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Dementia Community Support Scheme智友醫社同行計劃智友醫社同行計劃智友醫社同行計劃智友醫社同行計劃
Medical Social Platform
Dr Carolyn Kng HKEC Service Director (Primary & Community Healthcare)Consultant (Geriatrics), RTSKH
Dr Anna WuHKEC Deputy Service Director(Quality & Safety)Associate Consultant (Psychiatry), PYNEH
Introduction : DCSS Model ( Service Delivery + Medical Social Platform)
Persons with Dementia (PwD) - Journey from HA to DECC
DECC - CARE PACKAGE
MEDICAL SOCIAL COLLABORATION PLATFORM
POST PROGRAM ASSESSMENT
HKEC – Dementia Community Support Scheme (DCSS)
Objectives of Sharing
1. Needs of Persons with Dementia (PwD)
2. Program at DECCs (CFSC)
3. Medical-social collaboration
HA : PYNEH PSY + PYNEH GER + RTSKH GER
6 DECCs
HKEC DCSS – PwD characteristics
21
77
128
9
60-69 70-79 80-89 ≥90
Age group (years)
61
174
Male
Female
Gender (%)
(54%)
(74%)
Apr 17-Sept 17 Referrals: 325
Refusal: 61 (18%)
Early default: 29 (9%)
Attend >5 visits 235 (72%)
73
50
2
110
RH-Ger PY-Ger Other PY-PSY
Referral Source (n= 235)
Ger 126Psy
11858 34 21 4
No BPSD 1 2 3 4 +
Number of Patients with BPSD
233
2
GDS 4 GDS 5
Functional Stage (GDS)
152
73
3 7
Unaided Stick Quad Wheelchair
Walking Aids
225 (95%) walk
unaided or with stick
56
33
28
19
19
18
14
8
6
1
1
1
Apathy
Irritability
Depression
Anxiety
Sleep
Obsessive
Delusion
Appetite
Hallucination
Wandering
Lethargy
Aggressive
BPSD
GDS 4 Mild (233) GDS 5 Moderate (2)
Most
common
50%
HKEC DCSS – PwD characteristics
Chinese Disability Assessment for Dementia (CDAD)
• Average 80.0%
• Initiation, Planning & Organisation, Effective Performance168
67
Less Greater
Carer burden
(Zarit Burden Interview)
ZBI>=41
28 % Greater
Carer Burden
Cognitive test
HK_MoCA
N Valid 197
Missing 39
Mean 14.9
Median 14.0
Std. Deviation 5.6
HKEC DCSS – PwD characteristics
• Identify areas for improving medical-social platform (PF) collaboration
• Nov-Dec 2017 Questionaire (24 items) –
– 20 items with 5 point scale and 4 other items eg open-end
– 6 sections
A. PF Goals
B. PF Support
C. PF Leadership / Communication
D. Daily operations
E. Patient Benefit /Experience
F. Open ended
• Feedback positive from 6 NGOs
Ref : Operational Manual for DCSS
Medical Social Collaboration – How can we improve ?
2.5
3
3.5
4
4.5
5
Goals PF Support Leader. &
Commun.
Daily
Operations
Pt Benefits
and Exp.
Medical Social Collaboration Platform
Medical Social Collaboration – Evaluation
Questionaire : 4 questions with lower ratings
Daily operations
D16. DECC staffs – training
D14. Specialist support for care plan
Taskforce collaboration
C7. participation and commitment
C11. knowledge sharing and learning
Patient Benefits and Experience
3
3.2
3.4
3.6
3.8
4
4.2
4.4
4.6
4.8
5
Q18
Q19
Q20
Q21
Q18. Majority (>80%) of patients benefit from improved motivation and initiation
in the program.
Q19. >80% of patients benefit from improved mood in the program.
Q20. >80% of carers benefit from the carer support in the program.
Q21. >80% of users of the program have positive experience and satisfaction.
Medical Social Collaboration – Evaluation
Journey so far …..
Medical Social Collaboration – Learning TogetherSurvey + Open Feedback
1. Case Selection
• Understand : Patient Needs
• Listen : DECCs capacity
Medical Social Collaboration – Learning Points for SERVICE DELIVERY
DECC
Patients
2. Matching?
DECC strength
Patient needs & strength
Eg
Extensive carer support programs
Strong IT based cognitive training
Eg
Carer Stress
Higher performing educated PwD
Medical Social Collaboration – Learning Points for SERVICE DELIVERY
3. Program flexibility
�Carer interview
�Home visit
�Face to face mandatory?
�Telecommunication acceptable?
Medical Social Collaboration – Learning Points for SERVICE DELIVERY
4. Medical Support - Adhoc / crisis intervention
�Physical or mental problems
�Lack of logistics in operation guideline
Medical Social Collaboration – Learning Points for SERVICE DELIVERY
HKEC Medical Support - Adhoc / crisis intervention
1. Liaise with HA APNs by phone or email
2. Appointments made by Fast Track Clinic or advancing
existing specialty clinic appointment (AED attendance for
urgent matters)
3. Early intervention
4. Prevent admissions
Medical Social Collaboration – Learning Points for SERVICE DELIVERY
5. Post-DCSS support
Extension
program
DECC
regular
activities
DECC-
based
cognitive
training
NEC
Carer
support
service
SFI
cognitive
training
Long
term care
service
Medical Social Collaboration – Learning Points for SERVICE DELIVERY
6. Further program item?
• Advanced care planning (ACP)
�Legal aspects
�Financial assets, consent for medical
treatment, etc
�G.O., EPA…….
Medical Social Collaboration – Learning Points for SERVICE DELIVERY
1. Governance & Participation
Concept
• From Hospital-centric to
• Integrated Person-Centred Service
Practice
• Taskforce learning – questionaire & agenda to increase participation
• Rotating meeting venue
• ‘Download’ is not one way
• Mutual respect & consensus
• Monitoring
Medical Social Collaboration – Learning Points for Collaboration
2. Learning Together from Our Patients
• Overcoming training ‘inadequacy’
• Case sharing forum
• Best practice
• Outcomes sharing
Medical Social Collaboration – Learning Points for Collaboration
AcknowledgmentsDr CC Lau, CCE, HKEC
Dr Beatrice Cheng, HCE, RTSKH
Dr YP Chan, Consultant, PYNEH
HKEC DCSS Team
Ms Patricia Woo & Team
SWD
Chai Wan District Elderly Community Centre, Hong Kong Society for the Aged 香港耆康老人福利會柴灣長者地區中心Fong Shu Chuen District Elderly Community Centre, Tung Wah Group of Hospitals 東華三院方樹泉長者地區中心Ming Yue District Elderly Community Centre, Hong Kong Young Women's Christian Association 香港基督教女青年會明儒松柏社區服務中心Eastern District Elderly Community Centre, Hong Kong Society for the Aged 香港耆康老人福利會東區長者地區中心Wan Chai Methodist Centre for the Seniors 循道衛理灣仔長者服務中心Wan Chai District Elderly Community Centre, St. James' Settlement 聖雅各福群會灣仔長者地區中心
Dementia Community Support Scheme「智友醫社同行計劃」
Shun On District Elderly Community CenterTrue Light Villa District Elderly Community Center
17th Jan 2018
Background Information
Review Committee on Mental Health Expert Group on Dementia Develop a medical-social collaboration model to mild to moderate dementia Enhance functioning level, quality of life and better support the caregivers Roles of DECC Service arrangement Case referrals Arranging case conferences Reporting progress of programme implementation Operation logistics
Target Participants HA’s patients of having mild or moderate dementia DECC members who are suspected early dementia
Pilot Scheme February 2017 to January 2019
Medical Social Collaboration Model 1
1 - Operations Guideline on DCSS Version1.2
Programme Design
Training Modules
Updated Cases Status
HA
Cluster
Centre
Name
Total No.
of
Referral
No. of cases
receiving
booster
programme
No. of cases
Early default
No. of cases
completed
training
Kowloon
East
True Light Villa
DECC72 5 7 22
Kowloon
EastShun On DECC 43 8 10 13
Total 115 13 17 35
Updated Cases Status
7%
41%46%
6%
Age Group
60-69
70-79
80-89
>90
71
44
0 20 40 60 80
FEMALE
MALE
Gender
52
63
GERI PSY
Referral Source
Achievement – Collaboration with HA
As a bridge from medical to social networkAs a non-pharmacological treatmentBuild up good communication with APN on case managementCase conference as a feedback system to share information
Design care plan execute + home visit further discussionHolistic approach through different professionals perspectiveEarly intervention on case crisisMake referral according clients social needs e.g. LTC , specific
day care centre, etc.
Achievement – Elders & Caregivers
Elders Perspective Develop structure lifestyle activity programmeTo mobilize clients re-connect with the communityStart up new relationship and have time of enjoymentRe-define their own disease
Caregivers PerspectiveRelief caregivers stressEnriched the knowledge on dementiaBuild up support network of caregiversCommunity resources awarenessEarly intervention on case crisisSmooth transition to other Community Care ServiceAdvice on financial issue e.g. EPA (Enduring Power of Attorney)
Achievement – DECC
Capacity Building of DECCNew stimulus from different health professionalsDevelop extension programme for DCSS eldersStrengthen the community network and partnership of DECC Increase membership of elders and caregivers
Looking Forward
Social awareness of dementiaEnhance care support to old age caregivers
e.g. escort serviceSharing of information e.g. EHRSSAdvance care planning?