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?