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Medical Microsystem festival - taking care of elderly by Mind Map: Medical Microsystem festival -
taking care of elderly
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Medical Microsystem festival - taking care of elderly

elderly care in singapore

a macro-to-micro

macro strategy, Impetus to act - burning platform, Tangible - re-employment act, wellneess, prevention, access, ... (missed)

Social perceptions, getting used to the move from episodic care --> population based care, Pilot

Model, Alignment model (after ), major challenges: get healthcare workers, to understand new paradigm, pride of purpose

demographic changes

silver tsunami

adding years of healthy life

Singapore vs sweden vs USA


Living alone but not lonely

Singapore Payment:


healthcare cost 4% GDP

Extremely low number of beds

4000 extra beds in coming 5 years

episodic care --> population based care


end of life


connecting young to old

educating the public

Hidden epidemic in singapore: mental illness in geriatric population

Mental health in elderly

projected 186900 patients w dementia in 2050

often quite negelected & discriminated

Government dedicated funds to improve this field

Range of health services for the elderly

hospital based

home based, waiting time for nursing home 1 year, dementia daycare centers

National Dementia Strategy

Dementia Association

since 2006 community mental health teams

Clinical service

Regional Eldercare Agencies Partnership

Challenges and moving forward


increasing demand and expectations

foreign workforce: problems w language and culture


collaboration w community partners

more funding for mental health

policy changes

IMH dementia friendly wards

The Challenge of caring for people as they got older: US perspectives


population, Simple chronic disease (e.g. diabetes), Complex chronic (e.g. COPD and depression, end of life


Patient/person view

whole person and personal caring

-- missed some points


primary care





microsystems there when needed, patient in center


IORA, Team effective for Simple chronic patients, 2 MDs, 4-8 health coaches, patients, plan of care co-designed, co-managed w patient, ongoing care by phone, computer and co-managed w patients

Group health primary care: good for complex chronic patients, health risk, disease status, patient self-monitoring, clinical team, 3 MDs, 1 RN, 1 pharmacist, 1 physician assiastant, 3 medical assistants, scheduler, Ongoing care by phone, computer and in person with the right member of the team, patient reported measures of health risk and health status for care planning and outcomes tracking, Better care at slightly lower cost and much higher staff satisfaction

Dartmouth Palliative - end of life, Ira Byock, MD, Medical center based interdisciplinary team, MDs, RNs, Social workers, Nurse practitioners, healing arts, chaplaincy, patient and family, Provides services to diverse clinical microsystems (e.g. primary care, breast cancer program, intensive care), working to develop integrated regional services, much better care at much lower costs

Better life for elderly - Sweden, Göran Henriks


most elderly compared to Singapore/USA

Hospital days/year

Much variation in different areas in Sweden

Malnutrition + risk

Big challenge!

Six big challenges

lack of coordination and planning, many different actors taking care of multiple different illnesses

We often lack continuity and sustainability care

medication systems


To "love' the day - carpe diem

Quality by design, a clinical microsystems approach, Author: batalden

5 Ps

Measurement, nutrition, ulcers, fall prevention, dental health, etc.

Senior Dialogue - a regional competence network, support use of quality registers, special groups for support to relatives, developing regional networks, social questions, medication and elderly, care preventive work, Elderly and modern technology