Gaps of Thai Elderly Health Care Services: Promotion, Prevention, & Delaying Dependency ช่องว่างบริการสุขภาพผู้สูงอายุไทย : ส่งเสริม ป้องกัน ชะลอภาวะพึ่งพิง โดย รศ.ดร.วรรณภา ศรีธัญรัตน์ ในการประชุมวิชาการนานาชาติครั้งที่ 2 ปี 2560 (The Second International Conference 2017 : Healthy Aging-Anti Aging) สถานที่ประชุม โรงแรมริมปาว จังหวัดกาฬสินธุ์ วันที่ 3 สิงหาคม 2560 เวลา 10.45-12.00 น.

Topics Gaps of Thai Elderly Health Care Services: Aging Society in Thailand & Challenges Research Experiences/ Evidences: 15 years of Research on Aging (2545-2560) Synthesis of Continuing Care Service System for Older Persons: Case studies of Dementia & Stroke Comprehensive Dementia Care Service System Gaps of Thai Elderly Health Care Services: Promotion, Prevention, & Delaying Dependency Continuing Care: Horizontal vs. Vertical COC Acute/ Sub-Acute/Long-Term Care/Palliative Care (Intermediate Care/ Rehabilitative Care Service) Age-Friendly Service System

Figure 1: Population of Older Persons in ASEAN Countries in 2015 and 2040 [1, 2].

Aging Index in Asian Countries: Japan, South Korea and China (2014) Young society Aged society Completed aged society Super aged society Aging Index Country Japan South Korea China Singapore Thailand Vietnam Myanmar Malaysia Brunei Darussalam Indonesia Cambodia Philippines Laos United Nations. (2010). World Population Prospects in 2010. New York: Population Division, Department of Economic and Social Affairs, United Nations.

Aging Society in Thailand & Challenges Challenges of Population Aging Rising in caregivers’ demands Income and social security Increasing health care demands 1: 2 : 4

Aging Society in Thailand & Challenges Challenges of Population Aging Rising in caregivers’ demands Income and social security Increasing health care demands 1: 2 : 4

Integrated Health & Social Care Challenges of Health & Social Care demands: Longevity + chronic illnesses + disability > increase demands of health & social care services Chronic care Acute care Long-Term Care (LTC) Home & Community Institutions Tertiary care Secondary care Primary care Intermediate care Integrated Health & Social Care

Conceptual Framework: Health Care Service System, Thailand Acute Palliative Care Specialized LTC (DT-on top LTC) New Sub acute (intermediate care) Well Chronic Terminal HEALTH PROMOTION & PREVENTION LONG-TERM CARE Community Strengthening: Elders/ Family/ Community/ Local Government Strengthening Health Service System : (General HC Service System & Aged Care)

Research Experiences on Aging in Thailand (15 years) TOPIC 2: Research Experiences on Aging in Thailand (15 years) 2002: Health Service System and Health Insurance for the Elderly in Thailand: A Knowledge Synthesis 2005: Reviews and Knowledge Synthesis on the Thai Elderly. BE 2545-2550. 2010: Policy Driven on the Integrated Health and Social Service System for Older People’s Rights and Well-being 2014: Knowledge Management and Synthesis of Health Promoting Hospital Practice Guideline for Older People Care. 2015: Synthesis of Continuing Care Service System for Older Persons: Case studies of Older Persons with Stroke and Dementia 2016-17: Development of Comprehensive Care Service System for Older Persons with Dementia: A case study of Ban Fang Sub-district, Khon Kaen Province, North-eastern, Thailand.

Research Experiences on Aging in Thailand HEALTH CARE SYTEM : Health Services & Health Insurance System Reform (1,2,3 care) SOCIAL CARE SYSTEM : Residential Care Reform>Multipurpose Center> Senior Complex?? Chronic Care (DM & HT) Geriatric Clinics; Anti-Aging Medicine Senior Center/ Club; Elder homes LTC (ในชุมชน> สถาบัน) Intermediate Care Palliative Care HHC/Continuing Care Specialized LTC LTC - Family care team (FCT)/Caregivers (CG) Aging society >> Aged Society 2016 (16%) 2015 (15%) 2014 (14%) 2010 (12%) 2005 (10%) Fam Med (+Geriatric) DT (CM, CC, SM) LTC System Manager LTC Manager Aging Manager 2002 (9%) 2003: Elderly Act 2009: Revised Elderly Plan 2015-17: Government Policy

Health Service System and Health Insurance for the Elderly in Thailand : A Knowledge Synthesis Sritanyarat, W., Aroonsang, P., Charoenchai, A., Limamnuaylarp, S., Patanasri, K., Lertrat, P., Tanasetungkul, S., Panachet, P., Krilerk, M., Faculty of Nursing, KKU, Thailand

Health Service System and Health Insurance for the Elderly in Thailand : A Knowledge Synthesis (6 countries) Recommendations Searching Literature : Small world Method : Experts opinions Knowledge Synthesis Newspapers Literature : Policies/ Laws/ HCS/ HIS (6 Countries)

Health Service System and Health Insurance for the Elderly in Thailand : A Knowledge Synthesis (6 countries)

Reviews and Knowledge Synthesis on the Thai elderly. BE 2545-2550. Sritanyarat W, Aroonsang P, Atsantachai P, Chapter 2, Health status and service system for older people. Page 61-140. in Review and Knowledge Synthesis on the Thai elderly. BE 2545-2550. Foundation of Research and Development of the Thai Elderly and Health System Research Institute; 2010.

Sritanyarat W, Aroonsang P, et. al. (2010) Sritanyarat W, Aroonsang P, et.al. (2010). Policy driven on the integrated health and social service system for older people’s rights and well-being. National Health Fund Institute and Thai Health Promotion Foundation.

Health Promoting Hospital Practice Guideline for Older People Care Primary Health Care: Health Promoting Hospital Practice Guideline for Older People Care Srtanyarat W, Dumrikarnlert L, Editors, Aroosang P, Amornkitbumrung S, Piyawatanapong S, Anupun B, Bunrung W. Knowledge management and synthesis of health promoting hospital practice guideline for older people care. Health System Research Institute, Thailand (212 pages).

Elders with Stroke & Dementia CONTINUING CARE: ACUTE> INTERMEDIATE >LONG TERM CARE Elders with Stroke & Dementia Continuing care for older persons Sritanyarat, W. et.al. (2015). Synthesis of Continuing Care Service System for Older Persons: Case studies of Older Persons with Stroke and Dementia. Foundation of Research and Development of the Thai Elderly and Health System Research Institute and Thai Health Promotion Foundation and Khon Kaen University, Thailand. Khon Kaen: Klung NaNa Press.

SETTINGS Lopburi Province Lumpang Province รพ.แม่พริก รพ.ลำปาง 16 กม. Population (Province) 753,013 (2014) Elders 18.05% (2014) Population 93,403 (2014) Elders 15.61% (2014) กลุ่ม 1:2:3 = 88.37:9.97:1.66 (2556) กลุ่ม 1:2:3 = 91.95:6.87:1.17 (2557) รพช (12) ศสม (3) รพสต (27) เทศบาล (3) อบต. (11) Population (Province) 758,406 (2014) Elders 15.48% (2014) Population 116,500 (2014) Elders 15.82 % (2014) รพช. (10) ศสม. (2) รพ.สต. (28) กองสาธารณสุข (4) เทศบาลเมือง (2) เทสบาลตำบล (5) อบต. (15) รพ.ลำปาง บูรณาการ HHC/ / LTC (Palliative) NCD/ CM/ DM/ /Geriatric /PCP Stroke Unit Team/ CPG รพ.พระนารายณ์ KNCCM (NCD/LTC ) (Palliative) COC (HHC) – 3 H Stroke Corner Geriatric clinic (GRN) 16 กม. 125 Km. 120 Km. ศูนย์ฟื้นฟู Rehab center ต.กุดตาเพชร ต.ลำสนธิ ต.เขาน้อย ต.ซับสมบูรณ์ ต.เขารวก ต.หนองรี Population 26,956 (2014) Elders 3,388 (2014) 12.56% (2014) กลุ่ม 1 : 2 : 3 = 87.5: 10.2: 2.3 Stroke 54 (2.49 %) Dementia 2 (0.09 %) รพสต (6) อบต. (6) รพ.แม่พริก รพ.ลำสนธิ คนลำสนธิไม่ทอดทิ้งกัน (LTC) (ผู้สูงอายุ/ พิการ/จิตเวช) * แม่พริกโมเดล Maeprik’s Model (Elderly/ Fam/ Community) * ศูนย์ส่งต่อ/ เชื่อมประสานบริการ (Coordinated Care) (ฐานข้อมูลระบบดูแล ผสอ.รพ.ลำปาง) เครือข่ายดูแลต่อเนื่อง/ stroke LTC/ Palliative Care โครงการลานปัญญา/ รร.ผู้สูงอายุ Population 9,702 (2014) Elders 2,014 (2014) 20.75 (2014) (1) กลุ่ม (1 : 2 : 3) = (89 : 10 : 1) รพ.สต. (6) อบต. (7) ที่มา : กรมการปกครอง กระทรวงมหาดไทย : สาธารณสุขจังหวัดลำปาง

Results Synthesis of Continuing Care Service System for Older Persons : Case studies of Older Persons with Stroke and Dementia

1. VISIONS/POLICY(Networks-Integrated care-Holistic care-Continuing care/Community-based) 2. FINANCING/ RESOURCES (Health Insurance (UC)/ Hospital/ Community/ Welfare/ Private Fund) 6. INFORMATION /COMMUNICATION SYSTEM FORMAL -HospXP (OPD/IPD/PCU) -JHCIS, -SSB (OPD/IPD)- -PT Soft (PT) -Thai Refer INFORMAL -LINE / Facebook -Mobile Phone WORKFORCE: INTEGRATED CARE TEAM ADMINISTRATIVE TEAM (Provincial/ District Levels) OPERATIONAL TEAM Health & Social Care Team -Nurse Case Manager/ Community Health Volunteers (CHVs) -Multi-diciplinary care Team (RN/NP-Fam. Med-Family-PT-Psychologist-Pharmacist-Nutritionist-Social Workers) -CHVs Local administrative -Community caregivers (CCG) Specialty care team -Stroke specialist/ Dementia Specialty/networks Provincial Health Office (PHO) INTEGRATED CARE TEAM DISTRICT BOARD PROVINCIAL BOARD Tertiary care hospital Primary Care Unit (PCU) Health Promoting Hospital District Health Office (DHO) Primary Care Unit (PCU) Health Promoting Hospital Secondary care/District Hospital Outcomes (Older persons/Families) -Get access to services -Increase quality of life -Reduce indirect cost (Care Providers) Health promoting hospital (HPH) 5. MEDICAL PRODUCTS/SUPPLY (Drugs/Equipments/Devices-Home Care-Blood Lines) 4. CONTINUING CARE SERVICES (Continuing care center : CCM/LTC-EMS)(Stroke Fast Track/Rehab)(Dementia) Standard/ Guidelines of continuing care (Multidisciplinary/ CHVs/ Community caregivers) Figure 1 Framework of Continuing Care: Components of Continuing Care System

CONTINUING CARE SYSTEM (VERTICAL-HORIZONTAL) VERTICAL CONTINUING CARE PRIMARY CARE SERVICES TERTIARY CARE SERVICES PHO PCU HPH Social Sector Specialty COC Center/ CCM/LTC Coordinator เทศบาล อบต. พมจ. อาสาสมัคร ชมรมผู้สูงอายุ Fam. Med HHC Team/CC Specialty HPH Provincial Hospital Elders /Families CHVs/CCG Daily care (Small Team) (Big Team) COC (HHC/CC) Multidiscipline (H+S) ER/OPD/IPD/(IMC?) HPH Community SECONDARY CARE SERVICES Social Sector Horizontal Continuing care HPH เทศบาล อบต./ พม. จัดอาสา ชมรมผู้สูงอายุ กองทุนชุมชน HPH Fam. Med HHC Team/LTC HPH Community Hospital COC/LTCC /LTCM DHO ER/OPD/IPD/IMC? PCU Community (Coordinator - Vertical Continuing Care; Manager - Horizontal Continuing Care)

Vertical (Specialty/Acute) Vertical (Holistic-LTC) Integrated Continuing Care Team (Vertical-Horizontal) (Health-Social-Community) COC Center (Vertical) (COC/LTC Coordinator ) HHC/COC Center (Horizontal)(Holistic) (COC/LTC Manager) Elders/Families Daily Care Team (CHVs/Caregivers) (Multidisciplinary) HPH Team (Small Team) (Big Team) Horizontal Provincial Hospital Vertical (Specialty/Acute) Vertical (Holistic-LTC) Operational Team (Health-Social) -Small Team (NCM/HHCN+PT+CHVs) -Big Team (RN/NP, Fam. Med, PT, Psychologist, Pharmacist, Nutritionist, Social Workers, GRN) Daily Care Team (CHVs/ CCG) Social-Local Team (Local administrative) Community Team (Elders’ club) Specialty Team (Stroke/ Dementia) District Hospital COC/LTC Manager (Horizontal) (Vertical-Horizontal) COC/LTC Coordinator

GAPS: Policy Recommendations Redefining Definition of Continuing Care (vs. HHC) System Development : Vertical & Horizontal COC Integrated Health & Social Care Services at all levels of Care Development of Care Giver System (FCT & Community CG) Stroke and Dementia System on top LTC System Tertiary care Secondary care Primary care Long-Term Care (LTC) Home & Community Institutions Chronic care Acute care Intermediate care Integrated Health & Social Care OUTCOME GOALS: QUALITY ADJUSTED LIFE YEAR Longevity + Prevent/ Delay dependency (chronic illnesses + disability)

New COC “Continuing Care” Definition of CC: “ a continuity of care services in various phases of health and illness, including acute, intermediate, and long-term care (palliative care); as well as the continuity of care from health care institution to home” Goals of continuing care: “to reduce, delay, and prevent disability and dependency in old ages” Access

Continuing Care System New COC The continuing care system: integrate both health and social care; including acute, intermediate, and long-term care (palliative care); focus on both horizontal and vertical system of continuing care; the horizontal continuing care is, “the continuity of care within the catchment area of each health care level: primary, secondary, and tertiary care settings” the vertical continuing care is, “the continuity of care across all levels of care service system (primary<>secondary<>tertiary).

Putting Policy (Best Practice) into Practice 2015 Government Policy on LTC and Palliative Care (Family Care Team + Community Caregivers)

Family Care Team Putting Best Practice/Policy into Practice : Family Care Team + CG Family Care Team Elders (Home-bound/ Bed Bound) Persons with disability End of Life/ Palliative Care

Community Leaders/ Neighbors Primary Care Unit (PCU) (Case manager) -Head of HPH -NP/ Public Health Community Caregivers (Provide daily care) -Grooming -Feeding -Elimination Transfer -Doctor visit Community Hospital (LTC Coordinator/Team) -Nurses/ APN in community -Psychologist -Physical Therapist -Nutritionist -Social workers Social/Local administrative -Home renovation Money allowance Jobs Meals, ect.

District Health Board (Long Term Care) LTC Administrative Board/ Team Operational Care Team Household Family Long-Term Care for Dependent Older Persons by FCT

Sritanyarat, W., Pongpan, A., Lithongin, M., Piyawatanapong, S., et.al. (2017). Development of Comprehensive Care System for Older Persons with Dementia: A Case Study of Ban Fang District, Khon Kaen Province. Supported by Thailand Association of Caregivers for Dementia Patients , Institute of Geriatric Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Foundation of Research and Development of the Thai Elderly, Nursing Club of Dementia Patients, Thailand and Thai Health Promotion Foundation and Khon Kaen University, Thailand. Khon Kaen: Klung NaNa Press. (234 pages)

“Development of Comprehensive Care Service System Research Project on “Development of Comprehensive Care Service System for Older Persons with Dementia : A case study of Ban Fang Sub-district, Khon Kaen Province, North-eastern, Thailand”

ช่องว่าง: การดูแลผู้สูงอายุภาวะสมองเสื่อม ช่องว่าง: การดูแลผู้สูงอายุภาวะสมองเสื่อม PEOPLE Providers (Health/Social) : Limited Knowledge/Training Older Persons/ Families: Aging process/ Psychosis Lay Persons: Aging process/ Psychosis SERVICES Primary Care: Screening (Non-specific DT care) Secondary Care: No Diagnosis & Treatment Tertiary Care: Diagnosis & Treatment (Pharmaco) ENVIRONMENT Home/Community: (Need improvement/Modification)

ลดช่องว่างการดูแลผู้สูงอายุสมองเสื่อม: โมเดลบ้านฝาง ลดช่องว่างการดูแลผู้สูงอายุสมองเสื่อม: โมเดลบ้านฝาง ศรีนครินทร์ โรงพยาบาล โรงพยาบาลจังหวัด ขอนแก่น บ้านฝาง โนนฆ้อง รพสต ศูนย์สุขภาพชุมชน หนองบัว จิตเวชราชนรินทร์ 1-DT_EXPERT ลด GAP (การมี/เข้าถึง) บริการ สภาลูกขุน (3 ระดับ) 2-DT_SM 3-DT_CC 4-DT_CM 4-DT_CM 4-DT_CM 4-DT_CM ผู้สูงอายุภาวะสมองเสื่อม/ครอบครัว/ชุมชน

DEVELOPMENT OF DEMENTIA CARE SYSTEM on top of LTC SYSTEM Care Coordinator (CC-LTC-DT) Tertiary care Secondary care Primary care [Confirm Diagnosis & Treatment] (Consultation Services) HCSS [First Diagnosis & Treatment] Screening & Care (Hospital + Home) Dementia Care Manager (CM-LTC-DT) Multi-disciplinary Team RN/APN (CM-DT) Care Givers CHV Screening & Care Services (Home + Community Empowerment) (FTC/LTC + Dementia Case Manager) Integrated Health & Social Care Nursing System : Service, Education/Training, Research Long-Term Care (LTC) Policy: FCT + Care Givers (community)

Topic 3: Gaps of Thai Elderly Health Care Services: Promotion, Prevention, & Delaying Dependence

Topic 3: Gaps of Thai Elderly Health Care Services: Promotion, Prevention, & Delaying Dependence Continuing Care: Horizontal COC vs. Vertical COC (Discontinuity of care) Acute/ Sub-Acute/ Long-Term Care/ Palliative Care (Limited Access to Intermediate/ Rehabilitative Care) Comprehensive Dementia Care Service System (Availability/ Accessibility) Age-Friendly Hospital/ Community/ City (Providers/ Services/Environment) Providers: (Agism/ Stereotype) (Knowledge/Training) Services: (Anti-Aging) (Geriatric Clinic/ Holistic Clinic-AIT) (Specialty/ Disease-System Oriented vs. Comorbidity/ Multi-morbidity) Environment: (Structure + Process)

Recommendations: Age-Friendly (Service & Society/Community)(Technology) Care Providers (Health/Social/CG)(at all settings/levels) Training/ Education on Aging & Care (Primary, Secondary, Tertiary Care Levels) Services (Direct/Comprehensive/Holistic)(Promotion/Prevention) Provide Acute/Intermediate/ LTC/ Palliative Care Manage Continuing Care System (Horizontal/Vertical) Comprehensive (Dementia) Care Service System Community Based vs. Institutional Based Care Family/ Community Empowerment Environment (Healthy: Green/Clean/Easy/Safety) Hospital settings/ Community Settings /Housing (Bed/ Ramps/Walking cane/ Wheelchair/Safety/ Friendly areas/Corner/Others)

Thank you for your attention