Primary Health Care Initiatives 19th Asia Pacific Regional Conference of Alzheimer’s Disease International Concurrent Session A4 Primary Health Care Initiatives District-based Medical and Social Collaborative Model for Dementia Care 含有反射和模糊背景的圖片 (基本) 若要複製此投影片上的圖片效果，請執行下列作業： 在 [常用] 索引標籤上，按一下 [投影片] 群組中的 [版面配置]，然後按一下 [空白]。 在 [插入] 索引標籤上，按一下 [影像] 群組中的 [圖片]。 在 [插入圖片] 對話方塊中選取圖片，然後按一下 [插入]。 選取圖片。 在 [圖片工具] 底下，[格式] 索引標籤的 [大小] 群組中，按一下 [裁剪] 底下的箭頭，並指向 [裁剪成圖案]，然後按一下 [矩形] 底下的 [圓角化對角線角落矩形]。 同時在 [圖片工具] 底下，[格式] 索引標籤的 [大小] 群組中，按一下 [大小及位置] 對話方塊啟動器。在 [設定圖片格式] 對話方塊中，將影像大小調整或裁剪成高度為 2，而寬度為 2.4。若要裁剪圖片，請按一下左窗格的 [裁剪]，並在右窗格的 [裁剪位置] 底下，在 [高度]、[寬度]、[靠左] 及 [上方] 方塊中輸入數值。若要調整圖片大小，請按一下左窗格的 [大小]，並在右窗格的 [大小及旋轉] 底下，在 [高度] 及 [寬度] 方塊中輸入數值。 同時在 [設定圖片格式] 對話方塊中，按一下右邊窗格的 [反射]，然後按一下 [反射] 窗格的 [預設格式] 清單，再按一下 [半反射，相連]。 在 [插入圖片] 對話方塊中，選取另一張圖片並按一下 [插入]。 重複此處理程序，直到投影片上有三張圖片為止。 選取第二張圖片。在 [圖片工具] 底下的 [格式] 索引標籤上，按一下 [大小] 群組中的 [大小及位置] 對話方塊啟動器。在 [設定圖片格式] 對話方塊中，將影像大小調整或裁剪成高度為 2，而寬度為 2.4。若要裁剪圖片，按一下左窗格中的 [裁剪]，然後在右窗格的 [裁剪位置]，輸入值到 [高度], [寬度], [左] 和 [上] 方塊。若要調整圖片大小，請按一下左窗格的 [大小]，並在右窗格的 [大小及旋轉] 底下，在 [高度] 及 [寬度] 方塊中輸入數值。 選取第三張圖片。在 [圖片工具] 底下的 [格式] 索引標籤上，按一下 [大小] 群組中的 [大小及位置] 對話方塊啟動器。在 [設定圖片格式] 對話方塊中，將影像大小調整或裁剪成高度為 2，而寬度為 2.4。若要裁剪圖片，請按一下左窗格的 [裁剪] 然後在 [裁剪位置] 下方的右窗格中，將值輸入至 [高度]、[寬度]、[靠左] 及 [上方] 方塊中。若要調整圖片大小，請按一下左窗格的 [大小]，並在右窗格的 [大小及旋轉] 底下，在 [高度] 及 [寬度] 方塊中輸入數值。 選取第一張圖片。在 [常用] 索引標籤上，按一下 [剪貼簿] 群組中的 [複製格式]。 使用 [複製格式] 游標，在投影片上按一下第二張圖片。 選取第一張圖片。在 [常用] 索引標籤的 [剪貼簿] 群組，按一下 [複製格式]。 使用 [複製格式] 游標，在投影片上按一下第三張圖片。 按住 CTRL 並選取所有三張圖片。在 [常用] 索引標籤上，按一下 [繪圖] 群組中的 [排列]，指向 [對齊]，然後執行下列作業： 按一下 [對齊選取的物件]。 按一下 [垂直置中]。 若要複製此投影片上的背景效果，請執行下列作業： 選取圖片。在 [圖片工具] 底下的 [格式] 索引標籤上，按一下 [大小] 群組中的 [大小及位置] 對話方塊啟動器。在 [設定圖片格式] 對話方塊中，將影像大小調整或裁剪成高度為 7.5，而寬度為 10。若要裁剪圖片，請按一下左窗格的 [裁剪] 然後在 [裁剪位置] 下方的右窗格中，將值輸入至 [高度]、[寬度]、[靠左] 及 [上方] 方塊中。若要調整圖片大小，請按一下左窗格的 [大小]，並在右窗格的 [大小及旋轉] 底下，在 [高度] 及 [寬度] 方塊中輸入數值。 同時也在 [設定圖片格式] 對話方塊中，按一下左窗格的 [美術效果]，並在 [美術效果] 窗格中，執行下列作業： 按一下 [預設格式]，然後按一下 [模糊] (第二列，左邊第五個選項)。 在 [半徑] 方塊中輸入 30。 在 [常用] 索引標籤的 [繪圖] 群組中，按一下 [圖案]，然後按一下 [矩形] 底下的 [矩形] (左邊第一個選項)。 拖曳以便在投影片上繪製矩形。 選取矩形。 在 [繪圖工具] 底下，在 [格式] 索引標籤的 [大小] 群組中，將 7.5” 輸入至 [高度] 方塊，並將 10” 輸入至 [寬度] 方塊。 同時在 [繪圖工具] 底下，[格式] 索引標籤的 [圖案樣式] 群組中，按一下 [圖案填滿]，然後指向 [漸層]，再按一下 [其他漸層]。 在 [格式化圖案] 對話方塊中，按一下左窗格的 [填滿]，選取 [填滿] 窗格中的 [漸層填滿]，然後執行下列動作： 在 [類型] 清單中，選取 [星形圖]。 在 [方向] 清單中，選取 [從中央]。 按一下 [漸層停駐點] 底下的 [新增漸層停駐點] 或是 [移除漸層停駐點] 直到投影片中出現兩個停駐點為止。 同時在 [漸層停駐點] 中，如下自訂漸層停駐點： 選取投影片中左起第一個停駐點，然後執行下列作業： 在 [位置] 方塊中，輸入 0%。 按一下 [色彩] 旁的按鈕，然後按一下 [佈景主題色彩] 底下的 [白色，背景 1] (左起第一列、第一個選項)。 在 [透明度] 方塊中，輸入 60%。 從投影片左邊選取第二個停駐點，然後執行下列動作： 在 [位置] 方塊中，輸入 100%。 在 [透明度] 方塊中，輸入 0%。 同時在 [格式化圖案] 對話方塊中，按一下右邊窗格的 [線條色彩]，然後選取 [線條色彩] 窗格中的 [無線條]。 選取圖形。在 [常用] 索引標籤上，按一下 [繪圖] 群組中的 [排列]，指向 [對齊]，然後執行下列作業： 按一下 [貼齊投影片]。 按一下 [置中對齊]。 在 [常用] 索引標籤的 [繪圖] 群組中，按一下 [排列]，然後按一下 [移到最下層]。 選取背景圖片。 在 [常用] 索引標籤的 [繪圖] 群組中，按一下 [排列]，然後按一下 [移到最下層]。 Dr. Dai Lok Kwan, David MBBS(HK), FHKAM(Med), FRCP (Ire, Glasg, Lond) Specialist in Geriatric Medicine Chairman of Hong Kong Alzheimer’s Disease Association

Growing Trend of Hong Kong’s Aged Population (Mid-2011 to Mid-2041) Source: Hong Kong Census and Statistics Department, 2015

Dementia Friend Community Increased awareness and understanding of dementia Increased social and cultural engagement for the person with dementia Legal and other measures in place to empower people with dementia to protect their rights Increased capability of health and care services to develop services that respond to the needs of people with dementia Actions to improve the physical environment whether in the home, residential care, hospitals or public places Dementia Friendly Communities: Key Principles, Alzheimer’s Disease International (ADI), 2016

Principles of Dementia Friendly Community Dementia Friendly Communities: Key Principles, Alzheimer’s Disease International (ADI), 2016 People Involvement of Persons with Dementia Enhance understanding of public Enhance caring skills of caregivers Organizations Promote and provide timely diagnosis and post diagnostic support by primary health care and appropriate professionals Communities Social Physical Environment Environment Increase awareness Home Reduce stigma Service Facilities PWD engagement Public Facilities Partnerships Cross-sectoral Support Collaborative Approach Collective Commitment

District-based Medical and Social Collaborative Model for Dementia Care 10% Diagnostic Rate in HK Education to enhance skills and awareness for service providers Specialists such as Psychiatrist, Geriatricians Early Detection by caregivers, public service staff, NGO staff, etc. 90% Hidden Cases Referral complicated cases or when only necessary Early Diagnosis through detailed assessments by Occupational Therapist/Social Worker of HKADA to facilitate medical diagnosis by well-trained GPs Social Support System Institutionalization only when intensive nursing care needed Early Intervention, specialized day centre for dementia by HKADA with non-drug treatments, advance care planning and caregiver support, drug treatments by GPs

Project Sunrise : The 3 pronged Strategy Early Detection by Family Early Diagnosis by Community Health Care Professionals and Family Doctors Early Intervention and advance Care Planning Inception to Diagnosis < 3 months

Tsuen wan Project Sunrise launched in 2015 3-year pilot for 120 persons with dementia Supported by Photo Source: Apple Daily

Project Sunrise : Interim Client Profile (April2015 – May2016, 14 months) 175 people (70% female, 30%male) assessed by Detailed Cognitive Assessment 31 people finished diagnostic process and treatment started 81 people (46%) suspected to have dementia (67% female, 33% male) 88% 14 clients still under diagnostic process 51 people joined in Project Sunrise 12% 42 people (24%)  MCI 35 people (20%) normal aging 17 people (10%) mood or other problems 6 clients bridged to HA

Project Sunrise : Interim Client Profile (n=31) Variable Number (%) Age (Range: 72-91; Mean: 81) 70-79 80-89 90-99 11 (35%) 18 (58%) 2 ( 6%) Gender Male Female 19 (61%) 12 (39%) Level of Education None Primary Secondary Tertiary 9 (30%) 14 (45%) 6 (19%) MMSE Scoring <18 18 - 22 >22 16 (52%) 8 (26%) 7 (22%)

Project Sunrise : Interim Client Profile (n=31) Judgement by Consultant Panel of HKADA (Geriatrician, Psychiatrists) Result of Early Detection Assessment By HKADA (OTs, Social Workers) Diagnosis by Family Doctors Facilitate diagnosis 88% Correlated 12% suggested to further investigation, included: mood related, suspected hematoma, stroke

Project Sunrise : Interim Client Profile (n=31) Variable Mean Waiting time from application to EDS (Days) 28days Waiting time from EDS to Diagnosis (Days) 44days Total Time Needed: 72 days ~ 2.4 months

Interim findings from primary care doctors The model (actions) of interest PwD receive medical and social care from a close medical-social collaboration between primary care doctors and HKADA HKADA provides training for primary care doctors on dementia diagnosis and management A CDCP collaborates with primary care doctors to provide dementia assessment results and case background information Primary care doctors provide diagnosis and follow-up consultations, and feedback to the CDCP on medication and other management Qualitative interviews with primary care doctors, CDCP, and family caregivers in the programme conducted independently by HKU 1 2

Interim findings from Primary care doctors Initial themes from primary care doctors interviews NGO & resources support welcomed Otherwise difficult to engage PwD in primary care setting More effective and focused consultations with CDCP support (case manager role); shortened consultation time requirement Families of lower socioeconomic status would otherwise opt not to diagnose and treat even when dementia symptoms obvious Financing the practice Longer consultation time for PwD means decreased income for primary care doctors Medical voucher cannot cover consultation and medication costs Optimal patient load (high/medium/low): allowing choice for individual clinicians, some prefer low load 1 3 2

Interim findings from Primary care doctors Initial themes from primary care doctors interviews (cont’d) Training needs and specialist collaboration Specialist support and collaboration valued, especially when diagnosis less clear or complications arise (e.g., mood symptoms) Desired practicum & pedagogy, but noted the need to balance time cost for both trainer and students Need of clear clinical guidelines for decisions e.g. MRI indications Readiness of the society Need to raise further the family members’ awareness and mind set; cases identified in practice remains difficult to engage Focus resources on help-seekers rather than case-finding, while continuing public education 1 3 2

Interim findings from Primary care doctors Preliminary reflections Overall model direction promising Enhancing public-private partnership (PPP) Community dementia medical care network among specialists and primary care doctors, taking into account practice nature (solo, group, hospital) Financing (e.g., medication cost) an important factor in model feasibility Next action Fine-tuning of model design for Sunrise @ Kwun Tong 1 5 4 3 2

Interim findings from Family Caregivers Questionnaire survey of project participants (n=30) Overall satisfaction with project components (early detection service, primary care service, day centre): 4 to 4.5 out of 5 Both medical and social care viewed as important “Medication Treatment Important” “Non-pharmacological Treatment Important” “Care Planning Important”

Interim findings from Family Caregivers

Interim findings from Family Caregivers

Importance and Effects of Primary Care Balancing tasks between primary and specialist care could increase capacity and reduce costs (2016 ADI Report) Medical care is over-specialized causing delayed diagnosis and low diagnostic rate By task shifting and sharing, increase involvement of primary care staff can unlock capacity for increasing demand Estimated can lower the cost of care up to 40% for each person with dementia Increasing involvement of Primary care services is achievable with specialists’ guidance and support.  Source: http://www.alz.co.uk/research/WorldAlzheimerReport2016.pdf

Kwun Tong Project Sunrise launched in 2016 2-year for 80 persons with dementia Supported by Photos Sources: Apple Daily, On. cc

Kwai Tsing Project Sunrise launched in 2017 4-year for 200 persons with dementia Supported by District Office, Hong Kong Government Photo source: www.wikiwand.com

Future Roadmap for Dementia Care in Hong Kong

Seven-Stage Model for Planning Dementia Services Promulgated by World Health Organization (WHO) and the Alzheimer’s Disease International (ADI) Pre-diagnosis Diagnosis Post-diagnostic support Co-ordination & care management Community services Continuing care End-of-life palliative care  Enhance Public Awareness  Understanding of Dementia and related community resources Public Education & Prevention Primary Care (e.g. detection of suspected cases) DH, HA, SWD, NGOs, carers, private doctors Making the diagnosis Primary Care Specialist Care (e.g. SOP service provided by HA) HA, private doctors Provide Information and support to pwds and their family members in facing the disease Primary care (e.g. management of stable patients) Specialist Care Community Support (e.g. cognitive training, carer support services) HA, SWD, NGOs, carers, private doctors  Regular follow up and assess the needs of pwds and their family  provide suitable support and services  Continuous medical and community support  Management of complicated symptoms along disease journey Outreach services Community Support (e.g. cognitive training, carer support services) Carer Training HA (outreach medical services), SWD, NGOs, DH (outreach carer training), carers Medical and community support to manage increased unpredictable and complicated symptoms Acute and sub-acute medical services HA, SWD, NGOs, carers Special form of continuing care when a person with dementia is close to the end of his or her life Palliative care

Strengthen the Role of primary care in Dementia care With necessary training, Primary Care Doctors can play important role in Detecting and diagnosing Early Symptoms Act as gateway to services including community-based and specialist services Strong primary care foundation and network will allow stable cases of dementia to be managed in the community Effective stratification will allow specialists more time to handle complex cases

Enlarge the Role at Primary care level Inadequate expertise and capacity in primary care setting and non-medical sectors in detection and diagnosis Diagnosis Medical Treatment and intervention Proper gate-keeping to enable more effective and efficient use of specialist services Suitable Training to medical and health care professionals

Advocate for better Care Pathway for persons with Mild and moderate dementia by mental health expert group Elderly with memory loss and suspected cognitive impairment Early assessment of dementia by primary care professionals (private GPs, Public Family Doctors, Visiting Physicians, Nurse, OTs, etc.) Assessment by relevant specialists in public (referred by primary care) Confirm diagnosis and formulate care plan Tailored-made structured day care/home care/ carer support programs provided by community service units Specialist support for complicated cases Regular medical follow up at primary care setting

Capacity Building of care workforce Advanced GP training in Dementia Care by Institute of Alzheimer’s Education, HKADA 18 hours in-depth training with lecture, real case demonstration and case sharing, which covers: Early clinical diagnosis of dementia – Core clinical features and diagnostic criteria In-depth understanding on non-AD dementia Strategic pharmacological intervention for dementia Neuro-psychological assessments and Collaboration of multi-discipline to facilitate diagnostic process Behavior and psychological symptoms of dementia (BPSD) Mental capacity assessments, Financial planning, legal and ethical issues Skills in disclosure diagnostic result and care planning advice

Capacity Building of care workforce Organized by: Co-developed with: In collaboration with: Certified Dementia Care Planner (CDCP) Course 4 modules with total of 80 training hours, health care and social service professionals can: Be competent in assessment, care planning and management Support family caregivers in the caring journey Guide the families through the advance care planning Co-ordinate community resources for better care in community Module 1 Essentials for understanding dementia Module 2 Getting prepared: pre-diagnostic social cognitive assessment and caregiver needs appraisal Module 3 Care planning and management: counselling and caregiver support Module 4 Advance care management

Capacity Building of care workforce - Certified Dementia Care Planner (CDCP) About 350 health care and social service professionals graduated and certified as CDCP

Medical-social collaboration

Trend in Medical Service Trend in Social Service Future Trend in Hong Kong Medical-social collaboration in Dementia Care Trend in Medical Service Phase I: Extend medical services to community centers for the diagnosed cases Phase II: Dementia as one of the Disease Management under Public Private Partnership (PPP) Trend in Social Service Enhance Dementia Services in DECCs and NECs Support pwds to use dementia specific services by Community Care Service Voucher

Importance and Effects of Medical and Social Collaboration in Community Clear Care Pathways with structured coordination to ensure services are both person-centred and efficient (2016 ADI Report) Effective coordination can define roles and responsibilities within the care system, Holistic Case Management supports and monitors integration of care Continuous and sustainable support throughout the care pathways Increased coverage of comprehensive healthcare services is affordable, i.e. approximately 0.5% of total healthcare expenditure by 2030. Source: http://www.alz.co.uk/research/WorldAlzheimerReport2016.pdf