Presenter 1: Newly care model of elders person-centred assessment and smart health-promotion service

Presenter 1

Background: In Taiwan, there is an increasing trend of frailty in elder people. Elderly with debilitating conditions more likely to increase the chance of falling due to poor vision, ears, muscle strength, sense of balance, or a variety of drugs.Therefore, we establish an integrated assessment mechanism in medical system to assess healthy capacity for the elderly.

Objective: Using a person-centered integrated assessment, screening for loss of intrinsic capacity of elderly, and assessing health and social care needs to develop a personalized care plan.

Content: According to the new version of the “Integrated Care for Older People guidelines” , published by World Health Organization in 2019, the "Elderly Integrated Assessment" includes six items, Cognitive capacity, Locomotor capacity, Nutrition, Visual capacity, Hearing capacity, and Psychological capacity. Under the promotion of hospitals, clinics and health centers, the elderly suffering from chronic diseases will be targeted to be given an integrated assessment, so as to control the internal and external health at the same time.

Findings: We recruited 56 medical institutions to joint the plan, and completed “integrated health assessments” for the 5,042 elderly. We found that the abnormality rate of cognitive function was 4.28%, the abnormality rate of movement function was 8.93%, the malnutrition rate was 2.18%, the abnormality rate of visual function was 3.29%, the abnormality rate of hearing was 3.53%, and the depression rate was 2.99%. To prevent disability, we provide intervention measures to those elderly who got the abnormality result. We provided health education services for 712 participants, referrals to medical institutions for 149 participants, and referrals to community activities for 76 participants.

Sustainable application: In addition to recruiting medical institutions to involve in the assessment plan continuously, at the same time, we also build referral resources actively. Since to achieve the goal of preventing and delaying disability of the elderly, we need not only the early detection of the needs of the elderly, but also sufficient supportive environment for the elderly to maintain or improve their physical functions.