Primary Care and Older Persons – Key to Medical Social Integration

IntroductionJean Woo

Director, Cadenza Project

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

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

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

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?

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

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

List of diagnoses

• Gastroeosophageal reflux disease

• Ischaemic heart disease

• Chronic obstructive airways disease

• Osteoarthritis of knees; frozen shoulder; osteoporosis with vertebral collapse

• Reactive depression

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

VIDEO

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

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