Authors (including presenting author) :
Chan S(1)(2), Yu PPC(1)(2), Lee MP (1)(2), Lam W(1)(2), Chan YT(1), Yao S (2)
Affiliation :
1. Special Medical Service, Queen Elizabeth Hospital 2. Department of Medicine, Queen Elizabeth Hospital
Introduction :
HIV was first recognized in the USA in 1981 as a fatal disease. In Special Medical Service (SMS) of Queen Elizabeth Hospital (QEH), the implementation of case management system was first initiated in Jan 2012. HIV specialty nurses implement case management services with an emphasis on providing quality care and wellness promotion for PLHIV.
Objectives :
This paper aims to discuss the current challenges of PLHIV and to share our experience on case management for the aging HIV patients.
Methodology :
In order to acquire a comprehensive perspective on the current challenges of PLHIV, SMS has extensively reviewed the literatures and surveillance reports, including Centers for Disease Control and Prevention (CDC) and Department of Health (DH). The findings are summarised and implemented into practices to enhance our patients’ service.
Result & Outcome :
Since the success of cART, the average age of PLHIV has increased steadily. In the USA, an estimated 45% PLHIV were over 50 years old in 2015. By 2018, there are around 1500 patients follow-up in QEH SMS clinic. More than 40% of them are over 50 years old. A number of data shows that PLHIV have an increased number of co-morbidities compared to those without HIV. These include CVD and stroke, metabolic syndrome and Diabetes Mellitus, osteoporosis and fracture, renal disease, chronic neurological complications, and malignancies. In SMS, 21% patients over 50 years old are having more than 2 comorbidities. In view of increased life expectancy and increased co-morbidities of PLHIV, SMS has implemented case management system by using CCCFP model. Collaboration and coordination are essential components of case management system. The case manager is the facilitator of the process. Nurse, being a case manager, is uniquely positioned to assist patients’ and family’s comprehensive health needs and to allocate available resources to promote quality, and cost-effective outcomes. Common identified problems among aging HIV patients include drug compliance and polypharmacy, functional impairment and rehabilitation, cognitive impairment, inadequate social support, inadequate home care support, placement arrangement, and malnutrition etc. Care of PLHIV in SMS can be illustrated by Comprehensive Geriatric Assessment (CGA). To summarize our care: i) to consolidate co-ordination care by multi-disciplinary teams; ii) to strengthen preventive approach to tackle co-morbidities burden; iii) to enhance collaboration to improve the availability of quality care; iv) to emphasize person-centered care as well as patient and family empowerment. The prognosis of PLHIV has improved dramatically over the past 20 years, but rates of co-morbidities as well as geriatric syndromes increase significantly. The implementation of case management system and integrated care for HIV patients will be essential to the wellbeing of this aging HIV population. Our care model is to consolidate collaboration care among healthcare professional across different disciplines in order to provide integrated care in SMS.
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