The Community Geriatric Assessment Teams

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 rehabilitation 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. It is believed that the poor forced. interfacing between hospital and community ser- • Improved quality of care of the elderly residents vices has led to much grievances and this may jeop- is provided. The visiting general practitioner is ardize the goodwill and trust between the frontline still available for providing primary care whilst colleagues. the geriatrician can offer specialist advice and care. The Ruttonjee Hospital - Buddhist Li Ka Shing • There is good continuity of care given to cli- C & A Home Experience ents. They are treated and followed-up by the The Ruttonjee Hospital-Buddhist Li Ka Shing same team of service providers both in hospital C&A Home collaboration, was started on the 7th and after discharge. May 1993. The services provided by Ruttonjee • Better understanding of service provision and Hospital included the followings: environment settings on both institutions helps • Visiting doctor service (specialist care) considerably the planning and management of • Specialist clinic at the Aged Home health care to the elderly individuals. • 24-hour direct admission support • Through training and education programmes, • 24-hour hot-line advice the quality of care delivered by the Home staff • Specialist advice on client cares is improved. • Educational lectures to staff • There is the bonus of boosting the morale of • Assessment for special allowances, infirmary the Home staff. Home operators and nurses placements and housing feel they are readily supported by the hospital The provision of specialist geriatric service at service. the C&A Home through weekly visits by geriatri- • As evidenced by the statistical data, there has cians has resulted in the following achievements: been a significant drop in • There is high degree of integration between the - the number of visits to the outpatient depart two institutions. Apart from direct dialogue, ment (Fig 1) by 39%

11 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

- the number of the attendance by the C&A medical conditions in the elderly population.8 Home residents to the Accident & Emergency Through timely assessment and appropriate man- Department (Fig 2) by 35% agement, the incidence of common “geriatric prob- - the number of unplanned admission to gen lems” such as polypharmacy, adverse drug reac- eral hospital wards (Fig 3) by 28% tions, inappropriate use of restraints and - the number of bed-days left vacant in the C&A catheterization, pressure sores and faecal impac- Home (Fig 4) by 16% tion etc will hopefully be reduced in the commu- • The savings is estimated to be $63,000 per nity care settings. annum out-patient services and $1.45 million Through the provision of specialist multi-disci- per annum for in-patient services. plinary geriatric service and the development of • Other indirect savings such as ambulance trans- rehabilitation activities in the homes for elderly fer of residents to and from the service points people, the standard of care can be upgraded. cannot be accurately accounted for. Deterioration in health will be deferred and the elderly persons can be trained to reach their maximal New Frontiers - Community Geriatric potential in terms of functional status. In addi- Assessment Service (CGAS) tion, better support by the CGATs allow the C&A The Ruttonjee Hospital - Buddhist Li Ka Shing Home staff to save much administrative time and C&A Home experience has thus given insights into effort in arranging transport and escort for their a new boundary of geriatric care. In order to tackle residents to seek medical intervention outside the the problems arising from poor interfacing between home. More time can be devoted to professional hospital and community services, nine CGAT’s were and personal care. set up in mid-1994. The mission of this new ser- The dedication, goodwill and commitment of the vice is to ensure that aged care services are not community carers for elderly people are often taken confined within the four walls of the hospital, and for granted. In looking after the frail and fragile to enhance and preserve the health and quality of elderly persons, they face tremendous stress and life of elderly person in the community through strains.9 By the promotion of health education, timely assessment and appropriate management. training programmes and co-ordination of medical This is in line with the corporate vision of the Hos- as well as social services for the elderly persons, pital Authority to lead in collaborating with other the CGATs provide much valued support to the health care providers and carers in the community carers in the community setting, including those to create a seamless health care system.7 in residential homes and elderly persons’ homes. The typical community geriatric assessment It is well recognized that there are long waiting team comprises of geriatrician, occupational thera- lists for subvented C&A Homes and infirmaries.10 pist, physiotherapist, community nurse/health visi- There is no end to meet the forever increasing de- tor, medical social worker, and clerical officer. mand unless additional places in residential care The objectives of the community geriatric as- are complemented by parallel improvement in com- sessment service are detailed as follows: munity care in optimising the functional indepen- • To provide timely assessment and specialised dence of elderly people. The CGAS will be an es- early treatment for elderly patients with chronic sential step in this direction. illnesses and special needs. As the community ages, the quality of life de- • To improve the interfacing between hospitals pends more and more on the availability and qual- and welfare institutions at the district level. ity of health care. It is hoped that the CGAS will • To develop and provide community based re- form a solid starting point towards better, sustained habilitation programme for elderly person. and concerted efforts in the delivery of care for eld- • To ensure that placement into residential care erly people in the community. Determination of pri- for elderly persons is appropriate. orities between curative and preventive care, insti- • To promote quality of care of elderly persons tutional and community-based care, public and through teaching and education. private services in the presence of limited resources make the tasks of the CGAS in its role in co-ordi- Discussion nation of service difficult in the extreme. As well It is believed that the CGAS will enhance the as structural problems, gaps in mutual understand- elderly persons’ health, functional status and qual- ing and some power struggle between professions ity of life. The CGAS will undoubtedly identify many need to be overcome. previously unreported and undiagnosed treatable In tracing the development of aged care services,

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the intention of the medical sector to provide ap- people : the United Kingdom experience. In : propriately for elderly people become apparent. Grimley Evans J, Williams TF (eds). Oxford Over the years, those intentions have been over- Textbook of Geriatric Medicine. Oxford : Oxford taken by pressures on curative medicine and by University Press 1992:703-706. the domination of the private sector in medical prac- 3. Further Development on Hospital Geriatric Ser- tice. As far back as 1938, the government identi- vices. National Survey of Hospital Geriatric fied the aged as a category in the Medical Depart- Services. Information and Publicity Unit, Aged ment Statistics.11 In 1964, the White Paper on the & Community Care Division, Department of Development of Medical Services in Hong Kong Health, Housing, Local Government and Com- clearly identified the efforts of an ageing popula- munity Services, Canberra, Australia, 1993:3- tion on the demand for hospital beds. Develop- 4. ment of geriatric service in Hong Kong has been 4. Utilisation of Medical Unit, QEH, Medical & Ge- slow since the setting up of the first government riatric Unit, UCH by Age Groups from July to geriatric unit at Princess Margaret Hospital. How- December 1993. Source M.R.A.S. ever, elderly services have been well supported by 5. Finch J, Groves D. By women for women: caring the present Governor and the Hospital Authority for the frail elderly. Women’s Studies in the past few years. More and more geriatric ser- International Forum 5, 1982;5:427-438. vices have been set up. The CGAS has certainly 6. Hong Kong Government. The Five Year Plan become a new frontier in geriatric service. It serves for Social Welfare Development in Hong Kong - as a vital link in the continuum of services for eld- Review 1987. Hong Kong: Hong Kong erly people. Matching the appropriate service to Government Printer, 1987. the needs of the elderly persons is critical to well- 7. Hong Kong Hospital Authority, Business Plan being, particularly as this encompasses functional 1994 -1995, 4.2 Corporate vision 2000. ability and quality of life - enhancing functional well- 8. Commonwealth Guidelines for Assessment Ser- being is the highest goal of Geriatric Medicine. We vice. The Place of Assessment Teams, Depart- strive to add life to years but not years to life. It is ment of Community Services, Australia, 1987. the CGAT’s responsibility, therefore, to coordinate 9. Chow NWS. The Chinese family and support the variety of aged care services in the community, of the elderly in Hong Kong. The Gerontologist the scope of care provided by each, and the acces- 1983;23:584-588. sibility of the service to our clients. 10. Medical and Health Department/Social Welfare Department Report on the survery on the References requirement of infirmary beds, Hong Kong: Hong 1. Lee SH. Foreward. Public Health Report No. 1, Kong Government Printer, 1986. Department of Health. Hong Kong : Hong Kong 11. Hong Kong Government Report of the Director Government Printer, 1994 of Medical Services for the Year 1938. Hong 2. Grimley Evans J. Hospital service for elderly Kong Prison, Stanley, 1938.

13 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.