Post on 13-Dec-2015
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CADENZA Symposium 2009CADENZA Symposium 2009Primary Care & Older Persons – Primary Care & Older Persons –
Key to Medical and Social IntegrationKey to Medical and Social Integration99thth October 2009 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
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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.
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Source: Strategic Service Plan of Hospital Authority (2009 – 2012)
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2.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.
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Self-rated Health
Proportion (%)
Age Excellent Very Good Good Fair Poor Unknown/Missing
75 and above
0.9 6.5 27.9 44.2 19.5 1
65 – 74 1.3 9.9 24.6 50.8 13.3 0.1
All Persons
aged 15
and above 2.7 20 36 35.5 5.7 0.2
Source: Population Health Survey 2003 - 2004
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Extent of Limitation in
Accomplishing Moderate Activities Proportion (%)
Age No, Not limited at all
Yes, limited a little
Yes, limited a lot
Unknown/Missing
75 and above 39.3 39.5 19.7 1.4
65 – 74 60.0 31.0 8.7 0.3
All Persons aged 15 and above
84.1 12.6 3.0 0.3
Source: Population Health Survey 2003 - 2004
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Conclusion
1. 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.
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Conclusion
3. The provision of integrated medical and social care service is essential to support the elderly living in the community.
4. 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)
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Preparation for the Demographic Shift
1. Practitioners of Welfare and Health Sector Effort has been made by NGOs to promote co
mmunity-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)
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2. The Elderly
Increase of awareness of the elderly on the need to maintain their health conditions to prepare for positive ageing.
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3. The Community
The public is aware
of the issue and
advocates for
a healthy city.
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Collaborative Projects 1. Aged Support Community Network and
Community Volunteer Service8 NGOs collaborated with HA (HK West Cluster)
2. Hong Kong East Community Network7 NGOs collaborated with Eastern Hospital
3. Fall Prevention Project and Education Project on Hepatitis DiseaseNGOs in Shamshuipo collaborated with CMC
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4. Elderly Suicide Prevention Programme and Psychogeriatric Support Purchased Service
NGOs with Castle Peak Hospital
5. Outreach Service for High Risk Elderly and
Care Plans for Elderly
NGOs collaborated with Tai Po Hospital
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6. Fall Prevention Project Caritas collaborated with the Chinese University to
organize the project at 12 Centres
防跌測試
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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:
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enable early detection and follow up service provide preventive and rehabilitation service provide Integrated and seamless care service
for elderly discharged from hospitals
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2. Outreaching to elderly in the community, especially the deprived
義工量血壓
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3. 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
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4. 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
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5. Engaging the community
Mobilizing support from carers/family, volunteers, community leaders to provide community support.
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6. 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.
7. Mobilization of community resources for health programmes
Support from District Council, Community Investment and Inclusion Fund, donation and NGOs’ resources have been sought.
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Difficulties in Sustaining Collaboration
1. Development of integrated service is piecemeal and fragmented due to lack of long term planning.
2. Rely on the initiatives of the front-line practitioners but without support from policy makers.
3. Formal collaborative networks are lacking in some districts.
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4. Resources provided are on short-term or on project-basis.
5. Insufficient nurses and therapists to provide primary care and rehabilitativeservice.
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Recommendations
1. 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.
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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;
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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.
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2. 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.
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3. The need to adopt information technology to promote primary
health
care
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4. 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.
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徐祥齡在東莞創辦的橫瀝隔坑社區服務中心Source: takungpao.com
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Thank you