Enhancing care of persons with dementia through interdisciplinary medical social partnership in HKEC

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Abstract Summary
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Authors (including presenting author) :
Chan YK(1), Yuen WM(1), Au LML(3), Kong HL(1), Lin KL(1), Wong SFS(2), Po MYY(1), Ho SKS(1), Mak PKF(1), Wu YKA(3), Chan YP(2), Kng PLC(1)
Affiliation :
(1)Department of Medicine & Geriatrics, Ruttonjee & Tang Shiu Kin Hospitals (2)Department of Medicine, Pamela Youde Nethersole Eastern Hospital (3)Department of Psychiatry, Pamela Youde Nethersole Eastern Hospital
Introduction :
The Dementia Community Support Scheme (DCSS) is a pilot government project to support elderly persons with dementia (PwD) from PYNEH and RTSKH with integrated medical-social care program, in partnership with 6 district elderly community centres (DECCs). The aim is to empower dementia persons and carers for ‘ageing-in-place’, with less reliance on hospital care. The HKEC DCSS Task Force enabled strong collaboration between geriatrics and psychogeriatric teams across two hospitals, together with social sector.
Objectives :
To evaluate the DCSS program outcomes for PwD and their carers.
Methodology :
PwD demographics and assessments of pre-, post- and 6 months post program were described. Assessments included dementia severity (HK-MoCA), mood (GDS), disability (CDAD) and carer burden (ZBI) were collected from a registry. Carer satisfaction survey was conducted.
Result & Outcome :
348 PwD were recruited for the period April 2017 to November 2018. There was significant improvement in mood (GDS) and psychological wellbeing of PwD and the effect could be sustained to 6 months post program. Disability measured by CDAD did not show improvement for all subscales in the 2 time intervals, congruent with expected decline in PwD. Although the ZBI did not show significant change, carer satisfaction survey indicated DCSS enriched carers’ knowledge and caring skills, and empowered them with community resources for aging in place. The program promoted PwD integration into community that an increased usage of DECCs service was observed at 6 months post program (42.5% vs 63% of PwD).DCSS also reduced burden on hospital resources for dementia rehabilitation at geriatric day hospital and by occupational therapists. DCSS demonstrates some favorable outcomes for PwD and their carers in addition to strengthening cluster collaboration between geriatric and psychogeriatric teams at PYNEH and RTSKH as well as inter-sectoral partnerships. A concerted effort towards enabling ageing in place promotes sustainable care for PwD in the community, reducing the burden on hospitals.

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