As director of the Jockey Club Centre of Positive Ageing and a Professor in the Department of Medicine & Therapeutics at the Chinese University of Hong Kong, Professor Timothy Kwok has built a global reputation for his work in dementia care in hospital settings. Ahead of addressing next month’s International Dementia Conference in Birmingham, Professor Kwok talked to INSIGHTS about the scale of the challenge in Hong Kong, and how his team set about tackling it.
How is the worldwide trend to ageing populations playing out in Hong Kong? Is the demographic challenge any more, or less, intense there than it is in the rest of Asia?
The percentage of our population that is over 65 is now running at 13%, against a Southeast Asian average of about 10%. More worryingly, that 13% is expected to increase to more than 20% within 15 years, which means we are talking about a significant population increase: we have seven million people in Hong Kong, and some 90,000 nursing home beds. Add to this the reality of increasing longevity: against the Chinese mainland average life expectancies of 76 for men, and 78 for women, the Hong Kong numbers are 81 and 86, respectively.
So the challenge we face – indeed, what we have been facing for some time – is that we either need many more hospital beds or a way of legitimately bringing down the length of stay for the people who are occupying those beds. And this is all the more critical given that our hospitals here may be publicly funded, but primary care is not. The government does not pay for front-line services of that sort, which means that a lot of people who might in other parts of the world be going to see their local GP, in Hong Kong are going straight to hospital. This puts massive pressures on our convalescent services, in addition to what we must do in the way of acute care.
Given those numbers, in terms of just the growing need, I’d imagine even small but substantial incremental improvements can make a big difference?
Yes they can, but they need to be changes with impacts you can measure and, even more important, changes that can be sustained over time. And the sustaining part: that’s the challenge. To make that sort of difference, we discovered that you need buy-in from the outset at the very top. In our case, that meant commitment by our head nurse, whose dedication resulted in her actually doing her PhD in dementia care.
Was there one change that you focused on above all: something that you reckoned could be measured and could be sustained over time, and make a real difference – assuming also, of course, that you managed to pull it off?
Yes. I just mentioned resources and length of stay: we knew we couldn’t do much about resources and in fact would probably just lose a lot of time worrying over budgets and end up using the lack of resources as an excuse for not doing this, not doing that. But what did we actually have control over? How about this: we lower the average length of stay in our hospital.
But not just by mandating earlier release times…
No, of course: I used the word “legitimately” when I mentioned reducing length of stay. A third our patients are discharged into Care Homes: if they are not ready to go, they’ll be back, with all that that means in terms of more costs and distress to the patients. So they must go through a formal discharge procedure and be properly ready to leave. The question for us was: what can we do to facilitate earlier departures that work for them? Now, one aspect of care I have always thought of as counter-productive, understandable maybe in some circumstances but invariably distressing and not helpful at all to anyone, is the policy of physically restraining confused patients. We set about reducing restraint, largely by reducing the need for it.
How did you do that?
We invested in lower beds that could be raised for the sake of care staff but which could ordinarily be set much lower to minimise falls and make the whole process of getting in and out much easier. We installed pressure sensors that could assist in monitoring and reduce wandering. We moved nursing stations to the centre of the wards to improve visibility. We kept far better statistics on falls and made changes where we could as a result of what the data were telling us. We worked hard to secure that commitment from senior staff I talked about earlier, and staged regular workshops to offer education and reassurance to front-line staff so that everyone, simply everyone understood at all times what we were trying to achieve, and could celebrate our emerging success as we achieved it.
So you did achieve it? And you could measure it?
When we set out on this journey, about five years ago, our average length of stay for older patients with cognitive impairment was 23 days. The impact of what we were doing was not immediate; it’s always important to steer a steady course and not expect too much too soon. But we could see improvements within six months, not only in terms of length of stay but with the quality of life for both patients and their families and caregivers, and with our staff as well: there was just a better atmosphere on the wards. But the greatest triumph was with those length of stay numbers. We brought that average of 23 days down to 18.
Respect there! A reduction of 22% and with no change to the financial resources committed to the whole exercise?
That’s right. We did invest in some best practice workshops with June Andrews and her team from Stirling, but that sort of learning and sharing is always going on and sometimes produces significant returns on investment, especially when your key people buy into the process of implementing what you have learned.
Thanks, Timothy. We look forward to hearing more about it in Birmingham.
Alzheimer’s Insights is an online newsletter created for consumers -- primarily patients and carers -- who live with the challenge of Alzheimer’s disease. Based upon intelligent search algorithms that scour the Internet for the most read, relevant and useful stories from around the world, it is curated and published each Tuesday by a team of health and publishing experts. You can subscribe for future weekly newsletters here.