Malaysian Healthy Ageing Society Ms Susana Concordo Harding Dr Ng - - PowerPoint PPT Presentation

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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
• f 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
• lder people, their families, practitioners, government,

private sector

Hu Hua a Mei i Centre tre fo for r Successful cessful Ag Agein ing

• 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
• wn 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
• pportunity 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 nents of Succe cessfu sful Ag 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

• ther 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 rly Detec etecti tion

• n/

Dis isea ease se Prev event ention

• n

Chron

• nic

c Disea sease se Mana nagem gemen ent Primary imary preventi evention/

• n/

Immun uniza zati tions ns Long g term m care/ re/ Frail l care End of Life e Care re Acu cute te Illn lnes ess

Spirit Mind Body

Reha habili litati tation

• n

• ‘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

• peration

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
• f Singapore”
• An RCT research study on the impact
• f 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

• lder 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:

– Interdiscipli terdisciplinary ary Healt lth h Team am – Primar mary y care approach – Community-oriented Geriatric atric and Geront

• ntolog
• logy trainin

ning – Special attention to Trans ansit itio ional al and Pallia iativ ive e Care – 24H 4H cover verage age – Compr

• mpreh

ehensiv nsive e assessm smen ent and care planni nning using InterRAI Home Care, HMMC Initial Assessment and Care Plan Protocols – Emphasis on Care manage nageme ment nt, providing multi- dimensional trans-disciplinary intervention. – Use of IT 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