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					Journal of the Hong Kong Geriatrics Society • Vol. 10 No.2 July 2000

TC Sim M.B., B.S. (Singapore), FHKAM (Med)
Senior Medical Officer
EMF Leung M.B., B.S. (H.K.), FRCP (Edin), FHKAM (Med)
Chief of Service, Department of Medicine and Geriatrics,               J HK Geriatr Soc 2000;10:84-89
United Christian Hospital, Kwun Tong, Hong Kong                        Correspondence to: Dr T C Sim

Summary:                                                                   Although Hong Kong has a predominantly
     Factors associated with the ageing of Hong                        Chinese population and a culture that values care
Kong’s population has led to increasing need for long                  of the elderly by their own family, there has been a
term care. Nursing homes operated for profit provide                   marked change in the traditional family structure
the majority of long term care places. Residents in                    over the past two decades. There is an increasing
these homes are characterised by chronic diseases,                     tendency towards nuclear families which weakens
multiple disabilities and a high incidence of cognitive                family support for the elderly. Elderly people also
impairment. Therapeutic care is needed to maintain                     tend to have poor social support. About 10% of
the functional status of these frail elderly residents.                elderly people live alone and 12% with their spouse
There are service gaps in the existing system of                       only. Therefore about 22% of elderly people live in
community health care services. Delivery of health                     a p o t e n tia lly w e a k s u p p o r t in g n e t w o r k 4 .
care requires a highly co-ordinated effort with a close                Furthermore 60% of elderly people in Hong Kong
partnership between the hospital and nursing home                      report that they do not have a close family member
because residents are frequently transferred                           or friend 5. These are well documented risk factors
between these two places. Strategies to improve the                    for institutionalization 6,7.
standard of health care in these nursing homes                             Hong Kong is also experiencing another
include an active educational program for nursing                      demographic transition that is described as the
home staff, the role of community nurses to provide                    feminisation of ageing 8. There are more elderly
regular assessment and treatment, an integrated                        women than men but they are more vulnerable to
medical record to improve documentation between                        isolation than men. They tend to live alone and
t h e h o m e a n d h o s pi t a l a n d e m ph a s i s o n            receive less help from relatives compared to their
rehabilitation.                                                        male counterparts 9. There are twice as many elderly
                                                                       women compared to men in institutional care in
Rising demand for nursing home care in Hong                            Hong Kong10. With these social, epidemiological and
Kong                                                                   demographic trends coming together, Hong Kong
    Hong Kong has a rapidly ageing population. At                      can be expected to follow the situation in the West
the same time there is an epidemiological transition                   where demand for long term care is growing.
where chronic diseases are the leading causes of                           There has already been a rapid increase in the
disability and death now. Such diseases are more                       supply of nursing home beds in Hong Kong over
common in the elderly and the likelihood of needing                    the past decade. The current capacity of nursing
help with activities of daily living becomes greater                   homes exceeds the bed capacity of the Hospital
with aging. About 40% of the elderly in Hong Kong                      Authority. In 1997, the number of government
have difficulties in activities of daily living1.                      subsidized C & A and Home for the Aged places
    These factors result in the elderly segment of                     was 17,487 while private nursing homes had
the population consuming a disproportionate                            17,700 places 11. The important role of the private
amount of health and long term care services. Data                     nursing home industry in long term care is also
in the West show that admission rates to nursing                       seen in the West. In the United Kingdom, the private
homes rise exponentially after the age of sixty-five.                  sector accounts for more than two thirds of
The age-specific admission rate to nursing homes                       residential homes while 92% of nursing homes in
increases fourteen-fold between the ages of sixty-                     the United States are privately owned12.
five and ninety 2. In the United States, 43% of persons                    There were 19,200 persons waiting for care-and-
after the age of sixty-five will use a nursing home                    attention home admission and 7,600 persons
before they die while more than 20% of nursing home                    waiting for infirmary placement in 1998. Such a
residents will spend at least five years there3.                       long queue for placement means that for most

                                                                                     T C Sim et al • Geriatrics Care in POAH

elderly people, the need for long term care need to        Characteristics of residents in private nursing
be met by other means like private nursing homes.          homes in Kwun Tong
These waiting-list statistics also reflect a genuine           1,002 residents of private nursing homes in
need for long term care that must be met. This was         Kwun Tong was surveyed in 1998. The average age
shown in a study of elderly people who needed long         of residents was eighty years and 68% were women.
term care in Hong Kong. 59.3% of those waiting for         35% had contractures of the legs, 38% were bed or
infirmary placement were already residing in private       chair-bound and 39% had either urinary or double
nursing homes 13. With our present economic                incontinence. Assessment with the Katz Index of
climate, the government is unlikely to have a              ADL17 showed 93% had one or more impairments
sustained increase in funding for long term care.          in the activities of daily living. 30.7% in a subgroup
There is good reason to believe that private nursing       of 268 patients audited for polypharmacy were
homes will continue to be the mainstay of long term        prescribed at least five drugs. There was also a high
care in future.                                            incidence of cognitive impairment. A similar survey
                                                           of 317 residents in 1999 found that 67% had
Standards of care in private nursing home in               Abbreviated Mental Test (Hong Kong version)18
Hong Kong                                                  scores less than six. By comparison, the prevalence
     There are 430 nursing homes run for profit in         of dementia in Hong Kong’s elderly population aged
Hong Kong 8. In a newspaper interview, the resident        seventy years or older in the community is 6.1%19.
of a Shamshuipo home said, “This man behind me             This is consistent with experience in other
speaks only Toishanese. The other man there who            countries, where cognitive impairment in long term
has cancer is in hospital at the moment. I have            care facilities is much higher than the community
never spoken to the two women hooked on feeding            and ranges from 30% to 70% 20,21. (Table 1)
tubes and the others are just too frail to talk and
lie in their beds.”                                        Table 1. Characteristics of residents in private nursing homes
     He was among 12 residents living in a 700             in Kwun Tong
square foot flat with two toilets, without a fire escape   Mean age (years)                              80 ± SD (8.6)
and the kitchen was built in an illegal structure.         Male/Female (%)                            M 32% / F 68%
There were only two female amahs, one for the day          Lower limb contractures (%)                    350 (34.9%)
and the other for the night14. While there can be          Bed or chair-bound                             385 (38.4%)
wide variations in disability levels and standards         Urinary or double incontinence                 396 (39.5%)
of care between different nursing homes, the               Functional dependency in at least one ADL (%)          93%
interview is a fair description of the typical private     Polypharmacy                                         30.7%
nursing home in Hong Kong.                                 AMT score < 6                                          67%
     Private nursing homes in Hong Kong have his-
torically poor standards of care15. Recent changes             The survey showed that private nursing home
in legislation can help to improve standards in            residents have a high prevalence of medical diseases
future16. At present, however, the “revolving door”        and disabilities. A significant proportion of private
patient from the nursing home is a familiar sight.         nursing home residents are not ambulant. Most
Common examples include severely disabled elderly          have impaired cognition. There is also the added
patients who are admitted for conditions such as           burden of advanced age, polypharmacy, complex
dehydration, undernutrition, pneumonia or                  interaction of acute and chronic diseases.
pressure sores; improved after a lengthy period of         Neuropsychiatric conditions that cause problem
hospital stay and discharged back to the nursing           behaviors are common. Therefore providing care to
home only to be rapidly re-admitted for the same           the nursing home resident is a challenging task.
problems. An audit in United Christian Hospital            The complexity at this level requires a highly
showed that 26.8% of unplanned readmissions to             coordinated effort.
the Department of Medicine and Geriatrics were
from private nursing homes. There is an obvious            Service gaps and unmet needs
lack of continuity between treatment in the hospital          At present, the residents of private nursing
and care in the nursing home. Nursing home                 homes actually use an impressive array of formal
residents have specific characteristics that partly        health care services. Apart from the nursing home
explain why this service gap exists although Hospital      staff and private medical practitioner, other
Authority already has a sophisticated structure to         service providers include the acute hospital for
ensure continuity of care in the community.                inpatient care and outpatient clinics, day hospital,

Journal of the Hong Kong Geriatrics Society • Vol. 10 No.2 July 2000

community nursing service, community reha-                             nursing homes themselves. It has been famously
bilitation team, community geriatric assessment                        said “a nursing home is a facility that has few or no
team and Department of Health elderly health                           nurses and can hardly qualify as a home”22. There
teams and general outpatient clinics. There are,                       is a shortage of trained staff. The environment lacks
however, gaps among this existing range of service                     privacy and has inadequate facilities for social and
providers because we do not have a coherent                            recreational activities. Individual treatment plans
approach towards care of this group of elderly                         are often lacking. Rehabilitation is rare although
patients with chronic disabling conditions. They                       many residents need some form of maintenance
may be confused and unable to give an accurate                         therapy. One major reason for the poorer standards
history. They are often unable to participate                          of private nursing homes compared to government-
effectively in making decisions for their own medical                  funded ones is their lower cost. Profitability is a
care, especially when acute illness intervenes.                        natural consideration in any profit making business
Therefore a piecemeal approach where the nursing                       and private nursing homes provide less because
home resident is referred between various services,                    they usually charge less.
with none having overall responsibility, results in
lack of continuity of care. Some suffer unnecessary                    The need for health care in nursing homes
morbidity when they cannot gain access to the                             There are many factors that contribute to the
services that they require.                                            present state of private nursing homes. This
    The nursing home resident has basic needs like                     results in the elderly resident having many needs
food, shelter, assistance with activities of daily living              that are not addressed in the nursing home
and nursing care. Another need often overlooked                        environment. Despite the constraints described
is transportation. Many of these disabled elderly                      above, public expectations for the care of our
residents need assistance to attend medical                            nursing home residents are high. There is a
appointments. Transport services like Rehabus                          hypothesized link between unmet need for
and Hospital Authority NEATS can only partly fill                      assistance and increased use of acute hospital
this ne ed . T he se re sid ents of ten ne e d an                      services (see Figure 1)23. We need to improve the
accompanying person to help with the logistics of                      standard of care in private nursing homes or the
the outpatient clinic and to fill prescriptions at the                 residents will use the hospital eme rgency
pharmacy. They are also needed to provide key                          department by default. Leaving aside the nursing
information when the resident has impaired                             home cost versus quality conundrum, we can still
cognition. Nursing home residents often have to                        improve the standard of care with effective geriatric
depend on the home’s staff for this function                           outreach services to these homes.
because they lack adequate social networks. When
the nursing home staff cannot fulfill this function,
compliance with medical treatment can be                                                      Unmet need
disrupted and the health of the resident is
compromised. It is not uncommon for disabled                                                 Adverse events
residents to default medical follow-up for this
reason. This makes the capability to provide on-
site medical care in nursing homes important.                                               Negative health
    P r iv ate nur s ing hom e s d o not p r ov id e
comprehensive medical care. However they are                                               Elevated levels of
receiving people with severe illnesses from our                                              acute care use
hospitals. Therefore there is an urgent need to
improve the standard of nursing homes if patients                      Figure 1. Hypothesized Causal Chain 23
are to be discharged safely after a short length of
stay in hospital and maintained in a reasonable                            Fundamental to improving the standard of care
state of health in the homes. Without effective post-                  in private nursing homes is a clear concept of the
acute care, the nursing home resident is at high                       goals of nursing home care. Nursing home care
risk for either extended lengths of stay in hospital                   should fulfill the goals as listed in Table 224. Most
or for transfer back and forth between the nursing                     of these goals are similar to our care for the elderly
home and acute hospital.                                               in geriatric medicine and focus on functional
    Apart from the problems of the residents, we                       independence, quality of life, comfort and dignity of
should also look at the problems of the private                        the residents. Medical staff who cares for nursing

                                                                                           T C Sim et al • Geriatrics Care in POAH

home residents must keep these goals in perspective                 The residents have food and shelter in a reasonably
while addressing the usual aims of medical treatment                safe and clean environment. The goals of nursing
such as prevention and cure of acute illnesses.                     home care as listed in Table 1 are often neglected.
                                                                    Nursing home staff may perform most tasks for the
Table 2. Goals of nursing home care24                               residents, irrespective of individual ability. Most
1. Safe and supportive environment for the chronically ill.         staff take over functions like bathing, dressing, use
2. Provide rehabilitation to ensure best functional and cognitive   incontinence pads in place of the toilet and
   status.                                                          wheelchairs instead of encouraging ambulation.
3. Professional nursing care to delay progression of chronic        These helping activities reduce opportunities for
   medical illness.                                                 residents to practise the skills needed for activities
4. Prevent acute and iatrogenic medical disease.                    of daily living. In turn, this fosters the concept that
5. Dignity and comfort for chronically / terminally ill residents   elderly residents are not capable of basic self-care.
   and their carers.                                                It has been shown that compared to encouragement
6. Allow autonomy and decision making concerning end of             or minimal assistance, an actively “helping”
   life issues.                                                     intervention can reduce the elderly subject’s
                                                                    ability to perform a task 25. Nursing homes that
    Geriatric outreach services to nursing homes                    emphasize such custodial care can potentially
allow hospital-based geriatricians a unique                         increase disability in those residents they are
opportunity to integrate the home’s resources into                  serving. In contrast, the concept of therapeutic care
the hospital’s continuum of care. To form an                        requires a range of recreational and rehabilitative
effective partnership with the nursing home, the                    activities to maintain their functional status for as
geriatrician must be familiar with the home’s staff                 long as possible. In caring for such frail elderly
structure and routine. This can differ greatly from                 residents, it is useful for staff to see therapeutic
the hospital environment that we are familiar with.                 activity as being anything you do. Routine tasks
For example, aides that provide hands-on care may                   like activities of daily living, baths, meals or family
not be under the administrative control of the                      visits can be used to maintain skills, promote
nursing staff. Instead they often answer to the home                self-esteem and promote social interaction.
manager or owner, who may not be a trained health                   Motivation is an important factor in the elderly
professional. These aides may have received limited                 person’s ability to perform such activities and
education and even less training in health care.                    interventions to improve motivation should be
They may not be conversant in Cantonese and job                     developed by carers26.
turnover is high. Hence, apart from patient factors,                    The outreach team has a responsibility towards
the delivery of health care can be significantly                    continuing education of the nursing home staff,
influenced by the structure of the nursing home                     particularly the care aides. Care aides have a
staff. Awareness of the different priorities of the                 tremendous influence on the quality and type of
home managers, nurses and care aides can help                       care provided to residents. They have no formal
avoid conflicts that result in the patient receiving                training and respond intuitively to changes in the
sub-standard care.                                                  resident's condition. Experienced aides, however,
                                                                    can grasp the meaning of a situation for their clients
Strategies to improve the standard of care in                       or recognize the need for a particular action.
nursing homes                                                       Through close personal contact, they know the
1. Training for carers:                                             residents well and can provide a familiar and
    Private nursing homes have difficulty attracting                supportive environment that is very important for
qualified nurses because of the unpleasant job                      thoes with impaired cognition. Carers, however,
nature, long hours and poor pay. Shortage of                        often experience strss in coping with problem
properly trained staff leads to poor quality of care                behaviours. Staff burnout is a major hazard when
in the home. There should be an active program of                   there are high proportions of cognitively impaired
in-service training for the care staff. Apart from                  residents. A survey of staff needs in dementia units
formal lectures, this also includes partnering with                 in Canada found that management of their own
the care aides and providing them with knowledge                    stress levels was among the training topics that
and solutions to the problems that they face with                   had greatest demand 27 . There is a need for
particular residents.                                               continuing staff training and genuine
    An important area of education is staff attitudes               encouragement.
towards care of residents. Private nursing homes
commonly focus on custodial care of their residents.

Journal of the Hong Kong Geriatrics Society • Vol. 10 No.2 July 2000

2. Professional nursing care for private nursing                       nursing home is also strengthened with the use of
homes:                                                                 a simplified record of nursing issues to be followed
    Another strategy that can help improve nursing                     up by nursing home staff. The Chinese script should
home care is the role of community nurses as part                      be used in these nursing records for effective
of the geriatric outreach team. They can teach                         communication with the nursing home staff.
formal skills necessary for nursing medically
complex patients. Community nurses can also                            4. Rehabilitation assessment and training:
positively influence the nursing home staff in non-                        Rehabilitation should be an integral part of the
medical aspects of resident care. Where there are                      treatment of nursing home residents. This is
subacutely ill residents who require close                             particularly important for patients discharged
monitoring, the community nurse’s contribution in                      from hospital. Elderly patients are at high risk
assessment of the resident at home is particularly                     for deterioration in function after hospital
important as the geriatrician cannot see the                           discharge 28,29 . In consultation with a multi-
reside nts daily. They can perf orm on-site                            disciplinary team, provisions can be made for
assessment to detect new problems early. This                          rehabilitative activities in the nursing home or in
allows appropriate referral to the geriatrician and                    other facilities like the geriatric day hospital.
rapid identification of residents who need hospital                    Residents able to perform activities of daily living
care. The capacity to provide close monitering on-                     and small chores in the home should be encouraged
site also allows a variety of medical conditions to                    to do so. Bed-bound patients should have protocols
be treated in the home instead of transfer to acute                    for frequent turning to prevent pressure sores and
hospital. With close observation, nurses can keep                      regular assessment for aspiration and
febrile illnesses like upper respiratory tract                         undernutrition. Homes often lack the space and
infections or uncomplicated cystitis in the nursing                    facilities for proper recreational activities. Residents
home. The new routines and strange environment                         who are less disabled, however, do benefit from
encountered after transfer to an acute hospital                        group activities and recreational therapists can be
can be a disruptive experience to nursing home                         a valuable resource for this purpose.
residents, particularly those with impaired
cognition. Risk of iatrogenic problems like pressure                   Conclusion
sores and deconditioning are high. In selected cases,                      Private nursing homes have an established role
geriatric outreach teams working in partnership                        in the care of a highly specific population of elderly
with nursing home staff can offer treatment in the                     people with chronic disabilities. It is a challenge to
home without detracting from the quality of care                       provide a coherent approach towards long term care
provded.                                                               for this group of frail elderly people. Existing
                                                                       community resources are inadequate for their
3. Documentation of medical problems and                               complex needs. Reliance on our traditional hospital-
medications:                                                           based services is not an effective way to deliver
    Nursing home residents have often have                             healthcare to these elderly people. Outreach
multiple medical problems and may not be able to                       services led by geriatricians can provide the
relate their medical histories accurately. Proper                      leadership to integrate these homes into our health
documentation is a key strategy for improving the                      care system. We can form effective partnerships
standard of medical care in the nursing home. The                      with the nursing home staff to improve quality of
medical database of diagnoses, progress notes of                       medical care for elderly people residing in these
follow-up visits in the home, acute hospital records                   private nursing homes. Every effort should be made
and medications should be kept together. Such an                       to develop this new system of healthcare delivery.
integrated record facilitates medical decision-
making both in the nursing home, especially in the                     References
post-acute phase after discharge from hospital, and                     1. Leung MF, Lo MBN. Social and health status of elderly people in
vice versa. It also avoids interruptions in the medical                    Hong Kong. In: SK Lam (ed). The health of the elderly in Hong
record at a time when there are changes in the                             Kong. Hong Kong: Hong Kong University Press, 1997:43-62.
patient’s status. For example, this occurs during                       2. Freedman VA. Family structure and the risk of nursing home
                                                                           admission. Jour of Geronto: Soc Sci 1996;51B (2) S61-S69.
the acute illness that necessitates transfer from
                                                                        3. Kemper P, Murtaugh CM. Lifetime Use of Nursing Home Care. N
home to hospital and in the recovery phase when
                                                                           Eng J Med 1991;324(9):595-600.
the patient can be discharged back to the home.                         4. Leung EMF. Housing and environmental issues for elderly people
Continuity of care between the acute hospital and                          - a health and functional perspective. In: Phillips DR, Yeh AGO

                                                                                                       T C Sim et al • Geriatrics Care in POAH

    (eds). Environment and ageing: environmental policy, planning and         of biological and psychosocial function. J Am Med Asso 1963,185:
    design for elderly people in Hong Kong. Hong Kong: Centre of              914-9
    Urban Planning and Environmental Management, University of            18. Chu LW, Pei CKW, Ho MH, Chan PT. Validation of the
    Hong Kong, 1999:37-51.                                                    Abbreviated Mental Test (Hong Kong version) in the elderly medical
5. Chi I. Social support among Chinese elderly in four Asian cities.          patient. HK Med Jour 1995;1:207-211.
    HK Jour Geronto 1996;10(Supplement):369-372.                          19. Chiu HF, Lam LC, Chi I et al. Prevalence of dementia in Chinese
6. Lagergren M. Transferring to an institution - an analysis of factors       elderly in Hong Kong. Neurology 1998;50(4):1002-9
    behind the transfer to institutional long term care. Can J on Aging   20. McEwan KL, Maxwell D. Basic facts and figures about dementia
    1996;15(3):427-441.                                                       patients in institutions. In Gutman G (ed). Shelter and care of
7. Glazebrook K, Rockwood K. A case control study of the risks for            persons with dementia. Gerontology Research Centre, Simon Fraser
    institutionalisation of elderly people in Nova Scotia. Canadian J         University 1992:3-17.
    on Aging 1994;13(1):104-117.                                          21. National Center for Health Statistics(1994). Characteristics of
8. Bonita R. Women, ageing and health. Achieving health across the            nursing home residents. In National Center for Health Statistics
    life span. World Health Organisation. Geneva. 1998.                       PHS 81-1721. National nursing home survey. Washington DC: US
9. Chi I, Chow N. Housing and family care for the elderly in Hong             Government Printing Office
    Kong. Ageing International 1997;Winter/Spring:65-77.                  22. Butler RN. Why survive? New York: Harper and Row Publishers,
10. Woo J, Ho SC, Lau J, Yuen YK. Age and marital status are major            1975.
    factors associated with institutionalisation in elderly Hong Kong     23. Allen SM, Mor V. Unmet need in the community. In: Isaacs SL,
    Chinese. J Epidemiology and Community Health 1994;48:306-309.             Knickman JR (eds). To improve health and health care,1997. The
11. Social Welfare Department 1996-1997 Departmental Report                   Robert Wood Johnson Foundation Anthology. San Francisco:
12. Rhoades J, Potter DEB, Krauss N. Nursing homes - structure and            Jossey-Bass Inc., Publishers, 1997:132-160.
    selected characteristics, 1996. Rockville (MD): Agency for Health     24. Wong CP, Yu TKK, Leung JYY et al. Experience sharing of private
    Care Policy and Research; 1998. MEPS Research Findings No. 4.             nursing home (PNH) program in Hong Kong East Region. Geriatric
    AHCPR Pub. No. 98-0006.                                                   Quarterly Update July 1998:3-4.
13. Ngan R, Leung EMF, Kwan A, Yeung D, Chong A. (1996). A Study          25. Avorn J, Langer E. Induced Disability in nursing home patients: a
    of the Long Term Care Needs, Patterns and Impact of the Elderly           controlled trial. J Am Geriatr Soc. 1982;30:397-400.
    in Hong Kong. Research Report. Department of Applied Social           26. Resnick B. Motivating older adults to perform functional activities.
    Studies: City University of Hong Kong                                     J Gerontological Nursing 1998;24(11):23-30.
14. Wan C. The others are too frail to talk. South China Morning Post     27. Gutman GM, Killam J. Characteristics of six special care units in
    May 31 1999.                                                              British Columbia. In: Gutman G (ed). Shelter and care of persons
15. Cheng ST, Chan ACM. The future of the elderly homes in Hong               with dementia.. Vancouver: Gerontology Research Centre, Simon
    Kong: an ecological analysis. HK Jour Geronto 1993,7(2):29-33.            Fraser University 1992:19-41.
16. Social Welfare Department. Residential Care Homes (Elderly            28. Sager MA, Franke T, Inoute S et al. Functional outcomes of acute
    Persons) Ordinance. Hong Kong : Hong Kong Government                      medical illness and hospitalization in older persons. Arch Intern
    Printers1995.                                                             Med 1996;156:645-652.
17. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies          29. Woo J, Cheung A. A survey of elderly people discharged from
    of illness in the aged. The Index of ADL: A standardised measure          hospital. J HK Med Asso. 1993;45(4):291-297.


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