A Pilot Dementia Shared Care Programme between Hospitalist and Primary Care Physician

Abstract Description

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Authors (including presenting author) :

Chiu KCP (1), Chan NY (1), Lee SC (2), Kwong KW (3), Luk KHJ (4), Lee RSY (3), Chan HWF (4)

Affiliation :

(1) Department of Medicine, Queen Mary Hospital, (2) Nursing Department, Queen Mary Hospital, (3) Elderly Health Service, Department of Health, (4) Department of Medicine and Geriatrics, Fung Yiu King Hospital

Introduction :

The Memory clinic of Queen Mary Hospital (QMH) has collaborated with the Sai Ying Pun Elderly Health Centre (EHC) of Department of Health (DH) in the management of dementia with an attempt to develop a shared care model to enhance dementia care for EHC members and to reduce the impact of dementia care on the tertiary care system.

Objectives :

To report on the feasibility of a shared care programme between primary care physicians of DH and specialists of Hospital Authority (HA) in the care of dementia patients.

Methodology :

With consent, active EHC members of a regional district attending the Memory Clinic are referred to EHC for shared care. Inclusion criteria are mild cognitive impairment or mild dementia with or without stable dose of cholinesterase inhibitor. Patients with behavioral and psychological symptoms of dementia (BPSD) are excluded. In the programme, EHC multi-disciplinary team comprising of doctor, nurses, clinical psychologist, occupational therapist and physiotherapist will continue pharmacological treatment, provide cognitive and functional assessment and training, mood monitoring and carer skill training. These patients would have annual visits at QMH for review instead of the usual twice-to-thrice yearly follow-up.

Result & Outcome :

From 1st September 2018 to 28th February 2019, 51 EHC members attended Memory clinic. Twenty-six did not fulfill referral criteria. Eleven of remaining 25 (44%) were referred to EHC for shared care. 6 females and 5 males. Their mean age was 83.8 years and mean Abbreviated Mental Test score was 7.5. Those excluded for referral (n=40) included the followings: dementia medications not enlisted in EHC (40%); conditions warranting specialist follow-up (27.5%); significant behavioral and psychological symptoms of dementia (BPSD) (10%); without consent (10%); infrequent follow-up visit (annually) at QMH (7.5%) and advanced dementia (5%). During the programme, there was one patient referred back to QMH for management of BPSD. Conclusion: This pilot illustrated the feasibility of a collaboration between primary care team of DH and Memory clinic of a HA hospital in the care of dementia patients. With the programme, patients have more opportunities to receive cognitive rehabilitation and their psychosocial health would be better taken care of by a multi-disciplinary care team. Patients would also attend less frequently in the tertiary care institution and this might relieve the clinic load of a HA hospital. Future study is recommended to assess patient / family satisfaction, patient outcomes and the potential effectiveness of the programme on reduction of tertiary care burden.