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

cp@cpwong.com