Summary

The elderly population in Hong Kong has been increasing over the past thirty years. In addition, due to the popularity of nuclear family, the demand for social service has been on a rise as the elderly are left to care for themselves. Family physicians are often at the first line to identify the elders' needs when they approach the physicians for "discomfort" either physical or psychological. Hence understanding the needs and social services available will prevent the development of social problems and ensure early intervention. Medical social workers, having frequent contacts with elder persons presented with different problems and knowledge on community resources, can act as a bridge between the health care system and the community. The focus of discussion would be on an overview of the common needs of the elderly and the services available in the community to meet the needs.

摘要

過去三十年老年人口不斷增加，核心家庭日漸流 行，許多老人家常要獨立面對各種問題，他們對社會服務的需求便隨之而遞增。家庭醫生站在醫療服務的 第一線，當長者們訴說他們身心不適時，如果家庭醫生可以了解長者們的困擾，並對社會服務有一定認 識，就可以儘早加以援手，從而預防一些社會問題的發生或惡化。醫務社工在工作中常接觸有不同困難的 長者，加上對長者的需要和社會資源的認識，可以成為醫療體系與社區的橋樑，本文將集中討論長者們的 需要及有關之社區資源。

---

Introduction

The population of people aged 65 and above has grown 3 times over the past thirty years. Other than the change in population pattern, the change in social condition such as the outnumbering of nuclear families over extended families poses change in the pattern for care of the elderly. In addition, the limited living space in Hong Kong also creates problem for the younger generations in caring for their elders. Consequently, there is a shift of responsibility to the community for the care of the senior citizens.

Since the primary health care professionals including the general practitioners are often the persons whom older people turn to when they have "discomfort" either physical or psychological, they are usually the first to pick up the problems of the elderly persons. Hence, it is important to understand the needs of and the services available for the elderly so that the elderly can be directed to appropriate services to solve their problems.

Since the medical social workers (MSWs) serve patients under the health care system, during the work process, MSWs frequently receive referrals from the medical practitioners or are approached by the elderly for assistance. According to the needs, MSWs act as a bridge to link the elderly to the community services. This paper is designed to provide a practical guide for quick reference for the medical practitioners. Accordingly, it will focus on discussing the common problems of the elderly patients and the services available for them.

Needs of the elder persons

Identification of needs is very important before determination of the types of services required. Yet it should be noted that there may be multiple needs and they can be inter-related. More significantly is that it should be the elderly persons' own perceived needs that the professions have to address. Common areas of needs are health care, financial, personal care, accommodation, emotional support and education/vocation/leisure.

Health care

With the number of elderly persons increasing, there have been enormous health care needs. Other than medical treatment, disease prevention and health maintenance such as increase in physical activity, balanced diet and reduction in cigarette smoking etc. also warrant parallel development.

Financial

Money is important for the elderly to maintain their living and, if necessary, to purchase service to look after them.

Personal care

Those elderly who require assistance in daily functioning would need supportive services in the community if their families cannot provide such kinds of support. For the elderly who are frail and when supportive services still cannot cope with the caring needs, residential care would be the possible alternative. Nevertheless, it is normally considered to be the last resort as it usually is not the preferred means of care by the elderly persons.

Accommodation

Housing is a common problem for people in Hong Kong. Elderly persons are of no exception. They require a shelter that would facilitate their living in the community such as a flat with lift landing.

Emotional support

There has been a general misconception that older people are normally frail or have limited capabilities. In fact, many of them are free from cognitive or physical impairment. However, retirement associated with advance in age made the elderly persons lose their roles in life despite their capability. Even women who are housewives all along may be affected by their husbands' retirement. The presence of the husbands at home may create adjustment problem for the women who are used to not having interference to their home affairs. The "empty nest" syndrome, with children grown up leaving the parents, may intensify the feeling of being useless. In addition to the loss of role in life, old people may experience many other losses such as death of family members and friends. These again add on to the feeling of loneliness.

Although a large number of elderly persons are independent physically, there are still some who require care from others. The dependent state may produce feeling of helplessness, anger and frustrations. Therefore, effort has to be spent to address the needs of the elderly persons for dignity and integrity.

Education/vocation/leisure

In addition to emotional needs, other social needs may include education, employment and leisure. For vocation, it does not refer only to gainful employment, any work such as volunteer work can be under such category.

Community services

A wide range of services has been developed to cater for the service demand from the elderly.

Financial assistance

Comprehensive Social Security Assistance (CSSA)

A.	Application criteria
	Older persons who are 60 year old or above are classified as "elderly". Unlike the younger counterparts, they do not need to have certification by the medical officers to be of ill health or to be on unemployment ground in order to apply for CSSA. As long as they can meet the following additional criteria, they are eligible for the CSSA application:
	(Source: A Guide to Comprehensive Social Security Assistance, Social Welfare Department, January 2004 and website of Social Welfare Department updated on 22.3.04)
	1.	Has to be Hong Kong citizen for 7 years and reside in Hong Kong for the one year prior to the application except those become Hong Kong residents before 1.1.04.
	2.	Has to pass the assets test
		Table 1: Assets test No. of elderly   Asset limit ($) 1   34,000 2   51,000 3   68,000
	3.	Has to pass the income test, which is more or less equivalent to the CSSA payment.
		Table 2: Income limit/CSSA payment amount   1 elderly person   2 elderly persons Maximum rental allowance $1,265   $2,550 Maintenance $2,400   $4,530 ($2,265 x 2)   $3,665   $7,080
		Rental allowance is on reimbursement basis. That is, if the rent is less than the ceiling, the CSSA payment would be given on the actual rental expenses. But if the elderly would like to rent a place exceeding the rental allowance ceiling, he/she has to pay for the difference by his/her own means. There are other allowances in addition to the basic payment amount. If the elderly is 100% disabled, requiring constant attendance or special diet, extra fund can be granted if they are certified by the medical officers of the Hospital Authority or Department of Health according to the criteria. There are also grants to cover costs of medical, rehabilitation, surgical appliances and hygiene items e.g. wheelchair, hearing aids, stoma bags and diapers etc. Other additional funds include removal grant helping the elderly to move to a new residence and burial grant with maximum payment of $10,530 for the funeral if the elderly CSSA recipient dies. Since, funeral affairs are often the elderly person's major concern, with such payment, they can be relieved that there is fund for their final journey.
B.	Application procedure The elderly can approach the Social Security Field Units of the Social Welfare Department for application of CSSA. The service boundary is according to the location of the applicants' residence. For address of the relevant Field Units, reference can be made to the web page of the Social Welfare Department (www.info.gov.hk/swd). The easy way to direct the elderly is to ask them to go to the place where they can apply for old age allowance (so called“生果金”), as they should know some other elderly living nearby receiving old age allowance.
Social security allowance (SSA)
		Table 3: Social security allowance Type of allowance   Amount Normal old age allowance   $625 Higher old age allowance   $705 Normal disability allowance   $1,120 Higher disability allowance   $2,240
Application criteria
Applicants have to be Hong Kong residents living in Hong Kong for at least 5 years before the application. For normal old age allowance, applicants have to be between 65 and 69 years of age. There is a means test on asset and income. Nevertheless, the criteria are much more lenient than those for CSSA. For higher old age allowance and both normal and higher disability allowance, no means test is required.

Long term care services

According to the Social Welfare Department Elderly Branch, Manual of Procedures on Registration and Allocation of Long Term Care Services, "The Ageing in Place and Continuum of Care are the Government's policies on services for elders. Ageing in Place is to meet the elders' preference to age at home and to support their families to take care of them by providing appropriate support and care services. Continuum of Care is to provide care services for elders in residential, centre or home-based settings, it is essential to meet the changing needs of elders, thereby minimising the need for transfer of elders from one service to another as they age and become more frail, unless acute or infirmary care in a hospital setting is required".

From 28.11.2003, a new system was set up to implement the above policy. Under the new system, elderly persons are divided into 2 categories, namely: no or mild impairment, and moderate or severe level of impairment.

If the elderly are of mild or no impairment, they can apply for supportive services by themselves. The service providers are the District Elderly Community Centre (DECC), Neighbourhood Elderly Centre (NEC), Social Centre for the Elderly (S/E) and Integrated Home Care Service. The major service scopes of the units include:

District Elderly Community Centre (DECC)

• Education and personal development
• Volunteer development
• Counselling
• Elderly support team
• Carer support
• Social and recreational activities
• Canteen and laundry service

After the function of the DECC was enhanced, it became a major service provider of elderly services in the community. Hence, it can be approached for comprehensive services for the elderly.

Neighbourhood Elderly Centre (NEC)

• Education and personal development
• Volunteer development
• Health education and promotion
• Provide information on elderly welfare and referral for services
• Counselling
• Carer support
• Social and recreational activities
• Canteen and laundry service

Social Centre for the Elderly (S/E)

• Indoor and outdoor groups and activities
• Provide information on elderly welfare and referral for services
• Assist and encourage elderly to plan and participate at affair of the community
• Provide leisure facilities and meeting place for the elderly

Integrated Home Care Service (IHCS)

• Personal care
• Escort service
• House cleaning
• Laundry
• Shopping and delivery
• Meal service
• Simple rehabilitation exercise

If the elderly are of moderate or severe level of impairment, referral is required to put them on the Central Waiting List (CWL) for long term care services. The referral offices include DECC, NEC, S/E, Family services centres, medical social service unit etc. All these name lists can be downloaded from the web page of the Social Welfare Department as introduced earlier. The referring office upon initial intake of the case, will first refer the elderly for assessment by the Standardised Care Need Assessment Management Offices (Elderly Services) (SCNAMO(ES)s). The assessment result will determine what kind of service the elderly persons need and will be provided. The 2 main types of services are the Community Care Service (CCS) and Residential Care Service (RCS).

Community care service (CCS)

CCS refers to integrated home care service, enhanced home and community care services as well as day care centre for the elderly. For the integrated home care service and enhanced home and community care services, tailor-made home-based service is designed to meet the intensive personal and nursing care need of the elderly persons. Whereas for the day care centre, the elderly would go to the centre to receive care in day time and return home at evening. These services aim at helping to keep the elderly persons in the community.

Residential care service (RCS)

If supportive service at the community still cannot meet the caring needs, the elderly might need residential service. But it is usually the least preferred choice as the elderly persons usually would like to remain at home where they are familiar with. According to different levels of care from the least dependent to highly dependent, the institutional care are divided into 4 categories namely the Home for the Aged, Care and Attention Home, Nursing home and Infirmary. The first 3 categories are assessed by the SCNAMO(ES)s while the infirmary is assessed by the Community Geriatric Assessment Service.

Respite service

There are those elderly who remain in the community but require short term residential service. Respite service is in place to let the carers have a break for leisure or to handle their own personal problems. This acts as a form of support for the carers to help them continue caring for the elders in the community. The maximum length of stay per year is 6 weeks and the minimum is 1 day. The family can approach the referring offices such as the DECC and family services centres mentioned above to request them to make referral.

Conclusion

The information provided above only gave an overview of the common problems and the services available for the elderly that MSWs encounter at work, which is within the health care environment. Although there are many issues that cannot be addressed, it is still significant for the family physicians to have a general picture of the needs and community services available for early identification of the problems and intervention. For more detailed assessment and service provision, the physicians can inform and encourage the older people to seek appropriate services from the service providers. That would prevent the development of problems or further deterioration of the situation and finally enhance the quality of life of the elderly persons.

Key messages

1. Elderly persons might have a wide range of needs which might be inter-related. With understanding of their needs, family physicians can introduce appropriate services for the elderly for early intervention since very often the "physical discomfort" is the manifestation of other social problems.
2. With the enhanced function of the DECC, if elderly persons are identified by the family physician to have problems that warrant further investigation, they can be directed to approach them for service. Family service centres are another valuable source for screening of the problems and referral for appropriate services.
3. If the older persons are having regular follow ups in Hospital Authority hospitals, referral can be made to the medical social workers for screening, intervention and referral as well.

---

---

References