Community Geriatric Assessment Service Kowloon Central Cluster

Dr. Mak Ying FaiGeriatrician

Kowloon Central Cluster

Background

Global trendhospital care towards community care

Started in 1996 in KCCPre-admission assessmentSubvented Homes

Extended to cover Private Homes 1999

HA Direction

“… To shift the emphasis from inpatient to ambulatory and community care..”

(HA Annual Plan 05/06)

HA Direction

“…Major emphasis will be placed on strengthening care in the communityespecially in elderly homes, and decreasing dependency on hospital care…“

“.. The Visiting Medical Officer Scheme will be enhanced… “

(HA Annual Plan 04/05)

HA Direction

“…Enhancing system cost-effectiveness and improving population health through the development of Community-oriented Service Models… “

(HA Annual Plan 03/04)

HA Direction

“… HA must work to reduce avoidable hospital use if it is to deal with the future demands of the ageing population and with chronic health conditions…”

(CE keynote speech in HA Convention 2006)

Effects

↓ admission rate↓ Unplanned readmission rate, ↓ AED attendance rate ↓ Incidence of adverse events

Other Advantages

Convenience to patientsOne stop service↓ transportation↓ SOPD patient volume

Services

Pre-admission assessmentNursing homes – private and subventedScreening in Emergency DepartmentTraining nursing home staffNetworking with social services / service providers

Nursing homes

CatchmentKC, HH, TKW, YMT, TST,

No. of OAH = 77No. of residents = 7351Frail cases

TracheostomyCAPD

Nursing homes

SOPD FUMedical illnessPsychological problemsEthical and medico-legal issues

Follow up of frail elderlyInfectious outbreaks

Norovirus GastroenteritisInfluenza

Drug incidentsDM drugs

Collaborate with CHP, VHT (Visiting Health Team), LORCHE

Nursing Assessment

Nursing AssessmentPsychological SupportPatient EducationCase Conference

Training nursing home staff

Tube feedingRestraintPersonal careDrug incidents / Drug safety programInfectious outbreaks

Drug incidents – DM drugs 26.4.06

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Drug incidents – Public concern

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Drug Safety Program – 8/2006

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Teaching OAH staff

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Assessment of Drug Storage

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Assessment of Drug Storage

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Gastroenteritis outbreaks – 6/2006

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Gastroenteritis outbreaks – Public concern

Gastroenteritis outbreaks – Impact on Hospital

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Scabies

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Flu Outbreak 3/2008

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Visiting MO Scheme

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Computerized Patient Record in OAH -Remote CMS

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Nursing Procedures

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Blood Taking / Monitoring

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Environmental Assessment

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Networking with Service Providers / Social services

Elderly abuseMultidisciplinary conferenceLORCHE

Meeting with OAH operatorsCollaboration with KWH/OLMH CGAS

The End