Primary Care and Older Persons – Key to Medical Social Integration

1. Primary Care and Older Persons – Key to Medical Social Integration Introduction Jean Woo Director, Cadenza Project

2. Re-inventing primary health care: the need for systems integration • ‘…..developing primary care networks that are seamlessly integrated into the rest of the health system.’Julio Frenk.Lancet 2009; 374:170-173

3. Cadenza: promoting an elder-friendly Hong Kong • Impact of an ageing population on health and social services- chronic disease burden; Multi-morbidity- organ system v. patient centred approach- fragmentation v. integration of multiple services • How should we structure our services? The primary care setting has to be key • Two case studies to set the scene: illustration of the current piecemeal response to the ageing society and lack of coherent policies

4. Case One • F 80 years. Resident of Old Age Home • Presented to A&E with fall, and screened as part of a one year research project on study of profile of fallers presenting at A&E • Depression screen positive • Goes out to swim daily and goes to social centre • Fell while standing on one leg in the park

5. Case One • No one able to talk in OAH: all her friends have died in the 10 year period since moving in • Need to be back early evening: regimented existence • Health talks result in anxiety: ‘Do I have the disease?’ • Who can help her?

6. Case Two • F 80 referred to Geriatric Clinic by Integrated Clinic: ? Ischaemic heart disease. • List of complaints:-Chest pressure and shortness of breath on walking about 10 min, relieved by rest(1 year)-chronic sputum producer for many years: current smoker-Right should pain, left knee pain, back pain limiting movements (I year)-Left 4th trigger finger- Lump in abdomen when standing up:hernia awaiting surgical consultation- -Requests euthanasia:burden to society: no one cares and no one helps; long waiting list for multiple clinics; no medications; bad experience in A&E

7. Case Two • Cannot eat a lot: chest pressure after more than half a bowl of rice • Lives with unemployed daughter: lost husband, second daughter and grand child in recent years. • On CSSA $2330 per month • Son gives her a mobile phone but she only answers if it is from her son’s phone number. Does not know how to use telephone booking • Difficulty in rising from chair and getting out of bed. Walks with a limp; cannot lift arm above shoulder level. Protrusion of abdominal contents on standing up

8. List of diagnoses • Gastroeosophageal reflux disease • Ischaemic heart disease • Chronic obstructive airways disease • Osteoarthritis of knees; frozen shoulder; osteoporosis with vertebral collapse • Reactive depression

9. Geriatric Day Hospital • Sorting out multiple medical and social problems in one place • ‘Therapeutic video’…requested a repeat! • Little complaint of pain • Revealed new problem of urinary incontinence for which she was too embarrassed to mention to doctor • Used humour frequently as a coping strategy

10. VIDEO

11. Summary points of video • Sharp health and social commentary on all the current ills of our society! Inadequacies of current health and social services to deal with a not uncommon situation • No one takes ownership of her care • Services not achieving its aim of helping, although intentions are good • Service providers not attuned to needs; lack of humanistic response and empathy; over-reliance on technology and processes • Depression and higher suicide rates in the elderly not surprising

12. Exploration of solutions in the primary care setting • Management of chronic diseases • Role of social services • Social services: success and obstacles • Caregivers; psychological problems; outreach support; self-management; family doctor’s perspective • Development of models of primary care for the elderly