Transcript 9oct_1555_Michael_Lai

CADENZA Symposium 2009
“Primary Care & Older Persons –
Key to Medial & Social Integration”
Experience of HK NGOs in primary care :
success, obstacles and future plans.
Michael Lai, JP
Chief Executive Officer
St. James’ Settlement
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)
2. Liaison Service
e.g. Inviting CGAT outreach clinic in DCC、DECC
3. Health Prevention
e.g. Medical Check-up ,dental service, health talks
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 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, 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 :
The Chronic Care Model (CCM)
Health System
Community
Resources and
Policies
SelfManagement
Support
Informed,
Activated
Patient
Health Care Organization
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
Source : Developed by Mac Call Institute (ACP-ASIM Journals and Book)
Why integrate care?
Home &
Community
based social
services?
Primary
Care
PC
Alcohol &
substance
abuse care?
CM
Community
Mental Health
Center
HC
Source : Impact Implementation Care, University of Washington.
15
紅棉單張
Team Members (紅棉計劃)
17
Ongoing Depression Treatment
Health System:
Community
Sai Wan Ho Health Center
SelfManagement
Support:
Decision
Delivery
St. James’ Settlement
Support:
System
Psychiatrist
Design:
office nurse provided
PCP, nurse and review and
info on treatment
care manager all advice on tx
options, readiness
adjust
involved.
intervention, tx
Monthly contact
effectiveness
with pts by phone
assessment
via care manager
Informed,
Activated
Patient
Productive
Interactions
Clinical
Information
Systems
Pt roster with tx
summaries,
feedback to care
team
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes:
Outcome reference from US
80% remission in 2 yrs (40% for usual care)
Higher role functioning
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 groups
e.g. Health Bank, Community Nurse Clinic
Thank you