Transcript Long Term Care in Hong Kong: Is quality care affordable?

Ageing populations:
Implications for Hong Kong
Jean Woo, Cadenza Project Director
Faculty of Medicine,
The Chinese University of Hong Kong
and
Faculty of Social Science,
University of Hong Kong
Topics covered
• Desired outcomes for people who are ageing:
Health
Financial security
Engagement in society
• Adaptations from health and social services
• Contributions to these topics from work
supported by Cadenza
Health
• Top three causes of mortality are cancer,
cardiovascular diseases, and pneumonia
• Heart failure, chronic obstructive pulmonary
diseases and stroke account for the largest
proportion of patient bed days in the Hospital
Authority
• Dementia affects 6% of people aged 70 and over.
And the incidence is approximately 1% among
those aged 65 years and over, while the
prevalence of cognitive impairment is
approximately 15%
The ideal situation
•
•
•
•
Increasing life expectancy
No increase in disease incidence
Decreasing disability
Little disparities
Engagement in society
• Between 1991 and 2005, the percentage
of people aged 65 and over still
participating in the work force fell from
12.8% to 5.4%
• Psychosocial consequence of enforced
exit from the work force?
• Work stress impacts on health, but there is
little understanding of stress associated
with retirement
Finance
• Regional disparities in health and mortality
Figure from SF-12 thematic Household
survey, and HHSRF mortality data
Due to income, education, health service
access, air pollution, neighbourhood
deprivation….
Survey: Understanding of
Elderly Issues
• Objectives:
– To examine
• The image we have about the elderly
• Whether we know how to take care of our elders
• Method:
– Questionnaire
• Face-to-face interview
• Self-administer (web-based, paper and pencil)
• Participants:
– N = 2,694
Survey Findings: Image of the Elderly
% “Agree”
Questions
Elderly
Age 65+
Carer
Age 50+
Adult
Age 1849
Hospital
Professional
Undergraduate
Professional
n=580
n=413
n=808
n=322
n=339
71
70
59
51
48
• Most elderly people think positively
like when they were young
34
30
14
13
18
• Except physical work, most elderly
people can work like a youngster
33
44
56
57
59
• Elderly people should give way to
younger workers
76
64
14
16
13
• Most elderly people are unhappy
Survey Findings: health literacy and
carer skills
% “Agree”
Questions
Elderly
Age 65+
Carer
Age 50+
Adult
Age 1849
Hospital
Professional
Undergraduate
Professional
n=580
n=413
n=808
n=322
n=339
• Most elderly people’s teeth
would fall out
95
93
73
78
65
• If my family member becomes
demented, I know how to take
care of him/her
24
27
17
43
20
• Regarding health, only the
doctor will be able to tell elderly
people what to do
60
50
15
11
5
• I know where to go to get help
for the elderly
48
54
43
56
58
Summary of knowledge and
misconception survey
• Considerable knowledge
deficiency/misconception and negative attitude
in these areas, among all ages and among
professionals working in hospitals and students
of these professions
• Misconceptions more marked among older
people
• 94-97% of all respondents express wish to
discuss care plan with health professionals and
their families in end of life situations
Understanding of elderly issues
• Optimizing mental and physical function
• Ageism
• Knowledge of services and how we can
help ourselves
• Living environment
• Quality of dying
• Legal and financial issues
Importance of Informal Care
• Informal caregiving can add to the quality
of care in both domestic households and
residential living
• Community based informal care services
can also help decrease the need for
institutionalization
The Challenges of Building a
Sustainable Pool of Informal Carers
• Major caregivers for non-institutionalized
seniors tend to be “informal” carers
• Population structures that are already in
place have implications for the future
supply of the pool of informal caregivers
• The interface between formal and informal
care may also shift as population ageing
continues and place a greater demand on
support services
Strategies to Strengthen the role of
Informal Caregiving
• Empowerment
• Education
• Training
• Mixing and matching formal and
informal care
Reference:
Chau P.H., Yen E. and Woo J. Caring for the Oldest Old: "Mixing and Matching” Informal and
Formal Caregiving, British Medical Journal, 2007 Available at
http://www.bmj.com/cgi/eletters/334/7593/570#164600
Public Education
• Theme for 2008: Empowerment
Acquiring knowledge and skill to help
ourselves, targetting the areas
identified in the survey
• Strategy for knowledge and skill
diffusion:
radio, TV, newspaper, public education
fair, exhibitions, school events
Public Education: exploring
effective strategies
• Supermarket tours
Use universal settings that people can identify with
Active participation in educational event
Subsequent behavioural modification and diffusion of
knowledge
Involvement of the family unit
Cadenza Training Programme
Target
group
General
public
Informal
caregiver
Social and
health care
professionals
Training • Roadshows • Workshops • SelfActivities • Public
directed
• Site visit
web-based
seminars
• Self-help
course
• Carnivals
group
• Seminar
• Educational
• Clinical visit
leaflets
Cadenza Training Programme
Courses in May-June 2008
- Public seminar for general public
* Roads to a fulfilling and prosperous life at later year
- Workshops for informal caregiver
* Theme: Promoting health of older people in community
- Web-based course for professional
* Successful aging & intergenerational solidarity
Service needs from the
user’s perspective
• Results from focus groups
• Results from community survey of
people requiring long term care
discharged from hospitals
• Results from survey of End Of Life
care
Focus groups
• Elderly group (from NGOs; n=24;mean
age 65y)
- barriers to accessing government
services; concern regarding fees; lack of
trust of effectiveness of ‘cheap’
medications
-staff attitude (not helpful or friendly; not
caring)
-poor quality of private old age homes
Focus groups
• Service providers: n=24, two groups of health
and social care disciplines each
- service gaps (poor integration, interorganizational barrier and poor accessibility
- strategies towards prevention of deterioration
needed
- training for professionals: target negative
perceptions
- public education: health literacy and
empowerment
Community survey of those
requiring long term care
• 707 elderly people aged 65 years and over living
at home requiring carer, and 705 carers in NTE
and HKW
• Main factors influencing choice for opting for old
age homes were: impaired function, dementia,
depression, those already receiving community
services
• Education level, income geographic region,
knowledge of and accessibility to community
services did not influence preference.
End of life care
• Patients with chronic non-cancer diseases such
as gradual organ failure (heart, lung, kidney, liver,
degenerative neurological conditions )
• Cross sectional survey (n=75, mean age 84y),
showed common occurrence of symptoms :
limb weakness(92%); oedema(85%); fatigue
(85%); dysphagia (58%); pain 48%.
Some staff found it difficult to discuss EOL
issues with patients and relatives
• There is room for improvement in staff training in
this area
Service needs form the users’
perspective
• Seamless one stop service provided in a
transdisciplinary way, using a case
management approach
• Designed from the user’s perspective
• Covers health maintenance; how to cope
with living with various chronic diseases;
mental health support
• Cost effectiveness and cost benefit analysis
Management of chronic
diseases in ageing populations
Common themes in response
• Health promotion
• Self-management: concept of expert
patients
• Care/disease management: high risk
• Case management: high complexity
• Knowledge management: population
needs assessment, service planning
Care of the elderly: special features
• Requires a multi-faceted approach (physical,
functional, psychological, nutritional, social)
• Involves multiple health and social care
providers
• Presentation with the geriatric syndromes
(falls, incontinence, immobility, dementia)
• Focus on multiple co-morbidities and the
concept of frailty, rather than on individual
diseases
Current situation in Hong Kong
• Services heavily hospital based, resulting in
limited accessibility as well as increased costs
• Poor continuity of care
• Community self-help poorly developed
• Emerging needs of elderly living in residential
care homes
• Palliative care in all settings poorly developed
• Multiple service providers (SWD, DH, HA, CRN,
NGOs, private sector: interface less than ideal)
Current situation (cont)
• Increasing financial burden on healthcare
systems
• Sustainability likely depend on active
participation by individuals, both for
prevention and management
• Absence of a primary care system to
reduce demands on secondary and
tertiary care
New approaches
• Patients
Perception of illness, empowerment, compliance
• Professionals
Use of non-medical professionals; trans disciplinary
approaches
• Systems
Case management; community settings and group
activities to promote self-management, compliance with
treatment, lifestyle modification, through motivational and
behavioural changes
Self-management
• Programmes designed to help patients manage
symptoms and contain health care resource
utilization
• Systematic review:
71 trials of variable methods and standards;
publication bias. Small to moderate effects
shown for selected chronic diseases eg.diabetes
and asthma. ( Warsi a et al. Arch intern Med 2004; 164: 16411649)
• Not targetted towards multiple diseases/frailty
Major barriers to be addressed
in promoting self management
• Patient factors: need to emphasize retention:
programme needs to take into account cultural,
linguistic, access and convenience factors
• Professional factors: need for cultural change
away from medical model of management; need
to present convincing evidence of beneficial
outcome relating to disease management; need
to address financial support and sustainability
issues within an existing health and social
services framework
Current evidence regarding self
management programmes
• Use of toolkits for self-management may have
potential financial and clinical benefits (DeMonaco et
al PLOS Medicine April 2007 Vol4 Issue 4)
• Expert patient (lay-led) education programmes:
6 week CDSMP: mainly disease based. UK
target to cover 100,000 patients by 2010.
4 RCTs in the UK showed that patients’
confidence is increased but use of health care
resources were not reduced. (Griffiths C et al, BMJ 2007
334:1254-6)
Role of professionals
• Stepped care approach, with broad community
coverage by health professionals other than
doctors: Case manager liasing with GPs or
specialist nurses, supported by Consultants
• Nurses as leaders in chronic care, especially in
end of life care, adopting the principle of patient
centred supportive care: understanding patients’
perspectives
• Shift from disciplines/organization- centred
towards patient centred approach
System change?
The problem with guidelines and
standards in chronic disease
management
• Lack of evidence: difficulty in recruiting
frail elderly people into RCTs
• ‘Clinical trial evidence is shamelessly
extrapolated across time, population
subgroup, and condition: The Road To
Hell’ Iona Heath. BMJ 2007;335: 1185
Case management
• US Evercare model
Collaboration with GPs,other health and
social care professionals in primary care,
expanded nursing role in proactive
managed care for patients at high risk for
repeated hospital admissions and decline
in function, using a team based approach,
risk stratification using predictive tools to
identify high risk patients, selfmanagement and motivational interviewing
Outcomes of the case
management approach
• Evercare model: Fewer hospitalizations and
fewer prescription drugs; maintaining high levels
of patients satisfaction; no change in mortality
• For long stay nursing home residents, nurse
practitioner led programs in primary care has a
major effect in allowing cases to be managed
more effectively
(Kane R et al. J Am Geriatr Soc 2003;51:1427-34
• Hong Kong data (1980s): nurse led case
management of patients discharged from
hospital showed demonstrable benefits
(Mackenzie &Lee)
Adoption of the Evercare model
by the NHS in the UK
• ‘Community matrons’. Need to be fully
integrated into primary care
• Conflicting views on usefulness
“Evidence is weak for case management
for the elderly: unlikely to provide an off
the shelf solution to achieving the required
reductions in emergency admissions”
(www.kingsfund.org.uk/pdf/casemanagment.
pdf)
Adaptation of these principles
to the ageing population
• Programmes for chronic diseases as well
as frailty syndromes
• Functional, social, psychological,
nutritional, dimensions need to be
incorporated
• Patient as part of discrete social network
• Main outcome is ‘maintenance’ rather than
‘restorative’ with respect to function; and
maximizing quality of life
Advantages of group programmes
among the elderly population
• Mutual support
• Incorporate as regular social activity, and
therefore enjoyable, and not episodic
‘classes’ or rehabilitation’ programme
• Setting allows constant reinforcement of
information, and correction of
misconceptions
• Lower cost than one to one interaction
What has been done in
Hong Kong so far
• Community models in groups, led by team of
nurse/allied health/lay people, in partnership
with NGOs, for:
OA ( Wong YK et al. J Telemed Telecare 2005:11:310-315)
Stroke (Lai JCK et al. J Telemed Telecare 2004;10:199-205)
DM ( Chan WM et al. Applied Nurs Res 2005:18:77-81)
Dementia (Poon P et al. Int J Geriatr Psychiatr 2005;20:285-6)
Incontinence (Hui E et al. J Telemed Telecare 2006;12:343-7)
COPD (Woo J et al. J Eval Clin Prac 2006;12:523-31)
CHF (Hui E et al. Disabil Rehab 2006;28: 1491-7)
CDSMP
Summary of results
• Enthusiastic feedback, desire for
programmes to continue
• Demonstrable objective health and
psychosocial outcomes
• Healthcare professionals do not refer; do
not belief it has any place in the system
• Social care sector: not confident in getting
involved in ‘medical’ activities: concerns
regarding legal liabilities etc
Hospitals and OPD
Counselling
Day hospitals
Home care
Wellness Centre
Needs based case
management to
maintain
community living
Carer support
Community
rehabilitation network
Community geriatric
and psychogeriatic
outreach teams
• Healthy Lifestyle – healthy eating
and exercise for health
• Learning – Various interest groups
• Chronic disease management and
groups for health maintenance
Financial assistance
Community nurses and
allied health
Useful services: self-financing and
potentially income generating
•
•
•
•
Employment agency
Skills register for useful home services
OT & PT Aids
Dental
Primary Care
Average number of attendance at A&E Departments
- by age group
Average no. of attendance
7
6
0-4
5-15
16-24
5
4
25-44
45-64
65-74
75-84
85+
3
2
1
0
3 years before death
2 years before death
1 year before death
Primary Care
Average inpatient length of stay
- by age group
Average length of stay (days)
130
120
110
0-4
5-15
16 - 24
100
90
25 - 44
45 - 64
65 - 74
75 - 84
85+
80
70
60
50
40
30
3 years before death
2 years before death
1 year before death
The approach to aging
populations: summary
• Health literacy and
empowerment
• Emphasis on maintenance of
health and function and quality
of life (and of dying) rather than
curative/restorative goals
• System and culture change
towards and effective seamless
primary care