Introduction
Home-based Chronic Disease Management Service for the Elderly (CDME)

Background

CDME was firstly initiated and developed by Hong Kong Red Cross (HKRC) in 2014 to address the aging population issue in Hong Kong. This service aims to prevent deterioration of physical conditions among elderlies in the community who may be unable to visit public hospitals or elderly centers for learning about self-management on chronic diseases management due to physical limitations.

The service specifically targets elderlies living in the community who have been diagnosed with Hypertension and/or Diabetes and can continue to reside in their homes with proper selfcare management. Our goal is to reduce and delay the need for hospitalization and treatment for these diseases and their complications, reducing the burden on public healthcare systems and healthcare facilities and thereby enhancing the quality of life for the elderlies, enabling them to age in place.

The service is implemented through case referrals from various elderly services organizations, public hospitals, district health centers/express and support services center for ethnic minorities. "Home-based" home visit service will be rendered for approximately one year. It involves case managers and nurses conducting home assessments, regular visits by trained volunteers and monthly phone check-ins. The service focuses on promoting and assisting elderlies in self-managing chronic diseases from physical, psychological, and social perspectives.

We will compile the achievements of the project and create a service sharing collection to share with everyone. We hope to continue collaborating with our partners in the future to make the senior years of every elderly vibrant and colorful!

Objectives

- Assisting elderlies in enhancing their capabilities in chronic diseases self-management

- Enhancing the self-efficacy of elderlies in chronic diseases management

- Increasing the knowledge level regarding community resources amongst elderlies

Service Target

Priority is given to the elderlies aged 65 or above who have Hypertension and/or Diabetes, possess basic communication skills and maintain stable mental and emotional well-being. Preference is also given to elderlies living alone or with a caregiver

Service Boundaries

Hong Kong Island: Eastern District, Wan Chai District

Kowloon: Kwun Tong, Kowloon City, Sham Shui Po, Wong Tai Sin

New Territories: Tsuen Wan, Kwai Tsing, Sha Tin (Ma On Shan), Tuen Mun, Yuen Long (Tin Shui Wai)

Physical:

- Measure body weight, waist-hip ratio and blood pressure to understand the elderly's daily life and dietary habits.

- Provide education on relevant diseases and engage in simple exercises together.

- Remind the elderly to attend follow-up appointments and pay attention to medication compliance and management.

Psychological:

- Understand and provide accurate knowledge to alleviate the anxiety caused by diseases.

- Encourage and appreciate the efforts and achievements of the elderly in chronic disease management.

- Assist the elderly in stress relief through different approaches.

Mental Health:

- Observe the mental well-being of the elderly and identify any signs of concern at an early stage.

- Conduct preliminary assessments and make referrals for suspected cases.

Home Safety:

- Conduct initial assessments based on the elderly's home environment.

- Refer needy cases to the Department of Health for detailed evaluations and follow-up.

Social:

- Organize community activities related to health, such as visits to patient resource centers, accessible outings, healthcare talks and activities related to physical exercise or healthy diet.

Want to know more about how to become our beneficiaries or our trained volunteers to serve the community together ? Please click on the following service introduction video to learn more:

For matters relating to Elderly Caring Service, Home-based Chronic Disease Management Service for the Elderly, please contact us at Elderly Caring Service, Home-based Chronic Disease Management Service for the Elderly, Hong Kong Red Cross Head Office

Tel: (852) 2514 2268
Fax: (852) 3103 4010
Address: 19 Hoi Ting Road, West Kowloon, Hong Kong
Email: cdme@redcross.org.hk