CADENZA Symposium 2009 Primary Care & Older Persons – Key to Medical and Social Integration

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

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3. 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. Love in the Service of Hope

4. Source: Strategic Service Plan of Hospital Authority (2009 – 2012) Love in the Service of Hope

5. 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. Love in the Service of Hope

6. Self-rated Health Love in the Service of Hope

7. Extent of Limitation in Accomplishing Moderate Activities Love in the Service of Hope

8. Conclusion • 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. Love in the Service of Hope

9. Conclusion • The provision of integrated medical and social care service is essential to support the elderly living in the community. • 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) Love in the Service of Hope

10. Preparation for the Demographic Shift • Practitioners of Welfare and Health Sector Effort has been made by NGOs to promote community-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) Love in the Service of Hope

11. Increase of awareness of the elderly on the need to maintain their health conditions to prepare for positive ageing. • The Elderly Love in the Service of Hope

12. 3. The Community The public is aware of the issue and advocates for a healthy city. Love in the Service of Hope

13. Collaborative Projects 1. Aged Support Community Network and Community Volunteer Service 8 NGOs collaborated with HA (HK West Cluster) 2. Hong Kong East Community Network 7 NGOs collaborated with Eastern Hospital 3. Fall Prevention Project and Education Project on Hepatitis Disease NGOs in Shamshuipo collaborated with CMC Love in the Service of Hope

14. 4. Elderly Suicide Prevention Programme and Psychogeriatric Support Purchased Service NGOs with Castle Peak Hospital • Outreach Service for High Risk Elderly and Care Plans for Elderly NGOs collaborated with Tai Po Hospital Love in the Service of Hope

15. 6. Fall Prevention Project Caritas collaborated with the Chinese University to organize the project at 12 Centres 防跌測試 Love in the Service of Hope

16. 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: Love in the Service of Hope

17. enable early detection and follow up service • provide preventive and rehabilitation service • provide Integrated and seamless care service for elderly discharged from hospitals Love in the Service of Hope

18. Outreaching to elderly in the community, especially the deprived 義工量血壓 Love in the Service of Hope

19. 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 Love in the Service of Hope

20. 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 Love in the Service of Hope

21. 5. Engaging the community Mobilizing support from carers/family, volunteers, community leaders to provide community support. Love in the Service of Hope

22. 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. • Mobilization of community resources for health programmes Support from District Council, Community Investment and Inclusion Fund, donation and NGOs’ resources have been sought. Love in the Service of Hope

23. Difficulties in Sustaining Collaboration • Development of integrated service is piecemeal and fragmented due to lack of long term planning. • Rely on the initiatives of the front-line practitioners but without support from policy makers. 3. Formal collaborative networks are lacking in some districts. Love in the Service of Hope

24. Resources provided are on short-term or on project-basis. • Insufficient nurses and therapists to provide primary care and rehabilitative service. Love in the Service of Hope

25. Recommendations • 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. Love in the Service of Hope

26. 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; Love in the Service of Hope

27. 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. Love in the Service of Hope

28. 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. Love in the Service of Hope

29. The need to adopt information technology to promote primary health care Love in the Service of Hope

30. 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. Love in the Service of Hope

31. 徐祥齡在東莞創辦的橫瀝隔坑社區服務中心 Source: takungpao.com Love in the Service of Hope

32. Thank you Love in the Service of Hope