OUTREACH SUPPORT Mrs. Victoria KWOK JP, RSW Social Services Director

1. CADENZA Symposium 2009“Primary Care & Older Persons – Key to Medical & social Integration”9-10 October 2009 OUTREACH SUPPORT Mrs. Victoria KWOK JP, RSW Social Services Director The Salvation Army Hong Kong & Macau Command

2. Medical OutreachExamples

3. Source: HK SWD Homepage

4. Social OutreachExamples COMMUNITY CARE SERVICES Community Care Services aim to provide personal care, nursing care, rehabilitation training and social activities in a familiar home and community environment to frail elders who cannot receive care from their family members during day-time. Source: HK SWD Homepage

5. COMMUNITY SUPPORT SERVICES FOR THE ELDERLY Source: HK SWD Homepage

6. Support Teams for the Elderly Source: HK SWD Homepage

7. Day Respite Service for Elders 'Day Respite Service for Elders' provides temporary day care service for elders. It serves the objective of providing support and temporary relief for family members or relatives who are the main caregivers of elders requiring a certain degree of personal care whilst residing in the community. It aims at encouraging and helping elders to continue living in the community for as long as possible.'Day Respite Service for Elders' is provided by all subvented day care centres/units for the elderly. Service provision is from 8:00 a.m. to 6:00 p.m. from Mondays to Saturdays, depending on the centres' actual opening hours (closed on public holidays). Applicants may call or approach the day care centres/units for the elderly direct or request referrals through welfare or medical organisations. Source: HK SWD Homepage

8. Integrated Home Care Services Source: HK SWD Homepage

9. Enhanced Home and Community Care Services Source: HK SWD Homepage

10. Carer Support Service Source: HK SWD Homepage

11. Outreach to Hidden Elders The term "hidden elders" does not have a strict definition. It generally refers to elders who are disconnected from the society, do not know how to seek help or support, and are not known to the existing network of community support. The majority of them live alone without the support of family and friends and do not have normal social life and connections. HK Govt Press Release 20070828 LCQ8: Assistance to the unidentified elderly

12. Environment Improvement Scheme for the Elderly To improve the quality of life of needy elders, the Government earmarked a one-off funding of $200 million in the 2008-09 Budget to implement the 'Home Environment Improvement Scheme for the Elderly' (the Scheme) for five years. Its objective is to assist elders who lack financial means and family support to improve their dilapidated homes with poor fittings.  Source: HK SWD Homepage

13. Medical Outreach in PartnershipExamples KCC Elderly Care at Home Project Tai Po Hospital Alice Ho Miu Ling Nethersole Hospital Suicide prevention:LIVE LIFE Community Project for Cold Spell Warning for Senior Citizens and Elderly Living Alone 大埔那打素醫院與社區團體合作，設立「防跌門診」 Outreaching Home Care Services for the Elderly

14. Social Outreach in PartnershipExamples 慈惠服務 百靈鳥~長者生命教育計劃 「關懷裡」計劃於東九龍及沙田兩區推行一站式社區支援及社康拓展服務，為區內長者及護老者提供全天候及具體性的適切服務。

15. CADENZA COMMUNITY PROJECT: Chronic Disease Self-Management Programme (CDSMP)

16. CADENZA COMMUNITY PROJECT: Health-social Partnership Transitional Care Model for Post-discharged Elderly

17. Why Integrating Care?(in partnership) Individual/ client perspective Enhance quality of life and dignity by minimizing decline in abilities, promoting social inclusion and connectedness, and providing choice to stay at home Organization and system perspective Contributes to the sustainability of the health system Bottom line no evidence that a fragmented system works either for individuals or the system Janet M. Lum (2009) Myths, Models & challenges of Integrating Care

18. 合作伙伴關係 • 伙伴關係是指行政獨立的個體組織，通過分享資源、風險、責任和利益以實現共同目標。 • 合作可以減低組織之間的誤解，界限和阻礙（boundaries and barriers）。 • 伙伴合作策略推動跨部門, 界別, 組織, 專業, 服務和功能的協調和合作。 針對複雜社區問題, 需要多方面的界入 。 • 跨界別社區合作方式有多個模式 – 包括透過正規合約和協議監管關係的合作, 和以非正規關係, 透過互信網絡的合作。 • 合作機制立足於相互信任。 梁祖彬(2007)建立社區伙伴: 概念與實踐

19. 合作成功的因素 • 社會及政治環境, 合作歷史, 會員機構特色及文化, 社區背景, 互相信任和專重, 互相依靠需要(inter-dependency) • 合作組織的領導地位, 代表性, 妥協/協調能力, 彈性, 溝通機制(公開及緊密/ 正規及非正規聯繫) • 清楚共同認同的遠象, 方向, 目標和策略, 以社區整體利益為重, 而不是個別界別利益(不是為合作而合作)。有周詳的工作計劃– 需要評估, 目標, 優先次序, 策略, 評估資源需要及動員社區及外界資源, 表現指標及里程碑(milestones) • 領導– 技巧 - 啓發遠景, 鼓動参與, 公平公開處事方式,調解衝突, 建立共識, 尊重及信任伙伴 • 分享資源和資訊 • 伙伴的積極参與 • 公平和公開的辦事方法, 解決和調解機構之間的利益衝突 • 問責和交代機制 梁祖彬(2007)建立社區伙伴: 概念與實踐

20. Reaching OutWho takes the first step?

21. OUR EXPERIENCE

22. Partnership inIntegrated Development • Leadership + strong sense of ownership / mission  continuous innovation, development and improvement • Knowledge transfer + mutual enhancement  sustainability

23. Inside OutBasis of Interdisciplinary Collaboration Insider information – databases of medical and social institutions are the starting points to identify “hidden and high risks” client Insider assessment – professionals hold the key to identify what and whom to collaborate with Insider motivation – Continuous search for better outcomes / frustration at failure helps taking first steps to reach out

24. USER EMPOWERMENT Means to an End also An End in Itself Medical – Social – User Partnership

25. A Caring Community Volunteers Relatives, Friends, Neighbours Community Leaders Community Groups Community Business

26. InstitutionalIntegrated Development 3-leg stool is easy to squeeze in 4-leg chair is sturdy & lasting Initiators Partners Users 3-leg stool 4-leg chair Government Community Partners Users

27. Myth #1: There is one best setting for integrating care No single care setting is the “best” Variety of settings and models that work well • Bring care to people • Bring people to care • Provide care from hospitals to home • Combine care and housing • Provide care on the move at home and work • Individualized funding Janet M. Lum (2009) Myths, Models & challenges of Integrating Care

28. It is good to start with a round table and a stool

29. THANK YOU VERY MUCH!!!