frailty & strength in community final96 - [email protected] title frailty...
TRANSCRIPT
O u r A g e i n g Po p u l a t i o n : F r a i l t y a s a C o r n e r s t o n e o f H e a l t h & S o c i a l C a r e
FRAILTY MEETS STRENGTH IN THE COMMUNITY
Keep healthcare sustainable & affordableSupport aspirations & needs of the Merdeka Generation
Enhance CHAS
Extend MediShield Life coverage
Enhance community care and caregivingStrengthen primary care foundation
Build communities of care to support ageing in place
Empower Singaporeans to live healthilyManage diabetes
Encourage screening
Support women’s health
Strengthen community mental health services
Equip professionals and providersA progressive, future-ready workforce to meet demand
Adapted with permission from A/Prof Ian Leong, NHG Clinician Lead, Living with Frailty, Mar 2019
Front door(ED/Call Centre)
Inpatient Transit Community (Home)
Primary Care (GPs & Polyclinics)
Specialist Outpatient
Clinic
Intermediate Care Clinic
Primary Care engagement & collaborative programmes
Community Hospital
Nursing Home
Frailty-Ready System of Care
Frailty-Ready Transitions
AH-Nursing Home Flows
Frailty-Ready Community
Ambulatory Care for the Frail
Frailty-Ready Whole Hospital
© Copyright 2018 National Healthcare Group, Singapore. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any way, for or by any means electronic or mechanical, including photocopying, recording or otherwise, without the prior permission of the National Healthcare Group.
MANDAI
SIMPANGWOODLANDS
9
ANG MO KIO11
SERANGOON
8 HOUGANG
9BISHAN15
TOA PAYOH18
GEYLANG
7NOVENA-ROCHOR-KALLANG
13
SEMBAWANG4
YISHUN
7
760115
760131
400003
805910
737878
757614
520718
319264
760765
761426
521117
090007
521827
670629
730123
768992
760260
731569
460012
338771
320128
219458
520237
560113
670139
N
N
123456
Number of Community Health Posts
Number of Community Nurse Posts
Share a Pot® site
Population Health Improvement in the Community
Existing groups§ Faith-based§ Centre-based
Group activities to promote health & wellbeing
NEW!§ Identification § Outreach
Block mapping, screening activitiesJoint outreach & management
Last mile deliverySOCIAL
Social engagementPeer group support
HEALTHSteady: Falls, BalanceLean: DiabetesStrong: Frailty
Peer
sup
port
for
chro
nic
dise
ase
Coaching
Supported self-managem
entSkills for life
Inclusive community
Teams are § placed-based§ multi-disciplinary§ self-managed
Stealth health
Collaborative partnerships
Illustrated figures created by Lluisa Iborra from Noun Project
Discover, Activate, Connect, AppreciateCitizens as the Primary Unit of Health/Well-Being Production
ABCD
Neighbourhood conversations & visionStrong networks built on relationships
Increasing the “BY” space
Community maps
What can the residents do for
themselves without outside help?
What can they do with a little outside help?
What do they need to be done
for them?
DONE BY THEM DONE WITH THEM DONE FOR & TO THEM (WITHOUT THEM)
Asset-Based Community Development (ABCD)
PMHx§ Diabetic Mellitus§ Hypertension§ Hyperlipidemia§ Stable left lower limb
peripheral artery disease§ Coronary artery disease§ Major depressive disorder Appointments§ SOC PSY§ SOCVascular§ Polyclinic
1. Glipizide 15MG BD2. Metformin 750mg BD3. Sitagliptin 100mg OM4. Amlodipine 5mg OM5. Losartan Potassium 75mg OM6. Atorvastatin 80mg ON7. Carvedilol 12.5mg BD8. Plavix 75mg OM9. Omeprazole 20mg BD10.GTN 500mcg PRN sublingual11.ISMN 60mg OM12.Amitriptyline HCl tablet 10mg ON13.Glucosamine Sulphate 1000mg OM14.Bisacodyl 10mg PRN15.Lactulose 10mls TDS PRN16.Vitamin D3 1000unit OM
Mdm A, 69 Y/O, Chinese§ BADL & IADL
independent§ Community ambulant § CFS 4 § Stays with husband in a
one-room rental flat § Shifted to Yishun in 2017§ Referred by TOUCH SAC
OUTCOMES OF INTERVENTION1. Reduced and simplified medications2. Adherent to medications3. Followed dietary recommendations4. Regular exercise5. Followed care plan
§ Improved BP & DM control§ Ideal BMI§ Better mood
6. Single polyclinic appointment7. Familiar with community resources8. Volunteer at CNP & SAC
Case Study: Five Capacity & Capability Building Thrusts for Self Management
Health coaching Group activities to promote health &
wellbeing
Peer support for people living with
chronic disease
Supportedself-management
Asset-Based Community
Development
Case Study: Five Capacity & Capability Building Thrusts for Self Management
Mdm Lim Peck GeokFrail
Broke her arm after colliding with a passerby, protective family insisted that she stayed home & wore her arm brace >6 months. Encouraged by neighbour’s daughter to join Stepping Up workshop at Wellness Kampung to manage her frailty.
Mdm Chua PongCoronary heart disease
Neighbour of Mdm Lim; daughter is a Kampung Buddy who brings her to the Wellness Kampung everyday. Participates in daily exercise and has friends around her while her daughter is out doing Meals-on-Wheels visits.
Mdm Chang Yuen Ling Frail
Residents noticed her BMI dropping during Share A Pot®. Aunties at the Wellness Kampung look out for her by cooking food that she enjoys. SMART Nurses now monitor her nutrition.
Mdm Tan Ah MoyEarly dementia
aka “The Supervisor” of the group, coordinates activities of the day for the rest of the “Cover Girls.” The rest of the aunties look to her for “guidance.”
Community Capacity- & Capability-BuildingSeniors Looking After Seniors: Wellness Kampung Cover Girls
Web of SupportIt takes a village to age well in place…
Social Relationships and Mortality Risk: A Meta-analyticReviewJulianne Holt-Lunstad1.*, Timothy B. Smith2., J. Bradley Layton3
1 Department of Psychology, Brigham Young University, Provo, Utah, United States of America, 2 Department of Counseling Psychology, Brigham Young University,
Provo, Utah, United States of America, 3 Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
Abstract
Background: The quality and quantity of individuals’ social relationships has been linked not only to mental health but alsoto both morbidity and mortality.
Objectives: This meta-analytic review was conducted to determine the extent to which social relationships influence risk formortality, which aspects of social relationships are most highly predictive, and which factors may moderate the risk.
Data Extraction: Data were extracted on several participant characteristics, including cause of mortality, initial health status,and pre-existing health conditions, as well as on study characteristics, including length of follow-up and type of assessmentof social relationships.
Results: Across 148 studies (308,849 participants), the random effects weighted average effect size was OR = 1.50 (95% CI1.42 to 1.59), indicating a 50% increased likelihood of survival for participants with stronger social relationships. This findingremained consistent across age, sex, initial health status, cause of death, and follow-up period. Significant differences werefound across the type of social measurement evaluated (p,0.001); the association was strongest for complex measures ofsocial integration (OR = 1.91; 95% CI 1.63 to 2.23) and lowest for binary indicators of residential status (living alone versuswith others) (OR = 1.19; 95% CI 0.99 to 1.44).
Conclusions: The influence of social relationships on risk for mortality is comparable with well-established risk factors formortality.
Please see later in the article for the Editors’ Summary.
Citation: Holt-Lunstad J, Smith TB, Layton JB (2010) Social Relationships and Mortality Risk: A Meta-analytic Review. PLoS Med 7(7): e1000316. doi:10.1371/journal.pmed.1000316
Academic Editor: Carol Brayne, University of Cambridge, United Kingdom
Received December 30, 2009; Accepted June 17, 2010; Published July 27, 2010
Copyright: ! 2010 Holt-Lunstad et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permitsunrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This research was generously supported by grants from the Department of Gerontology at Brigham Young University awarded to JHL and TBS andfrom TP Industrial, Inc awarded to TBS. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
Abbreviations: CI, confidence interval; CVD, cardiovascular disease; OR, odds ratio
* E-mail: [email protected]
. These authors contributed equally to this work.
PLoS Medicine | www.plosmedicine.org 1 July 2010 | Volume 7 | Issue 7 | e1000316
© Copyright 2018 National Healthcare Group, Singapore. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any way, for or by any means electronic or mechanical, including photocopying, recording or otherwise, without the prior permission of the National Healthcare Group.
You think because you understand “one” that you must therefore understand “two” because one and one make two. But you
forget that you must also understand “and”.Sufi teaching story
Dr Wong Sweet FunSenior Consultant, Geriatric Medicine
Deputy Chairman, Medical Board (Population Health)Clinical Director, Population Health & Community Transformation
Chief Transformation OfficerClinical Director (Population Health)
Clinical Lead, Living Well
Khoo Teck Puat HospitalKhoo Teck Puat Hospital & Yishun HealthKhoo Teck Puat Hospital & Yishun HealthKhoo Teck Puat Hospital & Yishun HealthWoodlands Health CampusNational Healthcare [email protected]