Page 181 - Hospital Authority Convention 2018

Parallel Sessions

PS8.1 Medical-social Collaboration 13:15 Theatre 1

A Paradigm Shift in Elderly Care – from Hospital to Community
Kng CPL
Department of Geriatrics, Ruttonjee and Tang Shiu Kin Hospitals, Hong Kong
Increasing life expectancy is a celebration of good health and social care. Yet these services have become increasingly HOSPITAL AUTHORITY CONVENTION 2018
burdened by the prevalent frailty and multi-morbidity which parallel ageing. Older person with complex needs often
encountered with multiple providers are characterised by duplication and gaps in care. In times of need, it is daunting for the
older person or their carer to navigate the maze of community services, and easier to rely on hospital services.

In this session, our long journey from a hospital-centric paradigm towards community-based person-centred care will be
shared. The framework consists of community platforms led by clinicians with a shared vision for seamless care delivery.
Within these platforms, partnerships are forged between Hospital Authority’s clinicians, transitional care teams, community
nursing, patient resource centres with external partners involving social and health sectors, non-governmental organisations
and private operators. Platforms and structures provide opportunities for mutual information exchange, reducing duplication
and filling gaps through a coordinated approach by different care providers.

Good elderly care has traditionally adopted an interdisciplinary team approach. To face the silver tsunami, great elderly care
must further take on the challenge of embracing cross-sectoral partnerships for sustainable and holistic outcomes.

PS8.2 Medical-social Collaboration 13:15 Theatre 1

Medical-social Collaboration in End-of-life Care – The Hong Kong West Experience
Luk J
Department of Medicine and Geriatrics, TWGHs Fung Yiu King Hospital, Hong Kong

Older people tend to have multiple co-morbidities. One prospective study revealed that one-year mortality of older people
with advanced dementia living in residential care homes (RCHEs) was 34%. In order to foster better end-of-life (EOL) care
for older people living in RCHEs, the Hong Kong West Community Geriatric Assessment Team (HKW CGAT) piloted the EOL
Programme for RCHE in collaboration with two RCHEs in 2009. In the programme, patients/family members could select
one of the two pathways, specifically the Hospital Pathway and Accident and Emergency Department (AED) Pathway. In
the Hospital Pathway, elderly would be clinically admitted to a geriatric step-down hospital (instead of an acute hospital)
which was suitable for EOL care via an expedited route. In the AED Pathway, elderly would stay in RCHE as long as possible Tuesday, 8 May 2018
with support from the RCHE staff and EOL team of HKW CGAT. In October 2015, HKW CGAT was one of the four teams to
implement the Hospital Authority programme “Enhanced CGAT Services for EOL care in RCHEs” in Hong Kong.

In this presentation, the experience of medical-social collaboration between HKW CGAT and RCHEs in the implementation of
the EOL programme will be shared. The model of “12 Share” (12 S) in medical-social collaboration will be discussed. The 12S
model includes share goals and values, share knowledge and information, share programme development, share governance,
share manpower and resources, share care, share risk and responsibility, share training, share program promotion, share
monitoring and auditing, share researches, share outcomes and rewards.

179