The Community Geriatric Assessment Teams
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Chan HW, Wong CP, Liu SH •Community Geriatric Assessment Teams NEW FRONTIERS IN GERIATRIC SERVICE - THE COMMUNITY GERIATRIC ASSESSMENT TEAMS Dr. Hon-Wai Chan,† MBBCh(Wales) MRCP(Ire) Dr. Shao-Haei Liu, MBBS(HK) MRCP(UK) FHKCP FHKAM(Medicine) MHA(NSW) Senior Medical Officer and Officer-in-charge Hong Kong East Hospital Chief Executive Community Geriatric Assessment Team Department of Ruttonjee Hospital, Hong Kong. Geriatrics Dr. Chun-Por Wong, MBBS(HK) MRCP(UK) FHKCP FHKAM(Medicine) J HK Geriatr Soc 1996;7: 9-13 Consultant Geriatrician and Chief of Service Received in revised form 2 May 1996 Department of Geriatrics Address correspondence to: Dr. H.W. Chan Summary ity of health care. The care for the elderly requires In line with the corporate vision of the Hospital sustained and concerted efforts among various ser- Authority to lead in collaborating with other health vice providers, namely, those in the medical, nurs- care providers and carers in the community to cre- ing, allied health professions and welfare sectors. ate a seamless health care system, nine Commu- The CGATs mission is to ensure that aged care ser- nity Geriatric Assessment Teams (CGATs) were set vices are not confined within the four walls of the up in 1994. The CGATs serve to provide timely as- hospital; it serves as a link between hospital geriat- sessment and appropriate management of health ric service and community care. problems, improve the interfacing between medical and social services, develop community based re- habilitation programmes, ensure appropriate place- Introduction ment of elderly people into residential care and pro- Along with socio-economic progress, good pub- mote the quality of care for elderly persons through lic health measures and improvement in our health training and education for professional as well as care services, the people of Hong Kong have attained informal carers. excellent health indices of life expectancy, infant Specific service areas defined at this early stage mortality and maternal mortality rates.1 As a re- of community aged care service in Hong Kong in- sult, Hong Kong has become a rapidly ageing soci- clude the provision of specialist geriatric service to ety, and in particular the percentage of “old eld- local subvented Care & Attention Homes (C&A erly” people - 75+ and 85+, is increasing even faster. Homes) through regular visits, pre-admission assess- It is estimated that by the year 2000, over 15% of ment for clients on the Central Infirmary Waiting List the local population will be aged over 60. (Census (CIWL), multi-faceted medical examinations for cli- and Statistics Department, 1993) ents entering subvented C&A Homes, co-ordination Health problems associated with elderly people of community domiciliary services and referrals to are often characterised by multiple pathology, specialist outpatient departments and Day Hospi- chronic disability, atypical symptomatology, medi- tals. cation problems, together with diminishing family The Ruttonjee Hospital - Buddhist Li Ka Shing and social support.2 If these problems are not timely C&A Home collaboration, commenced in May 1993, and appropriately managed, the clinical and func- a pilot project of community geriatric outreach ser- tional conditions of elderly people will be prone to vice, has already justified the value of its existence, wide fluctuation and rapid deterioration. Health by showing a significant drop in the number of at- and welfare services for the frail and disabled eld- tendances by the C&A Home residents to the Acci- erly persons require sustained and concerted ef- dent & Emergency Departments and the number of forts met by various service providers, namely, those admissions to general hospital wards. Likewise, in the medical, nursing, allied health professions there has been a marked decline in the number of and welfare sectors. visits to the outpatient department, saving escort and The health care needs of elderly people can be transport time, and a decrease in the number of bed- listed as follows:3 days left vacant in the C&A Home. • Acute medical care As the community ages, the quality of life de- • Rehabilitation pends more and more on the availability and qual- • Respite care †Current address : Dr. H.W. Chan, Consultant Geriatrician, 9 Fung Yiu King Hospital, 9 Sandy Bay Road, Hong Kong. Permission granted for electronic reproduction in Hong Kong Medicine Online. Single copy may be made for the purpose of research, training or private study, and NOT for commercial distribution. Journal of the Hong Kong Geriatrics Society • Vol. 7 No.1 Dec. 1996 • Long-term care range of community-based geriatric services were • Psycho-geriatric service therefore developed. These include home-help ser- • Community care vices, social centres, multi-service centres, day care A comprehensive geriatric service should either centres, and community nursing, as well as insti- directly provide, or ensure that other agencies pro- tutional care by way of C&A homes, hostels, homes vide, all of the above elements to elderly disabled for the elderly and infirmaries. However, these com- persons living within the catchment area. munity services are relatively under-developed. In these developments, the initiative and policy thrusts Background have come mainly from the voluntary agencies and Hospital-based geriatric services non-government organisations. In addition, the It is not surprising that elderly people are the private sector has been playing an important role major consumers of hospital services. Analysis of in providing community support for elderly people. hospital data showed that 63% of our inpatients in A significant number of elderly persons, whilst on a typical medical ward are aged 65 or above4, and the waiting list for subvented C&A Homes or infir- this percentage is increasing progressively. Of ne- maries, are residing in private aged homes where cessity, hospitals are required to meet the needs of the standard of care varies widely.6 the elderly individuals, who are admitted for two reasons: Interface between hospital services and • Treatment of an acute illness community services • Assessment and management of a non-acute The link between hospital services and commu- on-going problem/disorder, where formal or nity services has traditionally relied on the dedica- informal community support systems have tion of medical social workers. However, there has failed been no other structured co-ordinating or commu- Due to inadequate responsiveness elsewhere in nication mechanisms between the service provid- the health system, the latter group is particularly ers in the medical and welfare sectors. The degree likely to present to general hospitals - a referral to of integration and coordination depends very much the Accident and Emergency Department often be- on mutual good will between all different concerned ing considered to be the only solution when the parties. domestic situation reaches crisis-point. Once ad- Staff involved in institutional care for elderly mitted, these individuals will require comprehen- people encounter much stress and difficulties in sive assessment, and in many cases acute care, meeting the needs of the frail and disabled indi- rehabilitation, and discharge planning. To ignore viduals. There has been a general lack of special- these needs and discharge the patient directly back ist multi-disciplinary geriatric service and support into the community, in the hope that the existing in C&A Homes, hostels and homes for elderly fragmented community services will address them, people. Visiting medical officers employed in these is no longer acceptable, since it can be expected to homes are usually general practitioners whose ser- lead to increased re-admission rates - the so-called vice tends to focus on primary medical care. Spe- “revolving door” phenomenon, worse clinical out- cialist geriatric support on the other hand, is quite comes and a more expensive health care system. inadequate. The scale of rehabilitation activities The existing geriatric services in the Hospital Au- that can be carried out in these homes are there- thority are largely hospital-based. As at end of fore limited. When the clinical conditions of the 1994, these comprise of 1064 hospital beds, 10 elderly person deteriorate or when the carers face specialist outpatient clinics and 270 Day Hospital uncertainties in looking after them, there would be places. no alternatives but to send them to the Accident & Emergency Department. Community-based geriatric services From the results of a recently carried out sur- Traditionally, care for elderly people in Hong vey involving 13 C&A homes during January to Kong has been family based, care in dependency March 1993 by the authors, it was noted that 59 - being the responsibility usually of the eldest son, 72% of home inmates were sent to out-patient clinic whose duty is established in the notion of “filial and 12-14% to A&E departments each month. Staff piety”. Over recent years, the migration of younger working in the hospital system are often then over- family members, women’s greater participation in burdened with these unscheduled admissions the workforce and the erosion of traditional values which are perceived to be inappropriate and un- have reduced the availability of family support.5 A necessary. On the other hand, home operators face 10 Permission granted for electronic reproduction in Hong Kong Medicine Online. Single copy may be made for the purpose of research, training or private study, and NOT for commercial distribution. Chan HW, Wong CP, Liu SH •Community Geriatric Assessment Teams Fig. 1 Buddhist Li Ka Shing C&A Home: Number of visits to Fig. 3 Buddhist Li Ka Shing C&A Home: Number of the outpatient department unplanned admissions to general hospital wards Fig. 2 Buddhist Li Ka Shing C&A Home: Number of Fig. 4 Buddhist Li Ka Shing C&A Home: Number of bed- attendance to the Accident & Emergency Department days left vacant in the C&A Home tremendous difficulties in organising transport and actual collaboration in service delivery is rein- escorts for their clients.