Organised by:

Malaysian Healthy Ageing Society

Co-Sponsored:

Ageing Well in the Community The Hua Mei Experience

•Ms Susana Concordo

Harding

•Dr Ng Wai Chong

Population Ageing & Health

• Poor health, loss of function and need for long term care is one of the key “feared” burdens of population ageing

• For governments, there is concern about health and long term care cost, and decreased productivity from older workers

• For family, concern over care givers’ burden and need for institutional care

• For Elders, poor quality of life and unhappiness in their last years

Population Ageing & Health Care

• Optimizing health and well being throughout the life course is critically important for all

• Preventing unnecessary acute and institutional care generally means better health, saves cost and helps support ageing in place, which is generally preferred by elders

• Health care system must be able to provide a spectrum of quality care in the community to promote and enable ageing well in the community throughout the life course

Tsao Foundation’s Vision • Working towards wellbeing of older people through their life course

by promoting and enabling: – Successful ageing

• Goal = Every mature Singaporean with a personal successful ageing plan in health, finance and social support

• Focus is on training, education and peer support on self efficacy and self care (including financial literacy, healthy living and chronic disease management)

• Applicable to all older people but greater preventive value for the healthier, more functional older people

– Ageing in place • Goal = Every older Singaporean can live securely and die peacefully in

their own home • Focus is on integrated community frail care service system, caregiver

support, and accessible built environment

The Three Initiatives of Tsao Foundation

Hua Mei Training Academy since 1993 as Hua Mei Training Centre

Hua Mei Training Academy – – Capacity building in ageing self care and care

provisions

Professional Training in community aged care for – – professionals (as content provider for WDA, SSTI, etc.

as well as our own signature courses i.e. community geriatric nursing)

– community partners

– volunteers

Training and coaching for individuals on successful ageing (“health, wealth and happiness”) through the life course

Caregiver support for sustainable care giving

International Longevity Center since 1996 as ‘Interagency Collaboration Division’

International Longevity Center –

Interagency Collaboration and policy advocacy through Policy relevant high impact ageing research and stakeholder platforms

“connecting the dots” between stakeholders – including older people, their families, practitioners, government, private sector

Hua Mei Centre for Successful Ageing

Provides a one-stop centre for community aged-care Services – – Create a spectrum of community based program

models –

• To meet a range of needs from the well to the frail in the community

• To optimize ability of individuals for preventive and self-care to age well

• To enable access to the right service at the right time, right place and right cost to age in place

• Each program is a stand-alone replicable model in its own right

The Theoretical Framework for Successful Ageing

WHO Active Ageing Policy Framework

Not just limited to the healthy, ambulant older people

Rests on three key pillars of:

– Income Security

– Health and access to health care

– Participation

Defined not so much as a fixed end point but the opportunity and ability to optimize on the above at any time in one’s life course

Requires multi-pronged strategies at national policy, community action and individual behavioral levels

Source: Active Ageing, A Policy Framework, World Health Organization, 2002

3 Pillars: Income

Security

Health & Health Care

Space for Participation

Successful Ageing Model Landmark MacArthur Foundation Study on Successful Aging in America (1995)

“Nurture (how we live) determines more than nature (our genes) on how well we age.”

Components of Successful Aging

Eden Alternative An ‘Alternative’ Culture of Elder-centred Care

Recognize the centrality of the human spirit

Health and social services are subservient

Physiological and security needs are not more important than the needs for companionship, dignity and self-actualization (the Three Plagues: Loneliness, Helplessness and Boredom)

Re-think and re-org care-activities towards ‘what really matters’

Hua Mei’s Delivery on Health

Central Importance of Primary Care in Population Ageing

7 C’s 1. 1st Contact – accessible, therapeutic relationship

2. Continual – ‘Medical Home’, non-transitional

3. Comprehensive – Health promotion, disease prevention, restorative therapy, chronic disease management, long term care support, end of life care

4. Community-based – prevention from ‘stepping up’ into high-cost care settings, culturally relevant and acceptable

5. Coordinated – through working with Care Management services, integrated with other supports

6. Care and Counseling – emphasis on communication, self-care empowerment, caregiver supports

7. Cost Effective – the most-appropriately-qualified-lowest-cost person for the job

Primary Health Care Needs in a Life Course

•Health Promotion •Disease Prevention •Acute episodic and restorative care

•Health Promotion •Disease Prevention •Acute episodic and restorative care •Chronic Disease Management

•Health Promotion •Disease Prevention •Acute episodic and restorative care •Chronic Disease Management •Long Term Care •Psycho-geriatric Care •End of Life Care

First Act

Second Act

Third Act

Emphasis on Self Care

Aging is a ‘Life Course’. How we age depends on how

we live in our youth: managing ‘health’, ‘wealth’,

‘relationships’ and other ‘departments’ of life.

An Integrated Approach to Health Inter-facing 3 delivery frameworks

– Treatment

– Self-care

• Awareness • Knowledge • Skills/practice • Motivation for

sustained, positive behavior towards a healthy and effective day-to-day practice

Whole Person Care Health Promotion/

Wellness Enhancement

Early Detection/ Disease Prevention

Chronic Disease Management

Primary prevention/ Immunizations

Long term care/ Frail care

End of Life Care

Acute Illness

Spirit

Mind Body

Rehabilitation

• ‘Stand-alone’ Models that can be integrated around a Person as her needs shift with advancing age

“SCOPE”

Hua Mei Clinic

Hua Mei Care Management

Hua Mei Counselling and Coaching

Hua Mei Acupuncture and TCM Centre

Hua Mei EPICC

Hua Mei Mobile Clinic

Component Programs within Hua Mei Centre for Successful Ageing

The Clinic

Care Management

Service

High

needs

and

very

frail

External Services Coordination,

incl. Drs (where not available in-

house)

EPICC

Review of past

assessment +/-

Comprehensive

Geriatric

Assessment

Counseling

and

Coaching The TCM

Clinic

Review of past

assessment +/-

Standardized

Home-based

Comprehensiv

e Geriatric

Assessment

Generally able

to attend Day

centre

Home-bound or

bedbound, near

End of Life.

Primary Care + Care management in a Team

Mobile Clinic

“SCOPE”

Occasional

reversion with

Rehab and

case

management

Mdm PAG, 75 yr lady who presented with a stroke 2 yrs ago. Referred to Hua Mei Care Management Service after discharge from hospital.

Referred to Hua Mei Clinic for Primary Care

Referred to Hua Mei Counselling and Coaching Programme for management of depression when son was arrested

Social worker from Hua Mei Care Management Service arrange prison visits and financial assistance

Routine assessment picked up poor visual acuity

Referred for eye operation

Liaise with MSW for financial assistance (for eye operation). Work with SAC for post op eye care.

Work with HNF re medication compliance

EPICC or Hua Mei Mobile Clinic if there should be

deterioration in function or care arrangement

SCOPE

“Self Care on Health for Older People of Singapore”

An RCT research study on the impact of quality of chronic disease management by instilling health-education and life-skills coaching in small groups of older persons who attend SACs.

Hua Mei Clinic Created 1996

The Age-friendly Principles, developed by the Age-friendly Advisory Group commissioned by the 2002 2nd UN World Assembly on Ageing in Madrid, to guide primary health care centres in modifying their structures to better meet the needs of the older persons:

Information, Education, Communication and Training

Health Care Management Systems Physical Environment of the Primary

Health Care Centres

WHO Pilot Site for Age-friendly Primary Care Clinic

Supported by HMCM and the rest of the HMCSA

Hua Mei Care Management Created 1998

Pioneered by TF in 1998 a community-based service approach

for frail, at risk elders with multiple health and social needs

aims at creating a sustainable health and social support system which enables the elder to remain living in the community

Main components: comprehensive assessment, coordination, networking, brokerage and advocacy for meeting needs

Not just an I&R service Supported by the rest of the HMCSA

Counselling and Coaching Programme Created 2009

Address the social isolation and mental health issues of elders as they transit through their third and fourth age

Support stressed caregivers of elders

Specialized in Geri-counseling, with an options of counseling at the elders’ own homes.

Created a Paracounselling Programme in 2010 as a ‘Manpower Multiplier’ to support the elders and monitor for deterioration

Hua Mei TCM Centre Created 1996

Mission : To support successful ageing by providing an integrative approach to treatment of chronic conditions that are often difficult to manage through allopathic medicine.

Started as an acupuncture clinic in 1996. Complemented with herbal TCM practice in 2006

Physicians are renowned practitioners from Shanghai TCM University Use of moxibustion, managing gynaecological conditions and

subfertility, and neurological conditions are specialties in this clinic Dr Gu Fa Long, the Medical Director is a member of the Complaints

Committee in Singapore TCM Practitioners Board

Hua Mei EPICC Created 2011

Hua Mei’s rendition of the PACE Model: Person-centred, Wellness-oriented, non-custodial

Team-managed Community-based Primary Health and Social care

Interdisciplinary Team is at the heart of the model: programme manager, primary care physician, nurses, social worker, physical therapist, occupational therapist, rehabilitation/geriatric aides, driver providing care management in a team

Demonstration Programme for 3 years co-funded by MOH/Tote Board

Not a custodial service by design – accepts participants with no care partners at home

Wellness focused

FRAIL ELDER AND FAMILY

CARE PARTNER

Day Health Centre

Counseling

Escort and

Transport

Therapy

ADL/IADL Supports

Care Manage-ment

Nursing ‘Sick Bay’ Facilities

Support for

Caregivers EPICC Model

Health Education and Life

Skills Training

Emergency Housing

Flexibility to pay home visits

Primary Care

Environmental Modification

Meals

Recreation

Socialization

Personal Development

Hua Mei Mobile Clinic Pioneered in 1993

• Team-managed Home-based Primary Care • The key features:

– Interdisciplinary Health Team – Primary care approach – Community-oriented Geriatric and Gerontology training – Special attention to Transitional and Palliative Care – 24H coverage – Comprehensive assessment and care planning using

InterRAI Home Care, HMMC Initial Assessment and Care Plan Protocols

– Emphasis on Care management, providing multi-dimensional trans-disciplinary intervention.

– Use of IT

HMCSA’s value Added Role

To be catalyst for community service system through multiple dimensions

– Implementing demonstration projects to pioneer new service model to meet unmet needs

– Building replicable models through standards, SOPs, and staff training

– Providing capacity building through training

– Creating collaborative platforms for stakeholders

– Being a learning lab for health and social service research and identification of emerging trends

Thank You