For information on 15.12.2016 HAB-P251 Hospital Authority Pilot Scheme on Dementia Community Support Services for the Elderly Purpose This paper briefs Members on the development of the Pilot Scheme on Dementia Community Support Services for the Elderly (the Pilot Scheme) 智友醫社同行 計劃, which aims at enhancing support for patients with mild to moderate dementia in the community via a medical-social collaboration model. Background 2. Dementia is a present day global public health challenge. In Hong Kong, the prevalence of dementia in people aged 60 years or above was estimated to be more than 100 000 in 2009 (around 10% of aging population) 1. The prevalence of dementia in Hong Kong in people aged 60 years or above is estimated to increase by more than threefold to 330 000 by 2039 as a result of population ageing 1. Persons with dementia have multiple care needs and require multiple levels of supports across various sectors. Apart from medical care, persons with dementia also require various social assistance and support. To tackle the problem, there is a need to develop an integrated and coordinated system that is comprehensive and complementary to the overall elderly services provided within the community. 3. Chaired by the Secretary for Food and Health, the Review Committee on Mental Health (the Review Committee) has been tasked to study the existing policy on mental health with a view to mapping out the future direction for the development of mental health services in Hong Kong. The Expert Group on Dementia (the Expert Group) formed under the Review Committee views that dementia care requires a continuous, coordinated cross-sectoral and multidisciplinary approach with an ultimate goal to prevent and delay the disease progress so as to allow persons with dementia to age in place and die in place with dignity. With this in mind, the Expert Group has put forward a package of recommendations ranging from public education and prevention, 1 Yu R, Chau PH, McGhee SM, Cheung WL, Chan KC, Cheung SH, Woo J. Trends in prevalence and mortality of dementia in elderly Hong Kong population: projections, disease burden, and implications for long-term care. Int J Alzheimers Dis 2012. doi.:10.1155/2012/406852.
- 2 - early identification, intervention, medical-social collaboration, capacity building, and research to enhance dementia care. 4. Upon the recommendations from the Expert Group, a pilot programme was proposed to strengthen the support for dementia patients at the community level via a medical-social collaboration model. The proposal was submitted for the Community Care Fund (CCF) funding support and approved by the Commission on Poverty (CoP) on 31 August 2016. Programme Details Objective 5. The primary objective of this Pilot Scheme is to develop a medical-social collaboration model in providing community support services to elderly persons with mild to moderate dementia so as to enhance their functioning level and quality of life and to better support the carers. The Pilot Scheme also aims at enhancing the capacity and expertise of the staff of non-governmental organisations (NGOs) at the community level in the provision of dementia support services to the elderly persons, hoping to alleviate the pressure of the specialist services of the Hospital Authority (HA) in the long run upon successful implementation of the Pilot Scheme and the territory-wide rollout of the programme. Service Model for People with Mild to Moderate Dementia 6. Under this medical-social collaboration model, patients with mild to moderate dementia who are considered suitable for joining the Pilot Scheme by HA will be referred to the District Elderly Community Centres (DECCs), which are under the Social Welfare Department (SWD) for the provision of community support services upon receipt of an informed consent by the patient and/or the carer. DECCs, with support from additional healthcare professionals (including nurses and occupational therapists/physiotherapists), will provide appropriate training and support for the patients and their carers (including day rehabilitation service, home management advice, carers education and respite care) according to an individual care plan formulated by HA to delay their cognitive and functional decline, and hence enabling them to remain in the community as far as possible. The HA clinical teams will attend regular case conferences with respective DECCs for cases referred from HA to ensure that a close medical-social collaboration is in place. Ongoing progress will be reviewed to enhance patient s functions and alleviate carer s burden. 7. HA will explore inviting selected general practitioners (GPs) with relevant training at private clinics in the community to render primary care to stable patients through the public-private-partnership (PPP) approach at a later stage of the Pilot Scheme to alleviate the burden to HA s specialist outpatient clinics in the long run.
- 3 - Coverage of the Pilot Scheme 8. 20 DECCs operated by 16 NGOs in eight districts, namely Sha Tin, Tai Po, Kwun Tong, Tseung Kwan O, Eastern, Wan Chai, Tuen Mun and Yuen Long were invited to join the Pilot Scheme to provide community support services to patients with mild to moderate dementia referred by the Hong Kong East, Kowloon East Cluster, New Territories East Cluster and New Territories West Cluster of HA. It is estimated that about 2,000 elderly persons would receive community support services under the Pilot Scheme in two years. Roles and Responsibilities 9. The Food and Health Bureau (FHB) assumes an overall leading role to steer the planning of the Pilot Scheme, oversee its implementation and conduct programme evaluation. The involvement and division of responsibility of various stakeholders are as follows : (a) (b) (c) (d) The role of HA in the proposed scheme includes: (i) identifying suitable patients and making referrals to NGOs; (ii) formulating care plan for individual patient referred from HA; (iii) assisting DECCs in the service arrangement according to agreed care plan; (iv) providing support for staff training of the NGOs; (v) assisting in monitoring NGO performance; (vi) attending case conference at DECC for patients referred from HA and (vii) providing input and participate in programme evaluation. The SWD (Elderly Service team) will be responsible for (i) discussing with HA and NGOs regarding care plan, service arrangement, case referrals and operation logistics; (ii) monitoring NGOs performance; (iii) attending case conferences at DECCs; (iv) coordinating and arranging training for staff of the NGOs; (v) handling enquiries, waiver arrangement and complaints; and (vi) providing input and participating in programme evaluation. The SWD (CCF team) will be responsible for (i) inviting NGOs and managing contractual arrangements; (ii) performing means test for cases referred to the programme; (iii) handling funding arrangement and verification of subsidy applications; and (iv) verifying financial reports submitted by NGOs. NGOs are required for (i) discussing with HA and SWD regarding care plan formulation, service arrangement, case referrals and operation logistics; (ii) coordinating with SWD to arrange DECC staff to participate in relevant training; (iii) providing programmes according to the care plans formulated by HA; (iv) complying with the contractual agreements made with SWD in the use of funding and provision of services; (v) arranging case conferences and reporting on the progress of programme implementation; (vi) providing relevant materials including audited
Target Participants - 4 - account for the purpose of reporting to CCF; and (vii) providing materials and participate in the programme evaluation. 10. The target participants of the Pilot Scheme are those who are aged 60 or above with the following criteria : (a) (b) HA s patients (referred by Geriatric or Psycho-geriatric Teams) diagnosed of having mild or moderate dementia (based on a standardised dementia staging tool which has to be confirmed); or Registered members of respective DECCs who are suspected to have suffered from early dementia or cognitive impairment. 11. At the initial stage, priority of referrals would be given to the existing members of the DECCs who are also HA s patients with mild to moderate dementia, and other suitable patients referred by HA. Financial Implication and Governance 12. The funding for the Pilot Scheme has been approved by CCF at the CoP meeting on 31 August 2016. The estimated cost of the Pilot Scheme will be about $99 million. For HA, the additional resource required is about $18 million involving additional eight advanced practice nurses (APNs) and four patient care assistant II (PCAII) plus some other programme cost and administrative fees. A Task Force (led by FHB) has been set up to steer the overall programme development. An HA Internal Task Group has also been set up to advise on programme planning, implementation logistics and monitoring. Way Forward 13. The Pilot Scheme will last for about two years from February 2017 to January 2019. HA will start referring patients in April 2017 after two months for training and programme preparation. The Task Force plans to commission an academic institution to conduct evaluation for the Pilot Scheme with a view to facilitating mapping-out the future direction of the provision of community support services for patients with mild to moderate dementia under the medical-social collaboration model. 14. The present pilot is the first phase to test out the service model for the provision of community support service for people with mild to moderate dementia. As the primary care doctors play a significant role in the service model, further expansion of the programme to involve their support will be explored at a later stage.
- 5 - Advice sought 15. Members are invited to note the Pilot Scheme for elderly patients with mild to moderate dementia as detailed in the paper. Hospital Authority HAB\PAPER\251 8 December 2016