plan

It is important to invite our elderly and the community to discuss the long term

plan.

http://ntkcc.caritas.org.hk/private/upload_photo/large_photo/ChD5H-yfE0N-BWXI3


徐祥齡在東莞創辦的橫瀝隔坑社區服務中心Source: takungpao.com


Thank you

1 Love in the Service of Hope CADENZA Symposium 2009 Primary Care & Older Persons – Key to Medical and Social Integration 9 th October 2009 Primary Care.

Documents

service of hope slide

community care service

social care service

need of care service

primary care service

intensive care service

demand of care service

levelintensity of care