1. Ageing populations: Implications for Hong Kong Jean Woo, Cadenza Project Director Faculty of Medicine, The Chinese University of Hong Kong and Faculty of Social Science, University of Hong Kong

2. Topics covered Desired outcomes for people who are ageing: Health Financial security Engagement in society Adaptations from health and social services Contributions to these topics from work supported by Cadenza

3. Health Top three causes of mortality are cancer, cardiovascular diseases, and pneumonia Heart failure, chronic obstructive pulmonary diseases and stroke account for the largest proportion of patient bed days in the Hospital Authority Dementia affects 6% of people aged 70 and over. And the incidence is approximately 1% among those aged 65 years and over, while the prevalence of cognitive impairment is approximately 15%

4. The ideal situation Increasing life expectancy No increase in disease incidence Decreasing disability Little disparities

5. Engagement in society Between 1991 and 2005, the percentage of people aged 65 and over still participating in the work force fell from 12.8% to 5.4% Psychosocial consequence of enforced exit from the work force? Work stress impacts on health, but there is little understanding of stress associated with retirement

6. Finance Regional disparities in health and mortality Figure from SF-12 thematic Household survey, and HHSRF mortality data Due to income, education, health service access, air pollution, neighbourhood deprivation….

9. Survey: Understanding of Elderly Issues Objectives: –To examine The image we have about the elderly Whether we know how to take care of our elders Method: –Questionnaire Face-to-face interview Self-administer (web-based, paper and pencil) Participants: –N = 2,694

10. Survey Findings: Image of the Elderly Most elderly people are unhappy Most elderly people think positively like when they were young Except physical work, most elderly people can work like a youngster Elderly people should give way to younger workers % “Agree” QuestionsElderly Age 65+ Carer Age 50+ Adult Age 18- 49 Hospital Profess- ional Undergrad- uate Professional n=580n=413n=808n=322n=339 4851597071 18 13 143034 1316146476 5957564433

11. Survey Findings: health literacy and carer skills Most elderly people’s teeth would fall out If my family member becomes demented, I know how to take care of him/her Regarding health, only the doctor will be able to tell elderly people what to do I know where to go to get help for the elderly 9593737865 60 50 15 11 5 2427174320 4854435658 % “Agree” QuestionsElderly Age 65+ Carer Age 50+ Adult Age 18- 49 Hospital Profess- ional Undergrad- uate Professional n=580n=413n=808n=322n=339

12. Summary of knowledge and misconception survey Considerable knowledge deficiency/misconception and negative attitude in these areas, among all ages and among professionals working in hospitals and students of these professions Misconceptions more marked among older people 94-97% of all respondents express wish to discuss care plan with health professionals and their families in end of life situations

13. Understanding of elderly issues Optimizing mental and physical function Ageism Knowledge of services and how we can help ourselves Living environment Quality of dying Legal and financial issues

14. Importance of Informal Care Informal caregiving can add to the quality of care in both domestic households and residential living Community based informal care services can also help decrease the need for institutionalization

15. The Challenges of Building a Sustainable Pool of Informal Carers Major caregivers for non-institutionalized seniors tend to be “informal” carers Population structures that are already in place have implications for the future supply of the pool of informal caregivers The interface between formal and informal care may also shift as population ageing continues and place a greater demand on support services

16. Strategies to Strengthen the role of Informal Caregiving Empowerment Education Training Mixing and matching formal and informal care Reference: Chau P.H., Yen E. and Woo J. Caring for the Oldest Old: "Mixing and Matching” Informal and Formal Caregiving, British Medical Journal, 2007 Available at http://www.bmj.com/cgi/eletters/334/7593/570#164600

17. Public Education Theme for 2008: Empowerment Acquiring knowledge and skill to help ourselves, targetting the areas identified in the survey Strategy for knowledge and skill diffusion: radio, TV, newspaper, public education fair, exhibitions, school events

18. Supermarket tours Use universal settings that people can identify with Active participation in educational event Subsequent behavioural modification and diffusion of knowledge Involvement of the family unit Public Education: exploring effective strategies

19. Cadenza Training Programme Target group General public Informal caregiver Social and health care professionals Training Activities Roadshows Public seminars Carnivals Educational leaflets Workshops Site visit Self-help group Self- directed web-based course Seminar Clinical visit

20. Cadenza Training Programme Courses in May-June 2008 - Public seminar for general public * Roads to a fulfilling and prosperous life at later year - Workshops for informal caregiver * Theme: Promoting health of older people in community - Web-based course for professional * Successful aging & intergenerational solidarity

22. Service needs from the user’s perspective Results from focus groups Results from community survey of people requiring long term care discharged from hospitals Results from survey of End Of Life care

23. Focus groups Elderly group (from NGOs; n=24;mean age 65y) - barriers to accessing government services; concern regarding fees; lack of trust of effectiveness of ‘cheap’ medications -staff attitude (not helpful or friendly; not caring) -poor quality of private old age homes

24. Focus groups Service providers: n=24, two groups of health and social care disciplines each - service gaps (poor integration, inter- organizational barrier and poor accessibility - strategies towards prevention of deterioration needed - training for professionals: target negative perceptions - public education: health literacy and empowerment

25. Community survey of those requiring long term care 707 elderly people aged 65 years and over living at home requiring carer, and 705 carers in NTE and HKW Main factors influencing choice for opting for old age homes were: impaired function, dementia, depression, those already receiving community services Education level, income geographic region, knowledge of and accessibility to community services did not influence preference.

26. End of life care Patients with chronic non-cancer diseases such as gradual organ failure (heart, lung, kidney, liver, degenerative neurological conditions ) Cross sectional survey (n=75, mean age 84y), showed common occurrence of symptoms : limb weakness(92%); oedema(85%); fatigue (85%); dysphagia (58%); pain 48%. Some staff found it difficult to discuss EOL issues with patients and relatives There is room for improvement in staff training in this area

28. Service needs form the users’ perspective Seamless one stop service provided in a transdisciplinary way, using a case management approach Designed from the user’s perspective Covers health maintenance; how to cope with living with various chronic diseases; mental health support Cost effectiveness and cost benefit analysis

29. Management of chronic diseases in ageing populations

30. Common themes in response Health promotion Self-management: concept of expert patients Care/disease management: high risk Case management: high complexity Knowledge management: population needs assessment, service planning

31. Care of the elderly: special features Requires a multi-faceted approach (physical, functional, psychological, nutritional, social) Involves multiple health and social care providers Presentation with the geriatric syndromes (falls, incontinence, immobility, dementia) Focus on multiple co-morbidities and the concept of frailty, rather than on individual diseases

32. Current situation in Hong Kong Services heavily hospital based, resulting in limited accessibility as well as increased costs Poor continuity of care Community self-help poorly developed Emerging needs of elderly living in residential care homes Palliative care in all settings poorly developed Multiple service providers (SWD, DH, HA, CRN, NGOs, private sector: interface less than ideal)

33. Current situation (cont) Increasing financial burden on healthcare systems Sustainability likely depend on active participation by individuals, both for prevention and management Absence of a primary care system to reduce demands on secondary and tertiary care

34. New approaches Patients P erception of illness, empowerment, compliance Professionals Use of non-medical professionals; trans disciplinary approaches Systems Case management; community settings and group activities to promote self-management, compliance with treatment, lifestyle modification, through motivational and behavioural changes

35. Self-management Programmes designed to help patients manage symptoms and contain health care resource utilization Systematic review: 71 trials of variable methods and standards; publication bias. Small to moderate effects shown for selected chronic diseases eg.diabetes and asthma. ( Warsi a et al. Arch intern Med 2004; 164: 1641- 1649) Not targetted towards multiple diseases/frailty

36. Major barriers to be addressed in promoting self management Patient factors: need to emphasize retention: programme needs to take into account cultural, linguistic, access and convenience factors Professional factors: need for cultural change away from medical model of management; need to present convincing evidence of beneficial outcome relating to disease management; need to address financial support and sustainability issues within an existing health and social services framework

37. Current evidence regarding self management programmes Use of toolkits for self-management may have potential financial and clinical benefits (DeMonaco et al PLOS Medicine April 2007 Vol4 Issue 4) Expert patient (lay-led) education programmes: 6 week CDSMP: mainly disease based. UK target to cover 100,000 patients by 2010. 4 RCTs in the UK showed that patients’ confidence is increased but use of health care resources were not reduced. (Griffiths C et al, BMJ 2007 334:1254-6)

38. Role of professionals Stepped care approach, with broad community coverage by health professionals other than doctors: Case manager liasing with GPs or specialist nurses, supported by Consultants Nurses as leaders in chronic care, especially in end of life care, adopting the principle of patient centred supportive care: understanding patients’ perspectives Shift from disciplines/organization- centred towards patient centred approach

39. System change?

40. The problem with guidelines and standards in chronic disease management Lack of evidence: difficulty in recruiting frail elderly people into RCTs ‘Clinical trial evidence is shamelessly extrapolated across time, population subgroup, and condition: The Road To Hell’ Iona Heath. BMJ 2007;335: 1185

41. Case management US Evercare model Collaboration with GPs,other health and social care professionals in primary care, expanded nursing role in proactive managed care for patients at high risk for repeated hospital admissions and decline in function, using a team based approach, risk stratification using predictive tools to identify high risk patients, self- management and motivational interviewing

42. Outcomes of the case management approach Evercare model: Fewer hospitalizations and fewer prescription drugs; maintaining high levels of patients satisfaction; no change in mortality For long stay nursing home residents, nurse practitioner led programs in primary care has a major effect in allowing cases to be managed more effectively (Kane R et al. J Am Geriatr Soc 2003;51:1427-34 Hong Kong data (1980s): nurse led case management of patients discharged from hospital showed demonstrable benefits (Mackenzie &Lee)

43. Adoption of the Evercare model by the NHS in the UK ‘Community matrons’. Need to be fully integrated into primary care Conflicting views on usefulness “Evidence is weak for case management for the elderly: unlikely to provide an off the shelf solution to achieving the required reductions in emergency admissions” (www.kingsfund.org.uk/pdf/casemanagment. pdf)

44. Adaptation of these principles to the ageing population Programmes for chronic diseases as well as frailty syndromes Functional, social, psychological, nutritional, dimensions need to be incorporated Patient as part of discrete social network Main outcome is ‘maintenance’ rather than ‘restorative’ with respect to function; and maximizing quality of life

45. Advantages of group programmes among the elderly population Mutual support Incorporate as regular social activity, and therefore enjoyable, and not episodic ‘classes’ or rehabilitation’ programme Setting allows constant reinforcement of information, and correction of misconceptions Lower cost than one to one interaction

46. What has been done in Hong Kong so far Community models in groups, led by team of nurse/allied health/lay people, in partnership with NGOs, for: OA ( Wong YK et al. J Telemed Telecare 2005:11:310-315) Stroke ( Lai JCK et al. J Telemed Telecare 2004;10:199-205) DM ( Chan WM et al. Applied Nurs Res 2005:18:77-81) Dementia (Poon P et al. Int J Geriatr Psychiatr 2005;20:285-6 ) Incontinence (Hui E et al. J Telemed Telecare 2006;12:343-7 ) COPD (Woo J et al. J Eval Clin Prac 2006;12:523-31) CHF (Hui E et al. Disabil Rehab 2006;28: 1491-7) CDSMP

47. Summary of results Enthusiastic feedback, desire for programmes to continue Demonstrable objective health and psychosocial outcomes Healthcare professionals do not refer; do not belief it has any place in the system Social care sector: not confident in getting involved in ‘medical’ activities: concerns regarding legal liabilities etc

48. Useful services: self-financing and potentially income generating Employment agency Skills register for useful home services OT & PT Aids Dental Wellness Centre Healthy Lifestyle – healthy eating and exercise for health Learning – Various interest groups Chronic disease management and groups for health maintenance Needs based case management to maintain community living Community rehabilitation network Community nurses and allied health Financial assistance Counselling Carer support Home care Hospitals and OPD Day hospitals Community geriatric and psychogeriatic outreach teams

49. Primary Care

51. The approach to aging populations: summary Health literacy and empowerment Emphasis on maintenance of health and function and quality of life (and of dying) rather than curative/restorative goals System and culture change towards and effective seamless primary care