Promotion of Preventive Care for

Older Adults in Primary Care

Settings in Hong Kong

Dr. Felix Chan Hon Wai, JP • Co-convener, Clinical Advisory Group on Hong Kong Reference Framework for Preventive Care for

Older Adults in Primary Care Settings, Task Force on Conceptual Model and Preventive Protocols,

Working Group on Primary Care

• Member, Elderly Commission

• Immediate Past President, The Hong Kong Geriatrics Society

• Service Director (Primary & Community Health Care), Hospital Authority Hong Kong West

Cluster

Population estimates and projection for people aged 65 years or

over and percentage of total population by age group in Hong Kong

(2010 to 2031)

Population ageing increases healthcare services consumption –

Average number of in-patients in HA hospitals by age (2010)

Phase of Care

ACUTE

Inpatient

REHAB/CONVALESCENCE

Inpatient

Primary &

Community Health

Ambulatory

Medical

Mobility

Cognitive

Self-care

Vocational

Psychosocial

Early Discharge

5

Working Group on Primary Care

Health and Medical Development Advisory Committee

Working Group on Primary Care

•Chaired by SFH

•Members: public and private

sectors, academia, healthcare

professionals, patient representatives

Task Force on Conceptual Model and Preventive Protocols

Task Force

on Primary

Care

Directory

Task Force on Primary Care

Delivery Models

Task Force on Primary Dental Care and Oral

Health

Clinical Advisory Group on Reference

Framework for Diabetes Care for Adults in Primary

Care Settings

Clinical Advisory Group on Reference

Framework for Hypertension Care

for Adults in Primary Care Settings

Clinical Advisory Group on Reference

Framework for Preventive Care for

Older Adults in Primary Care Settings

Clinical Advisory Group on Reference

Framework for Preventive Care for Children in Primary

Care Settings

Objectives(1)

1. Provide a common reference to all healthcare

professionals for the provision of continuing

and comprehensive care for older adults

2. Recommend evidence-based interventions

that promote health, prevent disease and

tackle major health risks of older adults; and

3. Educate and empower older adults and carers

6

Objectives(2)

4. Promote and maintain healthy active lives

5. Reduce avoidable morbidity

6. Stay well in their communities and avoid

hospital admission

7. Reduce health costs

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THE 5 BIG “I”s

Instability & Immobility

Incontinence

Intellectual Failure

Iatrogenesis

Members of the Clinical Advisory Group on Reference Framework for

Preventive Care for Older Adults in Primary Care Settings

Co-Convenors:

Prof Sian GRIFFITHS & Dr Felix CHAN Hon-wai

Members:

Dr Alfred AU Si-yan Prof LAM Tai-pong

Dr Stephanie AU YEUNG Suk-yin Dr Augustine LAM Tsan

Dr Alvin CHAN Chung-yuk Dr LAU Ho-lim

Dr Mark CHAN Suen-ho Miss Victoria LAW

Dr CHAN Wai-man Dr Horace LEE Yan-wang

Dr Eunice CHAN Yin-chiu Ms Peggy LEE

Dr CHEUNG Hon-ming Prof Diana LEE Tze-fan

Mr CHEUNG Tak-hai Dr Edward LEUNG Man-fuk

Dr NG Kwok-keung Dr Sigmund LEUNG Sai-man

Ms Stella CHENG Mr Eddie LO Chak-chuen

Prof Helen CHIU Fung-kum Ms Winnie MA Man-fong

Prof CHU Leung-wing Dr Christina MAW Kit-chee

Dr Kenneth Fong Nai-kuen Dr Francis MOK Chun-keung

Mr Lawrence FUNG Mr Bobby NG

Ms Sylvia FUNG Yuk-kuen Dr SHEA Tat-ming

Ms Joan HO Dr Frankie SO Hon-ching

Dr Ruby LEE Siu-yin Dr Thomas TANG Man-leung

Dr Bernard KONG Ming-hei Dr Doris TSE Man-wah

Dr Henry KONG Wing-ming Dr TUET On-sang

Mr KWAN Siu-yuk Dr Nelson WONG Chi-kit

Prof Timothy KWOK Chi-yui Prof Martin WONG Chi-sang

Professor Claudia LAI Kam-yuk Prof Thomas WONG Kwok-shing

Dr LAM Ching-choi Prof George WOO

Mr LAM Ding-fung Dr YEUNG Chiu-fat

Task Force meeting on 15 Apr 2011

Agreed on life-course approach and conceptual model

Focus on preventive care with respect to physical, psychological and social dimensions in primary care

Clinical Advisory Group (CAG) meeting on 20 Jun 2011

Adopted population-based and high-risk individual approaches

Made recommendations with reference to primary, secondary and tertiary prevention

Subgroup on Health Assessment meeting on 8 Sep 2011

Prioritise various health domains for preventive care

Emphasize functional approach and multi-disciplinary collaboration

Clinical Advisory Group (CAG) meeting on 1 Mar 2012

Draft of Core Document on Reference Framework and Module on Health Assessment

Deliberate on specific recommendations and assessment tools for preventive care in older adults

Task Force meeting on 25 July 2012

The Core Document was endorsed

Development plan for reference framework for

older adults

First phase

• Development of the Core Document

• Module on Health Assessment

Second phase

• Modules on Functional disability

– Visual impairment

– Hearing impairment

– Fall

– Incontinence

Third phase

• Modules on

– Mood problem

– Cognitive impairment

Core Document - Content

Chapter

1 Overview of Older Adults Health in Hong Kong

2 Integrated and Collaborative Approach

3 Role of Primary Care in the Preventive Care of Older

Adults

4 Development of the Reference Framework

5 Evidence-based Recommendations

6 Practice of Evidence-based Recommendations for Older

Adults with Different Functional Capacity

7 Future Directions

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Highlights of Chapter 1-4

1. Set the scene for preventive care of

older adults

2. Adopt conceptual model with multi-

dimensional health domains

3. Population-based life course approach

complementary with high-risk individual

approach

4. Emphasize multi-disciplinary care and

inter-sectorial collaboration

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Conceptual Models for Older Adults:

Population Approach Across Life-Course

DETERMINANTS OF HEALTH FOR OLDER ADULTS

INDIVIDUAL LIFESTYLE FACTORS

PHYSICAL AND

PSYCHOLOGICAL FACTORS

FAMILY AND SOCIAL

FACTORS

COMMUNITY AND

ENVIRONMENTAL FACTORS

SERVICE PROVISION

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Integrated Primary Care Service Model

Adapted from: Active Ageing: A Policy Framework, WHO, 2002.

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Chapter 5- Recommendations on

preventive care

1. Make recommendations on preventive care

based on evidence and appropriateness to

primary care settings

2. Adopt the classification of evidence from

Scottish Intercollegiate Guidelines Network

(SIGN)

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Levels of Evidence 1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias

1+ Well conducted meta-analysis, systematic reviews of RCTs, or RCTs with a low risk of bias

1- Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2++ High quality systematic reviews of case-control or cohort studies

High quality case-control or cohort studies with a very low risk of confounding, bias, or

chance and a high probability that the relationship is causal

2+ Well conducted case control or cohort studies with a low risk of confounding, bias, or

chance and a moderate probability that the relationship is causal

2- Case control or cohort studies with a high risk of confounding, bias, or chance and a

significant risk that the relationship is not causal

3 Non-analytic studies, e.g. case reports, case series

Expert opinion

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4

Grades of Recommendation A At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable

to the target population; or

A systematic review of RCTs or a body of evidence consisting principally of studies rated as

1+, directly applicable to the target population, and demonstrating overall consistency of

results

B A body of evidence including studies rated as 2++, directly applicable to the target

population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1

C A body of evidence including studies rated as 2+, directly applicable to the target population

and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++

D Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

Scottish Intercollegiate Guidelines Network (SIGN) Classification 18

Recommendation on vaccination

Recommendation

Influenza

vaccination

Annual seasonal influenza vaccination is recommended

for:

Older adults aged 65 or older; and

Those high risk groups.

Pneumococcal

vaccination Single dose of 23-valent pneumococcal polysaccharide

vaccination is recommended for:

Those who have never received any before; or

Have received one dose before 65 years but more

than 5 years earlier.

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Recommendation on healthy lifestyle: Recommendation

Smoking Ask about tobacco use at every opportunity.

Advise all current smokers to quit smoking.

Drinking Assess the quantity and frequency of alcohol intake in all

older adults.

Advise on drinking to minimize alcohol-related harm.

Physical

activity

Assess current level of activities.

Promote regular physical activity.

Obesity Screen for overweight and obesity.

Advise on behavioural interventions to optimize body

weight.

Dental health Promote oral hygiene as part of general health education.

Assess for oral health problems periodically.

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Screening for common chronic diseases:

Recommendation

Hypertension Annual screening of hypertension.

Diabetes

mellitus Periodic screening of diabetes mellitus for adults starting from age

45 years.

Screen for diabetes mellitus every 3 years if previous results are

normal. More frequent testing e.g. every 12 months is recommended

when risk factors are present.

Hyperlipidaemia Periodic screening of hyperlipidaemia for those aged 50 to 75 years.

Screen for hyperlipidaemia every 3 years if previous results are

within optimal range.

More frequent testing e.g. every 12 months is recommended when

risk factors of cardiovascular diseases are present.

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Cancer screening

Recommendation

Cervical

cancer Women aged (25-64) who have ever had sex:

to have cervical cytology test every 3 years after two

consecutive normal annual cytology tests.

Screening discontinued in women aged 65+ years if 3

previous consecutive tests are normal.

Colorectal

Cancer Asymptomatic average-risk individuals aged (50-75) years

should consider screening for colorectal cancer by one of:

Annual or biennial faecal occult blood test.

Flexible sigmoidoscopy every five years.

Colonoscopy every ten years.

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Screening for functional disabilities: Recommendation

Hearing

Impairment Opportunistic screening of hearing impairment is recommended for

community-dwelling older adults.

Visual

Impairment

Opportunistic screening of visual impairment is recommended for

community-dwelling older adults.

Incontinence Opportunistic screening of urinary incontinence is recommended for

older adults.

Falls Primary care providers are recommended to assess the risk of falls in

older adults opportunistically.

Depression Opportunistic screening of depression is recommended for older

adults.

Dementia Primary care providers should assess cognitive function whenever

cognitive impairment or deterioration is suspected, based on direct

observation, patient report, or concerns raised by family members or

carers.

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Other recommendations:

Recommendation

Polypharmacy

and Adverse

Drug Reactions

When prescribing new drugs to the older patients, review all

the medications so as to avoid possible drug duplications,

interactions or adverse drug reactions.

Assessment of

Social Network

and Support

Opportunistic screening on the social support networks of

older adults, including the social needs and the extent and

availability of social support available is recommended.

Carer Stress To provide personalised support to careers enabling them to

remain mentally and physically well.

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Chapter 6- Practice of Evidence-

based Recommendations

1. Advocate individualized approach to address

different needs of older adults

2. Broadly classify older adults into 3 categories

from a life course perspective

Independent with no known chronic diseases

Independent with chronic diseases

older adults with disabilities

3. Systematic health assessment complementary

with opportunistic strategies

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A Life-Course Perspective in

Maintaining Independence

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Preventive Care Strategies

Throughout the Life-Course

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Independent with No Known Chronic Diseases

Preventive Care Recommendations Frequency

Health education

and promotion

Vaccination, healthy lifestyle, nutrition, oral

health

Every opportunity

Screening for

hypertension

Measure blood pressure Annually

Screening for diabetes

mellitus

Check blood for fasting blood sugar Every 1-3 years

Screening for

hyperlipidaemia

Check blood for lipid profile Every 1-3 years

Screening for

overweight and

underweight

Check BMI +/- waist circumference

Monitor body weight and assess risk of

malnutrition

Annually

Screening for

colorectal cancer

Check faecal occult blood test Every 1-2 years

Screening for

functional impairment

Hearing, vision, incontinence, falls, dental,

depression, dementia, social isolation

Opportunistic or

when clinically

indicated

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Independent with Chronic Diseases Preventive Care Recommendations

Risk assessment of

hypertension and diabetes

mellitus (if any)

Risk assessment for secondary and tertiary

prevention

Review use of medications Screen for problems related to medication use and

polypharmacy

Screen for overweight and

underweight

Check BMI +/- waist circumference

Monitor body weight and assess risk of

malnutrition

Opportunistic screening of

functional impairment

Hearing, vision, incontinence, falls, dental,

depression, dementia, social isolation

Screening for abilities on

self care and daily living

Screen for daily living problems by Basic ADL and

Instrumental ADL

Assess social network and

support

Assess the need of social and carer support

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Older Adults With Disabilities

Preventive care Recommendations

Assess the abilities on self

care and daily living

Assess functioning of daily living in the community

by Basic ADL and Instrumental ADL

Opportunistic screening of

functional impairment

Hearing, vision, incontinence, falls, dental,

depression, dementia, social isolation

Assess risk of malnutrition Check BMI and monitor body weight

Review use of medications Screen for problems related to medication use and

polypharmacy

Assess social network and

support

Screen for carer stress

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Systematic Health Assessment

Identify target older

adults

• A systematic approach in identifying appropriate target older adults

Baseline Assessment

• Early identification of common health problems

• Define the level of function and risk profile

Formulate care plan

• To formulate a personalised preventive care plan for different categories (i.e. independent with no known chronic diseases, independent with chronic diseases, older adults with disabilities)

Care co-ordination

• Family doctor co-ordinates with a team of health care professionals to deliver a personalised care and helps older adult to navigate the different levels of health care system

Monitoring and review

• Monitor and review the implementation of preventive care plan

Chapter 7- Future Directions

To put greater emphasis on primary &

preventive care

To engage different healthcare providers,

professional organizations, non-

governmental organizations, community

stakeholders and social service agencies

to adopt, implement and further modify

the Reference Framework.

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Timeline Focus Activity

Short term Increase awareness

and facilitate

adoption

Develop summaries and Chinese version for core module

Organize CME/CPD programme

Letters to doctors and professional organizations

Prepare promotional articles in newsletters of professional

organizations/colleges

Prepare scientific articles

Intermediate

term

Identify service

gaps and provide

services as

appropriate

Discuss with stakeholders to identify service gaps in the

community

Explore feasibility to collaborate with professional

organizations/NGOs to develop and implement pilot projects

Long term Explore new service

delivery models of

care and other new

initiatives

Utilize the concept of “Community Health Centres” to

provide nursing and allied health support services for family

doctors

Promulgation Plan For healthcare professionals

For publicPrepare a patient version of the reference frameworks

Collaborate with other stakeholders, e.g. professional organizations, NGOs,

patient groups, to promote the use of the reference frameworks

Doing

Things

Cheaper

Doing

Right

Things

Doing

Things

Right

Doing

Right

Things to

Make

Things

Right

???

ACCESS :

Accessibility, Continuity, Collaboration, Education, Service quality & Sustainability

Are we doing better over time?

Supporting organizations Service providers in the public sector

1. Hospital Authority

Universities

2. Faculty of Health and Social Sciences, The

Hong Kong Polytechnic University

3. Faculty of Medicine, The Chinese University

of Hong Kong

4. Faculty of Medicine, University of Hong

Kong

Academy and Colleges

5. Hong Kong Academy of Medicine

6. College of Ophthalmologists of Hong Kong

7. Hong Kong College of Community

Medicine

8. Hong Kong College of Family Physicians

9. Hong Kong College of Physicians

10. Hong Kong College of Psychiatrists

11. Hong Kong College of

Otorhinolaryngologists

• Professional organizations (medical and

dental)

12. Association of Licentiates of Medical Council of

Hong Kong

13. Hong Kong Association of Gerontology

14. Hong Kong Dental Association

15. Hong Kong Doctors Union

16. Hong Kong Geriatrics Society

17. Hong Kong Medical Association

18. Hong Kong Society of Palliative Medicine

• Professional organizations (Nursing and

allied health)

19. Hong Kong College of Gerontology Nursing

20. Hong Kong Occupation Therapy Association

21. Hong Kong Physiotherapist Union

22. Hong Kong Psychological Society, Division of

Clinical Psychology

23. Hong Kong Society of Professional Optometrists

• Patient group

24. Alliance for Patients’ Mutual Help Organizations

• Other relevant stakeholders

25. Social Welfare Department

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Thank you!