20 years of community geriatric assessment service · mbbs frcp frcpe frcpg fhkam fhkcp specialist...
TRANSCRIPT
20 Years of Community Geriatric Assessment Service
Dr CP Wong JP MBBS FRCP FRCPE FRCPG FHKAM FHKCP
Specialist in Geriatric Medicine Private Practice
Outline
Geriatric Assessment
Breaking the Walls
20 Years of Evolutions
The Future
Geriatric Assessment
A multi-dimensional, inter-disciplinary, diagnostic process used to quantify an older individual’s medical, psychosocial and functional capabilities and problems with the intention of arriving at a comprehensive plan for therapy and long term follow up
Started in 1930 by Dr Marjory Warren, Lionel Cosin and Sir Ferguson Anderson
Geriatric Assessment
Meta analysis of controlled trials of CGA improves:
Mortality
Living condition
Physical and cognitive function
Hospital admissions
Best carried out at Home
Community Geriatric Assessment
Started in Australia in 1980
Community is the Key
There is strong evidence that older people will have better health outcomes if care can be provided in the community, earlier in the course of their illnesses, and immediately upon discharge from hospital.
89 trials including 97,984 persons
13% institutionalization; 6% hospitalization; 10% falls;
physical function
Death rate no change
Beswick et al, Lancet 2008
Ageing Population and Utilization of HA services (2010-2021)
6
13 16
18
33
38
44 38
43
48 52
58 63
0
10
20
30
40
50
60
70
2010 2016 2021
%
Year
Proportion of HA Service Consumed by Elderly Patients (65+)
All patient days
GOPC attendances
SOPC attendances
Projection of HK population aged 65+
2.4x
2.7x
3.6x
715 Homes 73 235 Places
RCHE Residents : Frail and Complex Needs Although only around 7% of elderly are living in RCHEs,
they are the high volume users of HA services & with
complex needs
8
All Elderly Patients
RCHE residents
Non-RCHE residents
% share of Patient Days (All Specialties) 22% 78%
% share of Patient Days (Medical) 31% 69%
Unplanned Readmission Rate (All Specialties)
31% 13%
Unplanned Readmission Rate (Medical) 36% 18%
3x
4.5x
4.5x
5x
Community Geriatric Assessment Service
Start to formulate a conjoint plan in 1991
WCHH Complex in Wong Chuk Hang
CGAT Community Geriatric Assessment Teams
Elderly homes – under SWD Social Welfare Dept
Hospital service – under HA Hospital Authority
Never ending negotiation
7 May 1993
1988
Kwong Wah Hospital Wong Tai Sin Hospital Tung Wah Hospital Tung Wah Eastern Hospital Fung Yiu King Hospital
Pao Siu Loong C&A Home
7 May 1993
1993 Results
39% SOPD 35% AED Attendance 28% Unplanned Readmissions
SHW DO
Funding from Govt
1994: Four CGAS Teams – subvented homes
1997-2001: More funding for private homes
2004: VMO additions
2010: Extension of more homes in KWC
Assessment Team Composition
Geriatrician
Nurse
Physiotherapist
Occupational Therapist
Social Worker
Speech Pathologist, Podiatrist, Dietitian
Regular Team Meeting
Main Roles of CGATs
18
1. Medical & nursing assessment & treatment for high risk elderly residents in RCHEs
2. Interfacing between the medical and social services
3. Community rehabilitation
4. Ensure that placement arrangements are appropriate
5. Promote care quality of RCHEs e.g. carer training, drug management, nursing care practices
6. Infection control & outbreak management
7. Ensure continuity of care between hospitals and RCHEs
Target Patients
Frails residents with complex health problems in elderly homes
Residents just discharged from hospitals
Terminally ill residents
Aims
Help residents to stay in the community with good health
Reduce unnecessary admissions and unplanned readmissions
Provide better support to terminally ill residents
Improve quality of service of elderly homes
Key Milestones of CGAS
Commencement of 8 CGATs firstly to subvented OAHs
Extension of service to Private OAHs
Provide professional advice on infection control and triage of suspected cases A new CGAT/VMO Collaboration Scheme in Residential Care Homes for the Elderly (RCHEs)
CGATs set up in 15 hospitals
21
1994
1997
2003 SARS outbreak
Post SARS
At present
Present Status
15 CGAT Teams
Serves 640 out of 715 Elderly Homes 90%
Annual attendance 637,800 visits
Impact to the Hospital
28% of all total acute hospital admissions in elderly in 2002
18% now after 13 years of CGAT service
50% cumulative admission rate in 6 months
20% of all OPD clinic attendances
Outcomes
54% OPD Clinic FU
19% AED Attendance
22% Ac Hospital Admissions
43% Ac Hospital Bed Days
32% Convalescence Hospital Bed Days
Luk et al J HK Soc Geri 2002 11:5-11
A&E Attendance 99-01 Attendance Rate of Residents in all Homes %
9.59
15.25
12.6413.14
13.7513.1013.40
11.26
10.1710.449.61
11.40
9.74
8.32
7.30
10.27
7.978.35 8.46 8.56
5.84
8.38
6.226.69
8.33
7.32
0
2
4
6
8
10
12
14
16
18
Jul-
99
Aug-
99
Sep-
99
Oct-
99
Nov-
99
Dec-
99
Jan-
00
Feb-
00
Mar-
00
Apr-
00
May-
00
Jun-
00
Jul-
00
Aug-
00
Sep-
00
Oct-
00
Nov-
00
Dec-
00
Jan-
01
Feb-
01
Mar-
01
Apr-
01
May-
01
Jun-
01
Jul-
01
Aug-
01
Unplanned AED Adm 99-01
9.12
12.9211.7411.43
12.7711.6012.5011.46
9.0810.369.87
10.69
8.257.74
5.68
7.867.087.387.65
6.436.027.596.658.008.057.57
0
2
4
6
8
10
12
14
Jul-99
Sep-99
Nov-99
Jan-00
Mar-00
May-00
Jul-00
Sep-00
Nov-00
Jan-01
Mar-01
May-01
Jul-01
Who have benefited?
Benefits
Save transport
Save waiting time
Save Manpower in Escort
Save overcrowding of Out Patient Area
Flexibility in FU
Seen by designated team
Benefits
Acute hospital: earlier discharge
Winter Surge support
Emergency Room consultation
As Case Manager for integration of service and drugs
Lessons to Learn
ONE on ONE
Break the Barriers
Lessons to Learn
Patient Centered Care
Are we doing that well?
Inter-cluster variations
Paper based records
Lousy IT adoption
Mundane routinized service
Home Operators – HA Staff relationships
10% Homes not yet covered
New homes emerging
Growth Trend of RCHEs (Enrollees)
33
14178
58121
0
10000
20000
30000
40000
50000
60000
70000
1985 1990 1995 2000 2005 2010 2015
Total No. of Enrolments
Year
Extension of CGAS to 66 more OAHs in KWC
Pilot 4 CGATs
Additional Funding to cover Private RCHEs
Additional funding for CGAT/VMO Collaboration
Scheme
SARS
Future Development
Bench Marks for Services
IT support
Care Protocols
Symptoms Check List
Cross sector seminars
Extend into End of Life Service
Off Hours Services
Will Integration Smash CGAT?
Integration of Medicine with Geriatrics
Integration of CNS with CGAT
The Key is:
Whether Patient Welfare is put well before Politics
Whether staff are happy in doing their work, instead of working under political pressure
Conclusions
Hong Kong is the only place on earth with full outreached medical service to all Elderly Homes from Public Hospitals
Elderly living in Elderly Homes are at a privilege
One-on-One Seamless Care + Breaking the Barriers + Patient Center Service are Essential
Don’t let Inter-departmental barrier Rebuild the Walls and Smash CGAT
Thank You