20 Years of Community Geriatric Assessment Service

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1 20 Years of Community Geriatric Assessment Service Dr CP Wong JP MBBS FRCP FRCPE FRCPG FHKAM FHKCP Specialist in Geriatric Medicine Private Practice

2 Outline Geriatric Assessment Breaking the Walls 20 Years of Evolutions The Future

3 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

4 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

5 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

6 Ageing Population and Utilization of HA services ( ) % Proportion of HA Service Consumed by Elderly Patients (65+) x 2.7x 2.4x All patient days GOPC attendances SOPC attendances Projection of HK population aged Year

7 715 Homes Places

8 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 All Elderly Patients RCHE residents Non-RCHE residents % share of Patient Days (All Specialties) 22% 3x 78% % share of Patient Days (Medical) 31% 4.5x 69% Unplanned Readmission Rate (All Specialties) 31% 4.5x 13% Unplanned Readmission Rate (Medical) 36% 5x 18% 8

9 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

10 Never ending negotiation

11 7 May 1993

12 1988 Kwong Wah Hospital Pao Siu Loong C&A Home Wong Tai Sin Hospital Tung Wah Hospital Tung Wah Eastern Hospital Fung Yiu King Hospital

13 7 May 1993

14 1993 Results 39% SOPD 35% AED Attendance 28% Unplanned Readmissions

15 SHW DO

16 Funding from Govt 1994: Four CGAS Teams subvented homes : More funding for private homes 2004: VMO additions 2010: Extension of more homes in KWC

17 Assessment Team Composition Geriatrician Nurse Physiotherapist Occupational Therapist Social Worker Speech Pathologist, Podiatrist, Dietitian Regular Team Meeting

18 Main Roles of CGATs 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 18

19 Target Patients Frails residents with complex health problems in elderly homes Residents just discharged from hospitals Terminally ill residents

20 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

21 Key Milestones of CGAS SARS outbreak Post SARS At present 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

22 Present Status 15 CGAT Teams Serves 640 out of 715 Elderly Homes 90% Annual attendance 637,800 visits

23 Impact to the Hospital 28% of all total acute hospital admissions in elderly in % now after 13 years of CGAT service 50% cumulative admission rate in 6 months 20% of all OPD clinic attendances

24 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 :5-11

25 A&E Attendance Attendance Rate of Residents in all Homes % Jul Aug Sep Oct- 99 Nov- 99 Dec- 99 Jan- 00 Feb Mar Apr- 00 May- 00 Jun Jul Aug Sep Oct Nov Dec- 00 Jan- 01 Feb- 01 Mar Apr May Jun- 01 Jul Aug- 01

26 Unplanned AED Adm 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

27 Who have benefited?

28 Benefits Save transport Save waiting time Save Manpower in Escort Save overcrowding of Out Patient Area Flexibility in FU Seen by designated team

29 Benefits Acute hospital: earlier discharge Winter Surge support Emergency Room consultation As Case Manager for integration of service and drugs

30 Lessons to Learn ONE on ONE Break the Barriers

31 Lessons to Learn Patient Centered Care

32 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

33 Growth Trend of RCHEs (Enrollees) Total No. of Enrolments Extension of CGAS to 66 more OAHs in KWC Additional Funding to cover Private RCHEs Pilot 4 CGATs Additional funding for CGAT/VMO Collaboration Scheme SARS Year 33

34 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

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37 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

38 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

39 Thank You