1. Primary Care and Older Persons – Key to Medical Social Integration Introduction Jean Woo Director, Cadenza Project

2. Re-inventing primary health care: the need for systems integration ‘…..developing primary care networks that are seamlessly integrated into the rest of the health system.’ Julio Frenk.Lancet 2009; 374:170-173

3. Cadenza: promoting an elder- friendly Hong Kong Impact of an ageing population on health and social services - chronic disease burden; Multi-morbidity - organ system v. patient centred approach - fragmentation v. integration of multiple services How should we structure our services? The primary care setting has to be key Two case studies to set the scene: illustration of the current piecemeal response to the ageing society and lack of coherent policies

4. Case One F 80 years. Resident of Old Age Home Presented to A&E with fall, and screened as part of a one year research project on study of profile of fallers presenting at A&E Depression screen positive Goes out to swim daily and goes to social centre Fell while standing on one leg in the park

5. Case One No one able to talk in OAH: all her friends have died in the 10 year period since moving in Need to be back early evening: regimented existence Health talks result in anxiety: ‘Do I have the disease?’ Who can help her?

6. Case Two F 80 referred to Geriatric Clinic by Integrated Clinic: ? Ischaemic heart disease. List of complaints: -Chest pressure and shortness of breath on walking about 10 min, relieved by rest(1 year) -chronic sputum producer for many years: current smoker -Right should pain, left knee pain, back pain limiting movements (I year) -Left 4 th trigger finger - Lump in abdomen when standing up: hernia awaiting surgical consultation- -Requests euthanasia:burden to society: no one cares and no one helps; long waiting list for multiple clinics; no medications; bad experience in A&E

7. Case Two Cannot eat a lot: chest pressure after more than half a bowl of rice Lives with unemployed daughter: lost husband, second daughter and grand child in recent years. On CSSA $2330 per month Son gives her a mobile phone but she only answers if it is from her son’s phone number. Does not know how to use telephone booking Difficulty in rising from chair and getting out of bed. Walks with a limp; cannot lift arm above shoulder level. Protrusion of abdominal contents on standing up

8. List of diagnoses Gastroeosophageal reflux disease Ischaemic heart disease Chronic obstructive airways disease Osteoarthritis of knees; frozen shoulder; osteoporosis with vertebral collapse Reactive depression

9. Geriatric Day Hospital Sorting out multiple medical and social problems in one place ‘Therapeutic video’…requested a repeat! Little complaint of pain Revealed new problem of urinary incontinence for which she was too embarrassed to mention to doctor Used humour frequently as a coping strategy

10. VIDEO

11. Summary points of video Sharp health and social commentary on all the current ills of our society! Inadequacies of current health and social services to deal with a not uncommon situation No one takes ownership of her care Services not achieving its aim of helping, although intentions are good Service providers not attuned to needs; lack of humanistic response and empathy; over-reliance on technology and processes Depression and higher suicide rates in the elderly not surprising

12. Exploration of solutions in the primary care setting Management of chronic diseases Role of social services Social services: success and obstacles Caregivers; psychological problems; outreach support; self-management; family doctor’s perspective Development of models of primary care for the elderly