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The Experience of a Small

NGO in HK---Mobilizing partners for

better support and care for the elders in

primary medical care

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Background of ELCSS-HK a multi-service NGO established in

1976

District based ( in Shatin , Kwai Chung and Tuen Mun

districts)

About 20 elderly units (and projects), 200 staff members serving the elders

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A Heath Promotion Project

• Conducted in social centre for 16 yrs

In a deprived public Estate

• Services Medical care: eye and foot caring Meals service: 40 Single/hidden

Elders• Supported by JC

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Limitation/ obstacles (in the context of primary care)

• Small in scale;

• Not linked to medical system

• Uniqueness

• Successful project but Not sustainable

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Reflection

• Similar situation of small NGOs today in HK

• How to involve small NGOs to primary care system??

• Primary Medical Care in Social Service

Not a why question! But how?

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Strategy Change of ELCSS-HK

• From single programme to district- base project

• Mobilizing partners for better support and care for the elders in primary medical care

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• (01 至 2003 年機構計劃 ) (key words)

•一條龍地區綜合化 one stop service• 2 4小時加全天候 24 hours•無夾縫兼及早預防 seamless多元化跨專業合作 multi-disciplinary

•身前死後皆無憂 Life/death education

•社會企業起風雲 social enterprise •快閃隱蔽………… ..Hide elders

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Primary Health Care ProjectsMedical Institutes /

Partners

a.

Community Health Care and Fall Prevention Clinic- Fragility Fracture Management for Older Adults社區防跌診所脆骨長者針對性之治療

The Chinese University of Hong Kong ,Prince of Wales Hospital, Shatin中文大學學系醫學院 ,沙田威爾斯醫院

b.

Mental Health Community Clinic- Early Assessment and Treatment, de-labeling精神健康社區診所為長者提供早期評估及治療，免除標籤

Psycho-Geriatric TeamPrince of Wales Hospital, Shatin沙田威爾斯醫院老人精神科外展隊

c.

No Worry Be Peaceful Group- Mutual support group for stable cases of depression (community dwelling older adults), with support from psycho-geriatric nurse and social worker 康寧無憂組為已穩定個案 (抑鬱症 )提供支援

Psycho-Geriatric UnitShatin Hospital沙田醫院老齡精神科

d.

Support Group for Family Caregivers of Demented Elders- Render practical and emotional support in the mutual support and self help group失智症家屬月會於照顧實務及情緒方面提供支援、互助自助

Psycho-Geriatric UnitShatin Hospital沙田醫院老齡精神科

e.

Chronic Disease Self Management Group for Diabetes Mellitus 糖尿病自我管理小組

The Chinese University of Hong Kongand Shatin Hospital中文大學及沙田醫院

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f.

Consultation by Registered TCM Practitioner- free of charge consultation, once a month中醫免費診症為長者提供免費診症及諮詢服務

Society for Promotion of Traditional ChineseMedicine and other Registered TCM

Practitioners中醫促進學會及其他義務中醫師

g.Oasis - Pain Management Project for Elderly「緩痛綠洲」長者痛症管理計劃

Registered TCM Practitioner / Physiotherapist/Occupational Therapist / Specialist on PainManagement / Orthopedic Surgery /Nurse

註冊中醫 / 註冊物理治療師痛症專科醫生 /骨科醫生 /職業治療師 /護士

hProject Life Garden - for elders with depressed symptoms生命花園計劃 -輕度憂鬱

Registered TCM Practitioner- to treat insomnia and depressive symptoms

adopting Auricular Acupressure Therapy (耳穴治療 )

中醫師 (耳穴治療失眠及抑鬱徵狀 )

iIntegrated Discharge Support Programmed for the Elderly Patients (長者離院計劃 )

HA (Tuen Mun Hospital 屯門醫院老人科 )

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理念。目標Rationale &Goal

共識Consensus

Continuous and reciprocal communication

持續，積極溝通

具體運作 (使之可行) Logistics & Operationalisation

Who何人 When何時 What何事 Where何地 How 如何 How much 幾何$

Why為何

-Target 對象

-Partners 伙伴

-Frequency頻密度

-Intensity and Duration 為期多久

-Coverage服務範圍

-Linkage among Parts 環節之間如何配合

-Venue 場地

-Packaging - Promotion & Mobilization -Sustain , Support & Motivate -Recording & Documentation -Feedbackmechanism

-Intersystem and Intra-system

communication

- Make users and family members well informed-Incentives

- Briefing & Debriefing 解說- MeaningMaking

From Rationale to Operationalisation (從理念、目標到實務安排)

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Community Fall & FracturePrevention Centre社區防跌預防中心

(started 2002)• Exercise Class• Tai Chi Practice• Volunteer Group• PT Exercise Class• Walking Aids • Structured and Regular

Programme (package)

• Home Visit• Home Modification• Educational Talk

(started 2008)

Community Healthcare & Fall Prevention Scheme社區保健及防跌計劃( 第三代社區防跌診所 )

Volunteer &

Social Support

義エ及其他支援

Enhanced

Package

增值套餐服務

Health

Programme

健康教育

Vibration

Therapy

震動治療

Community

Clinic

社區診所

Group

小組

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Success factors (proposed future primary care model )

- One-stop service and elders friendly

- Holistic and enhanced care program

-Integrated with existing centre service

-Volunteers and peer support/ family members mobilized

- Community based and centre-based

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- Appropriate Fee charging/incentives

- Targeted : tailor-made for elders having fall history

-Shared record/data

-Research built-in (by university)

- A trans-system collaboration ( hospital, university, private health sector and NGO )

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- Continuous collaboration - Open and learning team

- Solution focused instead of fault finding

- Effective communication/ shared mission for intra and inter systems

- Close collaboration among professionals

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Future Challenges

- Only Individual effort? policy support ?

- Resources implication: manpower, facilities, space of the centre??

-Evidence based?? and How??

-Culture change?? (Shared ownership)

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In sum• In line with the healthcare reform , while

developing basic models for primary care service:

• Social workers are get ready• Small social service units in the district level

should be networked• Linked the preventive care services to the public

health medical system • 12 factors to enhance cooperation are identified

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Thank You