Hong Kong's Health System

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1 Hong Kong's Health System Gabriel M. Leung, John Bacon-Shone Published by Hong Kong University Press, HKU Leung, M. & Bacon-Shone, John. Hong Kong's Health System: Reflections, Perspectives and Visions. Hong Kong: Hong Kong University Press, HKU, Project MUSE., For additional information about this book No institutional affiliation (9 Jan :58 GMT)

2 CHAPTER 11 Long-Term Care and Care for the Elderly Chu Leung-Wing and Iris Chi Chu Leung-Wing, Chief of Geriatric Medicine at Queen Mary, and Iris Chi, a social work and gerontology professor at the University of Hong Kong, and, most recently, at the University of Southern California, give an insightful account of the long-term care needs and directions for change that would be necessary to satisfy demand as a result of the demographic transition that Paul Yip and colleagues highlight in Chapter 4. Neither the Harvard Report nor the government s 2001 consultation document examined the issues of longterm care closely. Chu and Chi s chapter fills this gap. They identify the root problem as being a fragmented care system which does not take into account the patient-centred principle that is required by the nature of long-term care. Drawing on a wide array of international examples, they argue persuasively for an integrated long-term health and social care policy that is coherent and engages with the acute care sector, rather than considering each in isolation, as has been the case previously. Ultimately, Chu and Chi come to the same conclusion as other authors in this book that the financing of reform underpins the success or failure of any long-term care strategy, and call on the government to examine overseas experience such as Japan s newly consolidated long-term care insurance programme. Introduction The Elderly Population in Hong Kong In 2004, 0.82 million people in Hong Kong were aged 65 years and over, which represents 11.7% of the population. The proportion of elderly people in Hong Kong is likely to increase to 24% in 2031, which will create enormous demand for long-term care and health care services for the elderly. This demographic

3 224 Hong Kong s Health System: Reflections, Perspectives and Visions change is related to a decrease in birth in Hong Kong (Census and Statistic Department, 2002; Authority, 2003). The elderly dependency ratio will increase from 382 in 2001 to 562 in The average life expectancy at birth in Hong Kong in 2001 was 78.2 years for men and 84.1 years for women. Closely related to the health care needs of the elderly is the life expectancy at and above 60 years old. In 2001, the average life expectancy at 60 was 21.4 years for men and 26.0 years for women, and at 80 was 8.1 years for men and 10.6 years for women (Census and Statistic Department, 2002). The increased life expectancy results from an improvement in public health and nutrition, but is also related to improved medical care for very elderly patients ( Authority, 2003). However, improved survival may not mean normal health without disability or functional improvement. Elderly people have multiple chronic diseases, functional impairments and need regular medical services (Chu et al., 1998; Woo et al., 1997). The Health and Long-Term Care System for the Elderly All Hong Kong citizens are entitled to inexpensive health and social care services. Moreover, for those who benefit from the Comprehensive Social Security Allowance scheme, the service fees are waived a scenario that is very common among frail elderly patients in hospitals. As a result of escalating health care costs and an ageing population, the Authority now has an annual budget deficit of $601 million per year ( Authority, 2004). The Social Welfare Department is responsible for the policy and funding of social services. At present, social services for the elderly are categorised into community support (non-residential) and residential care services ( Authority, 2004; accessed on 12 July 2004) (Table 1). In the past, long-term care services for the elderly referred primarily to residential care services, which were largely provided by non-government organisations. Over the past decade, the private old age home industry has been developing rapidly, and private old age homes now form the main service group for residential care homes for the elderly in Hong Kong. Meal delivery and personal care services are the key non-residential homecare services available to elderly people who live in their own homes. The great demand for long-term residential care services has been a problem for many years, and the problem is increasing. At present, institutional care is quite commonly utilised, and approximately 8% of the Hong Kong elderly now reside in residential care homes and hospital infirmaries ( Authority, 2004; text_eng/ser_sec/ser_elder/index.html accessed on 12 July 2004.). The majority of residential care homes in Hong Kong are low quality private old age homes, and a minority are government subvented care and attention homes and selffinancing homes (Table 2).

4 Long-Term Care and Care for the Elderly 225 Table 1 Long-term Care for the Elderly in Hong Kong Spectrum of Long-term Care Services for the Elderly A. Community Support Services for the Elderly* 1. Family services** 2. Neighbourhood Elderly Centres 3. Social Centres for the Elderly 4. District Elderly Community Centres 5. Day Care Centres, which include general care for the demented elderly 6. Home Help Services 7. Enhanced Home Care Services 8. Support Team for the Elderly through a volunteer network 9. Carers Support Centre B. Residential Care Services for the Elderly* Residential Care Homes for the Elderly 1. Self-care Hostels for the Elderly 2. Homes for the Aged 3. Subvented Care and Attention Homes 4. Residential Care Homes for the Elderly Pilot Project on Continuum of Care 5. Private old age homes including Bought Place Scheme and Enhanced Bought Place Scheme 6. Infirmary (under the Authority) Notes: *Applicants are assessed by the MDS-HC (Standardised Care Assessment Mechanism for Elderly Services); ** family services include Comprehensive Social Security Scheme, Disability Allowance and Higher Disability Allowance. Alternative health and long-term care service models for the elderly with appropriate health financing policies are urgently needed. Effective solutions should be explored and implemented in the near future to avoid catastrophic incidents in both health and social care services for the elderly. Care Services for the Elderly Disease Burden of the Elderly in the Community At present, the main killer diseases in the elderly population include cancer, heart disease and pneumonia, and the main chronic diseases include arthritis, hypertension and diabetes mellitus (Leung and Lo, 1997; Chu et al., 2004; Chiu et al., 1998; Lau and Lok, 1997) (Table 3).

5 226 Hong Kong s Health System: Reflections, Perspectives and Visions Table 2 Long-term Care for the Elderly: Institutional Care in Hong Kong Residential Care Homes for the Elderly under the Social Welfare Department (1 to 5) and the Authority (6) Number of Elderly 1. Hostels for the Elderly Homes for the Elderly (Homes for the Aged) 7, Subvented Care and Attention Homes 11, Self-financing homes 3,203 (16 in Hostels, 1,108 in Homes for the Elderly and 1,945 in Care and Attention Homes) 5. Nursing Homes 1, Infirmary 2, Private old aged homes (approx.) 41,000 Total = 67,161(8.19% of the elderly population*) * Note: 65+ elderly population = 0.82 million in 2004 Waiting time as at June Hostels for the elderly: 18 months. Total of 5 applicants waiting. 2. Homes for the aged: 23 months. Total of 1,671 applicants waiting 3. Subvented Care and Attention homes: 31 months. Total of 16,631 applicants waiting. 4. Enhanced Bought Place Scheme in private old age homes: 12 months. (Total number of applicants waiting = same list as subvented care and attention homes) 5. Nursing Home: 40 months. Total of 5,265 applicants waiting. 6. Infirmary: 32 months. Total of 4,458 applicants waiting. 7. Private old aged homes. Total of 0 applicants waiting. Grand total = 28,030 applicants waiting Note: Numbers based on data from March to June 2004 Issues in Primary Health Care in the Elderly Primary health care for the general population is largely provided by the private sector, and the government is responsible for approximately 10% of this service through general out-patient clinics. The proportion of private doctor consultation for the elderly is less than that for the young, and approximately 70% of elderly people consult general out-patient clinics for primary health care problems (Census and Statistics Department, 2001). Most of the patients that attend these clinics are either old or poor. Primary care providers are mostly private doctors who manage episodic health problems well, but are inexperienced in detecting and managing chronic geriatric problems. For example, dementia is sometimes dismissed as normal ageing phenomenon without appropriate investigation and treatment.

6 Long-Term Care and Care for the Elderly 227 Table 3 Causes of Death and Common Chronic Diseases in the Elderly Top killer diseases in the elderly in 2001 ( Authority Statistical Report ), ( Authority Statistical Report ) 1. Cancer 2. Heart disease 3. Pneumonia 4. Cerebrovascular diseases (stroke) 5. Chronic lower respiratory disease 6. Kidney diseases (nephritis, nephrotic syndrome, etc.) 7. Diabetes mellitus 8. Injury and poisoning Common chronic diseases (Leung and Lo, 1997), (Chu et al., 2004), (Chiu et al., 1998), (Lau and Lok, 1997) 1. Arthritis ( %) 2. Hypertension (32 33%) 3. Fracture (17.1%) 4. Peptic ulcers ( %) 5. Diabetes mellitus ( %) 6. Coronary heart disease ( %) 7. Hyperlipidaemia (7.4%) 8. Dementia (6.1%) 9. Hyperthyroidism (6.1%) 10. Chronic obstructive airway disease ( %) 11. Stroke ( %) 12. Asthma (3.0%) Health promotion to improve lifestyle (e.g., stopping smoking, maintaining a healthy diet and exercising), disease prevention (e.g., fall prevention and influenza vaccination for the elderly) and the early identification and control of chronic diseases are important. These measures would improve the health of the whole population and decrease geriatric health and long-term care needs in the years to come. The Elderly Health Service of the Department of Health provides health promotion programmes for members of its Elderly Health centres. However, no data regarding improvement in the health status of the elderly as a result of these programmes have been reported. Moreover, elderly citizens who are not members of these centres do not have access to the programmes. Present Organisation of Care for the Elderly care for the elderly is a continuum, with cyclic fluctuations from acute to sub-acute conditions and rehabilitation, pre-discharge planning and post-

7 228 Hong Kong s Health System: Reflections, Perspectives and Visions discharge care. The latter should bridge seamlessly with community health and long-term care services. The main objectives of hospital medical care for the elderly are diagnostic assessment, the treatment of moderate or severe illness and the subsequent rehabilitation to pre-morbid health and functional status. Independent or supported quality living in the community after discharge is the goal. Over 90% of the hospital care and specialist medical care for the elderly is provided by the Authority (Chu et al., 1998). Nearly all frail elderly people who live in old age homes go to Authority hospitals if they need hospital care (Leung et al., 2000; Luk et al., 2002). It is important to realise that elderly patients consume a large proportion of the Authority s in-patient services. Although elderly people aged 65 years and above only comprised 11.4% of the Hong Kong population in 2002, they consumed 52.1% of the Authority s in-patient services (n = 11,021 on 31 March 2002). This proportion has progressively increased, and is much higher than the corresponding figures of 46.8% in September 2000 and 49.9% on 31 March This is a result of the ageing population and the very low fees for public in-patient and specialist outpatient services compared to similar services in private hospitals. The majority of residents in private old aged homes benefit from the Comprehensive Social Security Allowance Scheme (Health and Welfare Bureau, 1997). In the past, there was a tendency by residents of residential care homes to over-use in-patient services, but this has improved since the provision of outreach geriatric services through the Community Geriatrics Assessment Team service (Luk et al., 2002). In Hong Kong, hospital care for the elderly is functionally divided into acute hospital, sub-acute hospital (convalescent and rehabilitation) and long-stay hospital (infirmary) care services (Figure 1). In 2004, there were seven hospital clusters in Hong Kong. Every hospital cluster has one or more accident and emergency department in the acute hospitals. Some hospitals have both acute Levels of Care Acute Care Transitional care* Subacute Care (Extended Care or Intermediate Care) Transitional care* Long-stay Care (Infirmary Care) *Bridging community health and long-term care services Figure 1 care for the elderly

8 Long-Term Care and Care for the Elderly 229 care and convalescent and rehabilitation wards. However, in most acute hospitals, the convalescent and rehabilitation wards for elderly patients are located in the extended care hospitals in the same cluster. Elderly patients are often transferred to these facilities for step-down convalescence, rehabilitation and discharge planning (Table 4). Table 4 Acute and Extended (Sub-acute/Rehabilitation) Care s in Hong Kong Cluster Acute care Extended care Long-stay infirmary Hong Kong West Queen Mary Fung Yiu King Fung Yiu King Tung Wah Tung Wah Grantham (Respiratory infirmary) Hong Kong East Ruttonjee & Tang Tung Wah East Ruttonjee & Tang Siu Siu Kin Wong Chuk Hang Kin Pamela Youde Tung Wah East Nethersole Eastern St. John Cheshire Home, Wong Chuk Hang Chung Hom Kok St. John Cheshire Home, Chung Hom Kok Kowloon East United Christian Haven of Hope Haven of Hope Tseung Kwan O Kowloon West Princess Margaret Our Lady of Maryknoll Princess Margaret Caritas Medical Centre Wong Tai Sin Caritas Medical Centre Kwong Wah Yan Chai Our Lady of Maryknoll Yan Chai Wong Tai Sin Yan Chai Kowloon Central Queen Elizabeth Kowloon Kowloon Hong Kong Buddhist New Territories Prince of Wales Shatin Shatin East Tai Po Tai Po Alice Ho Miu Ling Cheshire Home, Shatin Nethersole North District New Territories Tuen Mun Pok Oi Pok Oi West

9 230 Hong Kong s Health System: Reflections, Perspectives and Visions The majority of elderly patients with acute conditions are admitted after consultations at accident and emergency departments. The diagnostic procedures that are followed include history taking, physical examination, laboratory investigations, radiological procedures, urgent treatment and acute and sub-acute management. For subsequent rehabilitation, discharge problems and long-term management, elderly patients are often transferred to sub-acute geriatric or rehabilitation wards in the same hospital, or to extended care hospitals within the same cluster (Table 4). Drawbacks of the Present Organisation of Care for the Elderly The current acute hospital care model is primarily organ and discipline-based. The service model is principally organised by specialty and sub-specialty, and is department-based. Cross-specialty and allied health services are provided on a consultation or referral basis, and laboratory and radiology support services are arranged according to the judgments of the primary clinical team. This type of service model, which originated in the historical clinical service model for handling acute infective outbreaks at the turn of the century, is appropriate for acute infective illnesses or acute diseases without chronic disability. The hospital ward environment (the hospital bed and the layout of the accessory facilities) is also primarily designed for professional care purposes, and not from the perspective of the frail elderly patient. For example, bedside rails are usually pulled up to prevent falls, but unfortunately falling from the bed when climbing over the bed rails actually increases the chance of serious injury. The presence of multiple pathologies in elderly patients means that the traditional approach to diagnosis and management, which aims to make a single diagnosis in the young patient, is frequently inappropriate. Approximately 70% to 80% of the elderly have more than one diagnosis (Chu et al., 1998; Woo et al., 1997; Leung and Lo, 1997; Chu et al., 2004; Census and Statistics Department, 2002; Chu et al., 2003). Most patients have multiple diseases, which may or may not have been diagnosed previously (Chu et al., 1998). In acute hospitals, the early diagnosis of both acute conditions and pre-morbid multiple diseases would pave the way for a holistic management plan. The prompt medical or surgical management of the acute disease together with comprehensive geriatric assessment and subsequent rehabilitation to independent living is the ultimate measure of success in the hospital management of elderly patients. In most acute hospitals, the primary emphasis is to treat the acute episode and achieve a quick discharge to vacate beds on a daily basis for the next batch of acutely ill patients. Avoidable disability may be overlooked and will not be managed appropriately or promptly. Moreover, the patient unfriendly acute hospital environment has a negative effect on functional ability outcomes in frail elderly patients after hospitalisation. In addition, psycho-social issues, such as financial difficulty, inadequate carers and elder abuse, are often overlooked.

10 Long-Term Care and Care for the Elderly 231 Acute illnesses are commonly associated with de-conditioning during hospitalisation. Rehabilitation is needed in at least 50% of elderly patients after an acute illness, and this is often neglected by general physicians and surgical colleagues, who usually do not have the appropriate training in geriatric medicine. Chronic diseases, including stroke, Parkinsonism, chronic obstructive airway diseases, hip fracture and osteoarthritis, may lead to chronic disability and the need for long-term care support. The neglect of rehabilitation thus increases the proportion and severity of disability after acute and chronic illnesses. The characteristics of frail elderly patients include the presence of multiple medical problems, multiple medications and acute and sub-acute medical problems, on top of chronic medical diseases. They are prone to suffering from adverse effects after drug treatment or surgical procedures and de-conditioning after bed rest, and experience a significant decline in function. They commonly have falls, fall-related injuries, hospitalisation-related complications, delirium, dementia and depression. Overall, they have a higher mortality and morbidity after hospitalisation than young patients. Social needs are prevalent in elderly patients, and in caregivers. Long-term care needs in the form of home care or institutional care are common. In summary, elderly patients have multiple needs, which include aspects of social, psychological, physical health and functional status. Dysfunctional syndromes often occur after acute illness and hospitalisation in the frail elderly (Figure 2). These needs are inter-related and often intertwined. Health and Conceptual Model of Functional Decline Functional Older Patient Acute Illness, Possible Impariment ization Hostile Environment Starvation Depersonalization Medicine Bedrest Procedures Depressed Mood Negative Expectations Physical Impairment Dysfunctional elderly patient Figure 2 The dysfunctional syndromes of frail elderly patients in the general ward setting

11 232 Hong Kong s Health System: Reflections, Perspectives and Visions functional, psychological and socio-economic status are important considerations in the care of elderly people, and as geriatric patients are typically frail, a multidimensional and multidisciplinary approach is the cornerstone of the success of any geriatric service programme (Chu, 1998; Rubenstein and Rubenstein, 1992; Chu and Lam, 1997; Chow and Chi, 1997; Fox and Puxty, 1993; Stuck et al., 1993). Figure 3 summarises the key domains of the assessment and management of elderly patients, and Figure 4 describes the core members and supporting members of multi-disciplinary geriatric teams (Figures 3 and 4). Physical health and diseases Functional status The frail geriatric patient Psychosocial health statue Socioeconomic and environmental status Figure 3 Multidimensional geriatric assessment of the elderly patient Core members Geriatrician Nurse Social worker Occupational therapist Physiotherapist By consultation Other speciaties or subspecialties Supporting members Psychogeriatrician Dietician Podiatrist Speech therapist Prosthetic and orthotic specialist Clinical psychologist Volunteer Pastoral care Core members Nurse Geriatrician Social workers Elderly patient Occupatinal therapist Physiotheraphist Figure 4 A multidisciplinary geriatric team

12 Long-Term Care and Care for the Elderly 233 Role of Geriatric Medicine in Acute Care for the Elderly Geriatric medicine can effectively handle the complex diagnostic, investigative and management issues of frail elderly patients. An interdisciplinary approach with a close-knit geriatric team is an approach that has been proven effective in the management of frail geriatric patients, and leads to improved outcomes, such as the ability to carry out the activities of daily living, and health care service utilisation, such as decreased hospital readmission. History of the Development of Geriatric Medicine in Hong Kong Geriatric medicine has been defined as the branch of general medicine that deals with the clinical, rehabilitative, psychosocial and preventive aspects of illness in elderly people. The term geriatrics was coined by the US physician Dr Nascher in However, the pioneer of geriatric medicine was Dr Marjory Warren of the UK. Based on the British model, Hong Kong established its first geriatric unit in 1975, but the development of geriatric medicine was slow in the first ten years. However, in recent years, the importance of geriatric services for the elderly community has been gradually recognised. At present, there is at least one geriatric service per hospital cluster (Tables 5 and 6). In 2004, there were seven hospital clusters (Table 4) and it had been proposed that five mega-clusters be formed. Inadequate Acute Geriatric Care in Acute s Most elderly patients are admitted through accident and emergency departments into the various adult departments (medicine and geriatrics, surgery, orthopaedics, ophthalmology and neurosurgery). The in-patient statistical data from 2001 and 2002 shows that most elderly hospital admissions were related to medical conditions. Elderly patients are either admitted into the general medical wards or to geriatric wards. The latter have shrunk tremendously with the integration of geriatric medicine and internal medicine in (Table 5). At present, only three hospitals retain functional acute geriatric wards (Tuen Mun, the United Christian and Ruttonjee ). Unfortunately, the present arrangement of admitting frail elderly patients into the general ward setting is detrimental to the quality of care, the clinical outcome and the health care cost. Undoubtedly, elderly patients with acute medical problems that resolve themselves completely without much physical, cognitive and functional impairment can be treated and managed satisfactorily in the general medical ward setting. However, less than 50% of elderly patients belong to this category. The

13 234 Hong Kong s Health System: Reflections, Perspectives and Visions Table 5 Geriatric Service in the Authority by Cluster Year Cluster Unit/Ward/Team Acute Geriatric Ward in Acute 1994 Hong Kong West Queen Mary Geriatric Team Nil after SARS in Fung Yiu King (Integrated) 2002 Tung Wah Geriatric Department 2004 Grantham Geriatric Team (Integrated) Geriatric Department 1990 Hong Kong East Ruttonjee & Tang Geriatric Department Siu Kin 1995 Pamela Youde Geriatric Team Nethersole Eastern 1996 Tung Wah East (Integrated) 1995 Wong Chuk Hang Geriatric Team 1995 St. John (Integrated) 1996 Cheshire Home, Geriatric Department Chung Hom Kok Geriatric Team (Integrated) 1974 Kowloon East United Christian Geriatric Ward Yes 2000 Tseung Kwan O Geriatric Team Nil (Integrated) 1991 Haven of Hope Geriatric and NA Rehabilitation Unit 1975 Kowloon West Princess Margaret First formal Geriatric Nil after Department integration 1978 Caritas Medical Centre Geriatric Department Nil after integration 1982 Kwong Wah Geriatric Unit 1994 Yan Chai Geriatric Team (Integrated) 1995 Our Lady of Geriatric Team Maryknoll (Integrated) 1995 Wong Tai Sin Geriatric Team (Integrated) (Table 5 to be continued)

14 Long-Term Care and Care for the Elderly 235 (Table 5 continued) Year Cluster Unit/Ward/Team Acute Geriatric Ward in Acute 1993 Kowloon Central Queen Elizabeth Geriatric Team (Integrated) 1995 Kowloon Geriatric and Rehabilitation Unit 2003 Hong Kong Buddhist Geriatric Team (Integrated) 1985 New Territories East Prince of Wales Geriatric Team 2001 Shatin (Integrated) 1997 Alice Ho Miu Ling Geriatric Unit Nethersole 1998 Tai Po Geriatric Team (Integrated) 1990 New Territories West Tuen Mun Geriatric Department Yes majority of elderly patients have acute medical illnesses on top of their existing chronic medical diseases and physical and cognitive impairments. These frail elderly patients have multiple diseases, physical and cognitive impairment in addition to possible social problems. They need the expertise of a multidisciplinary geriatric team to treat, rehabilitate and provide the necessary psycho-social intervention. The general medical ward setting can only treat the acute episode of illness, and does not have the system in place or the staff expertise to simultaneously manage physical and cognitive impairment and social problems. The problem of quick discharge and frequent unplanned readmission (Chu and Pei, 1999; Chu and Pei, 1999; Kwok et al., 1999) has led to the well-known revolving door phenomenon (Figure 5). The prevention of these unplanned readmissions is possible in up to 50% of cases (Chu and Pei, 1999). As the present computerised system in the Authority captures patient activity (such as number of admissions, occupancy and length of stay per episode), many frail elderly patients who have been going through a rapid turnover in acute care wards will be shown on the system as having had multiple episodes with short lengths of stay per admission. They are readmitted again because medical problems that are unresolved because of the overemphasis on short hospital stays and because of complications such as pressure sores that have been acquired during previous admissions (Stuck et al., 1993; Chu and Pei, 1999; Chu and Pei, 1999). Eventually, both the frail elderly patients and the health care system suffer.

15 236 Hong Kong s Health System: Reflections, Perspectives and Visions Table 6 Geriatric Services in the Hong Kong West Cluster Acute hospital care Queen Mary (Integrated Model) Grantham (Direct accident and emergency transfer) Convalescent care Fung Yiu King Tung Wah Grantham Geriatric rehabilitation beds Fung Yiu King Tung Wah Grantham Long-stay infirmary beds for Fung Yiu King geriatric patients Tung Wah Pre-discharge programme Queen Mary, Tung Wah, Fung Yiu and post-discharge support King, Grantham Geriatric Day as day Fung Yiu King rehabilitation centre Tung Wah Geriatric Specialist Clinics Queen Mary Geriatric Specialist Outpatient Department Queen Mary Memory Clinic Queen Mary Falls Clinic Queen Mary Nutrition Clinic Fung Yiu King Continence Clinic Hong Kong West Outreach Geriatric Doctor Clinics in over 60 old age Community Geriatric homes (subvented care and attention homes, private Assessment Team old age homes and day care centres) Visiting Medical Officer under the Community Geriatric Assessment Team Visiting Medical Officer programme Central Infirmary Waiting List clients pre-admission assessment Domiciliary visits medical, nursing, physiotherapy and occupational therapy Educational and training programme for caregivers and the elderly in the community Health education programmes with community partners It would be a better approach to admit and manage frail elderly patients (e.g. elderly patients who are admitted from old age homes, elderly patients with significant physical impairment or dementia and socially frail elderly) in specially designed settings with multidisciplinary teams of health care professionals who can provide the necessary care and prevent unwanted iatrogenic events (Palmer et al., 1994). Pre-discharge planning, post-discharge support and community health care should be developed to provide prompt and efficient bridging support. In the present health care system, the initial few weeks after hospital

16 Long-Term Care and Care for the Elderly 237 Journey of an Elderly Patient Admission to an acute hospital Acute medical ward Geriatric beds Subacute Rehabitation Discharge Home Old age home Private old age home Revolving door Subvented care and attention home Figure 5 An elderly patient in the Hong Kong hospital care system discharge is a vulnerable period for the frail elderly, during which they are prone to a decline in health and functional status, and are often readmitted to hospital because of inadequate support after discharge. Lack of a Systematic Approach to Acute Geriatric Care The fundamental problem in the present organisation of hospital care for the elderly is the lack of a systematic approach to acute care. Although multidisciplinary and multidimensional geriatric assessment is frequently practiced in extended care hospitals, there is a general lack of acute geriatric services in most acute hospitals in Hong Kong. At present, only two out of the twelve acute hospitals in Hong Kong have designated acute geriatric wards. The number of elderly in acute hospitals is huge. To be cost-effective, acute care for the elderly has to be focused, and to attain a cost-effective health care model the targeting of frail elderly patients in acute geriatrics care programmes is necessary. Geriatric patients are physically, cognitively and psycho-socially frail.

17 238 Hong Kong s Health System: Reflections, Perspectives and Visions The settings for geriatric assessment should be located at sites where the frail elderly are present such as medical, surgical, and orthopaedic and emergency room settings. Geriatric assessment and intervention should start at the same time as the treatment of medical diseases to prevent functional decline. The core elements of acute care for the elderly programme can be summarised as follows (Palmer et al., 1994). Target patients should be the frail elderly at accident and emergency departments and medical, orthopaedic, neurosurgical and surgical wards, with particular attention given to elderly people who are residents of old age homes. Comprehensive geriatric assessment should be undertaken, with a multidisciplinary team round or case conference. Intervention in the form of a prehab programme should be used to prevent functional decline in an appropriately designed ward environment. A rehab programme should be used to reverse functional decline and improve the ability to perform the activities of daily living. Finally, there should be comprehensive discharge planning with early pre-discharge planning and post-discharge support and appropriate placement. A case management approach is effective, and should be employed. In this manner, clinical outcomes will be optimised and unnecessary hospital admissions prevented. Inadequate rehabilitation after acute illness in the frail elderly is also a problem, and the waiting time for geriatric day hospital rehabilitation is long. Inadequate transportation to geriatric day hospitals is another obstacle to the provision of adequate day rehabilitation for the frail elderly, who because of moderate disability usually require transportation support, such as non-emergency ambulance transport, from home to the hospital. Geriatric Health Care at Residential Care Homes for the Elderly Elderly people who live at home or alone constitute 12.4% of the elderly population aged 65 and above (11.2% of elderly men and 13.6% of elderly women) (Luk et al., 2002). Although community and primary health care is largely provided by private family doctors and general out-patient clinic doctors, specialist geriatric services at old age homes are provided mainly by community geriatric assessment teams and partly by community health nurses. A new programme of visiting medical officers began in October 2003 to improve infection control and provide ad hoc primary or geriatric medical care for frail elderly residents of old age homes. Since that time, 78 visiting medical officers have been appointed as part-time Authority staff to upgrade the previously inadequate primary and geriatric care in 178 old age homes throughout Hong Kong.

18 Long-Term Care and Care for the Elderly 239 Service Gaps and Duplication Issues in the Health Care and Long-Term Care of the Elderly Multiple and continuing gaps in traditional care models (Figure 6) may lead to elderly patients falling through the cracks (Coleman, 2003). The fragmentation of care leads to the frustration of elderly patients and caregivers, and causes potential harm to patients. Examples of this fragmentation include the prescription of multiple repeat or similar drugs by multiple doctors or of being given no drugs at all while waiting for a new case appointment. The latter is a common transitional care problem for the elderly in Hong Kong. In the community, a single frail elderly person commonly receives multiple health care services, such as those of a private family doctor, visiting medical officer, orthopaedic doctor, ophthalmologist, cardiologist or endocrinologist, and multiple social services, such as being a member of several multi-service or social centres for the elderly and receiving home help services. Current problems include the fragmentation of care, service gaps, the overlapping of services and poor communication and coordination. An integrated geriatric health and longterm care team across both the health and social sectors would be able to Authority Social General Outpatient Clinic Clinical Care Day Acute Residential Care Service Hostel, Home, Care and Attention Home, Nursing Home Carers Social Centres Home Help Services, Enhanced Home Care Services, Integrated Home Care Services Specialist Outpatient Clinic Infirmary Subacute Community Support Services, Neighbourhood Elderly Centres, Social Centres (for the Elderly), District Elderly Community Centres, Multi-Service Centres for the elderly Elderly Health Centre, Department of Health Private Doctor, Visiting Medical Officer * Private Old Age Homes * Bought-place scheme Figure 6 Present organization of health and long-term care for the elderly in Hong Kong

19 240 Hong Kong s Health System: Reflections, Perspectives and Visions substantially overcome these undesirable issues. Unfortunately, however, the current financing and public policies do not facilitate this development. Moreover, public health and social policies still lead to unhealthy competition for clients and create major gaps in services for the elderly. At present, separate service providers come under different budgetary areas in the Department of Health s Elderly Health Service, the Authority, the Social Welfare Department and non-governmental organisations. Most elderly people use public health and social long-term care services. Only a small proportion of the elderly population seeks services from private hospitals, clinics and social services. In general, the objectives and policies of the different service organisations differ, and policies on service direction may also be different. In terms of collaboration between different elderly service providers, a model of service purchasing between organisations is in operation, but it is limited in its ability to bridge gaps or eliminate overlaps. For example, frontline staff have difficulty working together as integrated teams, despite the overlap of services. Loose collaboration is the current practice, but this is far from ideal. There has been slow development in the interface between the public and private health sectors. Communications have been improved, and private doctors can obtain a discharge summary of their own patients from Authority if they have pre-registered. The recent public-private collaboration with visiting medical officers in the Caritas Evergreen Home is one of the successful pilot projects that have been implemented by one of the authors at the Hong Kong West Cluster (Chu et al., 2004). The present organisation of health care for the elderly indirectly gives rise to the overuse of hospital care services over community care services. A cost containment trend has shifted care away from acute to sub-acute care, which shortens the length of hospital stay in acute hospitals per episode of admission. However, this is a mere consequence of concentrating only on the activity figures, and there is no cost incentive to decrease unnecessary hospital readmissions. Moreover, there has been an overemphasis on specialty-led and organ-based disciplines, which are all very costly. The main financial issue in the health care system for the elderly is inadequate financial resources for public health care. Most of the elderly are poor and would obviously choose to use the public health care services rather than private sector services. The financial condition of the current generation of the elderly and the next generation is neither good nor optimistic. Financial Disposition of the Current and Next Generation of Elderly People In 2000, the Hong Kong government conducted a survey on the current generation of elderly people (aged 60 and above) and the next generation (aged 45 to 59) to obtain a better understanding of their financial situations (Census

20 Long-Term Care and Care for the Elderly 241 and Statistics Department, 2002). Altogether 2,180 respondents aged 60 or above and 1,867 aged 45 to 59 were surveyed. The survey results showed that the income of the current elderly generation is still mainly provided by the family, with 58% of older people receiving a family contribution of an average amount of US$800 a month. However, the importance of the role of the family seems to have been diminishing, as a survey that was conducted in 1996 showed that 71% of older persons received financial support from family members. Only a small percentage of elderly people had a formal source of income such as a salary (12%) or retirement benefits (15%). Those who were still in employment earned a median monthly income of US$750. Of those who enjoyed retirement benefits, most only received lump sums on retirement, and very few received regular monthly payments. The lump sums had a median value of US$8,125 and did not enable the elderly to support themselves for long. Older people of this generation did not generally own many assets. About 24% owned self-occupied properties, and 4% had investments such as stocks and bonds. Although the great majority had Table 7 Major Sources of Income for the Current Elderly Population (Retrieved from 2001 Census data) Item Proportion Salary 6.54% Retirement protection 3.27% Financial support from children and/or relatives 44.96% Comprehensive Social Security Allowance 17.06% Old Age Allowance 24.02% Others 4.04% cash deposits, the values were not very high, as the amount of interest was small (Table 7). The survey showed that about 10% of elderly people relied on the Old Age Allowance as their main source of income, despite its modest rate of payment, and of this group about one third received financial contributions from their families and had a total average monthly income of US$140. The remaining two thirds did not receive any family contributions, and had to rely on an average monthly income of US$95. Furthermore, according to the General Household Survey in the second quarter of 2000, 74% of the households in the lowest income bracket had elderly family members, and most of these households in fact comprised single elderly people or elderly couples. We do not know what the income of the next generation of elderly people will be after retirement, but 30% are working or have worked with employers who provide retirement benefits for their employees. With the introduction of the

21 242 Hong Kong s Health System: Reflections, Perspectives and Visions Mandatory Provident Fund, most of them should enjoy retirement benefits in one form or another. They are also richer in assets: 37% have self-occupied properties, 11% invest in shares, bonds or unit trusts, and 96% have bank deposits. Judging from the reported dividends and income from investment, the average value of their assets, not including property, should be in excess of US$12,960. In summary, a proportion of the next generation of elderly people will have an improved financial standing upon retirement compared with the current generation. Nevertheless, the majority of these people may not be adequately protected. Although the next generation of elderly people appears to be financially better off at present, the majority of them (around 67%) have not made any arrangement to meet their future financial needs. Although 58% of them indicated that they would rely on the financial support of their children after retirement, the actual family size of the next generation of elderly people is getting smaller. Around 55% have only one or two children, and 12% have no children at all. The reduction in family size is expected to affect how the soon to be old will finance their post-retirement living. We are concerned that there may be a group in the next generation of elderly people who are currently on low incomes and have few or even no children to support them. After retirement, they could quickly exhaust their savings or retirement benefits, and will subsequently fall into the welfare safety net. The Mandatory Provident Fund will take some 30 to 40 years to mature and will have a limited effect in the interim, and the benefits for people with low incomes are limited even in the longer term (Chi, 2004). Problems with Long-Term Care for the Elderly In 1993, the Social Welfare Department assessed 97% of private old age homes in Hong Kong to be below standard (Cheng and Chan, 1993). In 1996, the Residential Care Homes (Elderly Persons) Ordinance was implemented. All old age homes have since been required to obtain licences, which specified statutory requirements for environment and staff grade or strength. The health care services in these facilities were judged to be inadequate, and many frail elderly people resided in poor quality old age homes, while the health and functional status of the residents who lived in subvented care and attention homes was much better. This represents a mismatch of the public financial support and the needs of the frail elderly. In 1997, the Deloitte report on the needs of elderly people for residential care suggested a shift from subvention to purchasing a quality system in the form of a contractual agreement (Health and Welfare Bureau, 1997). A standardised care needs assessment using the minimum data set instrument was implemented in November 2002 to assess the needs of elderly people who might require a home or institutional care ( Authority, 2004). The assessment

22 Long-Term Care and Care for the Elderly 243 mechanism covers all applications for institutional and home long-term care services, and the central philosophy is ageing in place. The key issues within the Hong Kong long-term care system are a high demand for institutional care and the poor quality of care in residential care homes (old age homes). In general, the quality of care in private old age homes is low, and the waiting times for subvented care and attention homes, nursing homes and hospital infirmary beds are unacceptably long (Table 2). Alternatives to institutional care were severely neglected in the past, and only in recent years have community supportive services been upgraded. Nowadays, Home Help Services, Enhanced Home Care Services and Integrated Home Care Services are all available. General nursing care is provided at home by the Enhanced Home Care Service and the Integrated Home Care Service, whereas primary medical care is provided only by the Integrated Home Care Service. The waiting times for day care services are long, and there are very few dementia day care places in the day care centres. Service gaps and duplications are common problems. A case management approach is needed to arrange the services in these programmes, with a case manager who is a trained geriatric nurse or social worker. Caregivers are very important in the care of the frail elderly. Several caregiver support and training programmes, which aim to upgrade the knowledge and skills of caregivers, are in operation ( index.html accessed on 12 July 2004). The practical difficulty is that most family caregivers, such as frail elderly spouses, or busy children, may not have the health, physical strength or time to provide adequate caregiving to frail geriatrics. Collaboration between long-term care service providers (Enhanced Home Care Services and Integrated Home Care Services) and geriatric medical services on a cost-recovery basis for the Authority has recently been implemented. This involves some cost sharing, but it must be understood that all of these service providers receive funding from the government. Interestingly, there is also costshifting. Some self-financing residential homes and private old age homes utilise loopholes in the present health care system and over-use the Authority hospital services to save medical and nursing staff costs. Residents are commonly sent to accident and emergency departments and stay in hospitals for mild complaints that could have been managed in the old age home if the home had been willing to provide geriatric medical and nursing care. This is related to the lack of directives from the government to improve the level of on-site geriatric health care for old age homes. A directive from the funding authority is needed to upgrade the medical and nursing support in these residential homes to avoid the unnecessary use of hospital services. Even the newly introduced accreditation system is only a voluntary exercise, and is unlikely to improve the quality of the residential care service.

23 244 Hong Kong s Health System: Reflections, Perspectives and Visions Private health care loses competitiveness for the sick elderly. The charges for hospitalisation per day or specialist out-patient department or general out-patient clinic consultations are much cheaper than private doctor charges, and for elderly people who receive a Comprehensive Social Security Allowance, there is no charge at all. Thus, the majority of Hong Kong s elderly are dependent on government subvention in both health and social care services. This is true for the care and attention homes, which are subvented by the government, and for private old age homes, where 80% of the residents are Comprehensive Social Security Allowance recipients (Luk et al., 2002). Thus, the fee for living in old age homes is also borne indirectly by the government. At present, only a small minority of elderly people can afford private health and long-term care. Integration of the organisation of geriatric health and long-term care is needed, and should be accompanied by a corresponding public financing arrangement. The way in which long-term care can be financed has become a major policy issue in Hong Kong. The majority of frail elderly in need of long-term care are still being cared for by family members. However, when elderly family members are in need of long-term care, many families find it difficult to provide physical care and financing. Families that cannot afford to pay for the private long-term care services have to apply for public assistance. Due to the constraints of public funding, the development of long-term care services is extremely slow, and the quality of care is poor. Over 8% of the elderly population live in residential care homes, which is an alarming figure, and is higher than most of the developed countries in the world. All of the local studies on the preference of living arrangements for frail older people indicate that residential care homes are not preferable. We should question the appropriateness of the current long-term care policy, programmes and practices. Furthermore, one wonders what the quality of life is like for elderly people who do not choose residential care. In recent years, the Hong Kong government has introduced several initiatives to reform long-term care services. For example, it has adopted a gate-keeping mechanism to control the eligibility for long-term care services. Instead of building nursing homes, the government has focused on developing district-level enhanced home care and community support services for vulnerable elderly people. Another initiative is the contracting out of all long-term care services using competitive bidding, an exercise that has saved the government money in long-term care expenditure, as it previously subsidised these services. For instance, the unit cost of the recent bidding on residential care facilities was half that of the subsidised unit cost before 2000, and these new facilities are taking in even more frail elderly residents than before. Although there is merit in cost-efficiency, many queries have been raised about the quality of care and the effectiveness of these services. These initiatives have served to quickly release part of the pressure on the public funding of long-term care, but without a comprehensive policy and new sources of funding to support long-term care services, the new measures may not be able to meet the challenges that Hong Kong will face in coming years.

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