Overview of the Community-

Based Long-Term Care Pilot

Model
for the older people
Content
1. General information
2. The community-based long-term care pilot model for
older people
3. Stakeholder mapping and structure
4. Resources in the Case management system
5. Case management process
6. Initial achievements
7. Gaps and challenges
8. Lessons learnt
9. Recommendations
1. General information
• Project name: Regional TA-9928: Developing Innovative
Community-based LTC Systems and Services
• Donor: The Japan Fund for Poverty Reduction (JFPR)
through Asian Development Bank (ADB)
• Country Project holder: Vietnam Ministry of Health (DHI)
• Field Implementing Agency: HelpAge International in
Vietnam in partnership with the provincial Association of
the Elderly
• Field implementation duration: July 2023 – November
2024
1. General information
(cont.)
• Purpose: Pilot building a
community-based long-term care
model for older people (OP) in
Vietnam
• Who needs long-term care?:
People who experience, or are at risk
of developing, significant loss of
intrinsic capacity and diminished
functional ability due to mental or
physical illness and disability; Priority
is given to people from households
with difficulties and lack of care
 1. General information (cont.)
• Location: Intergenerational Self-help Club: ISHC

Thanh Hoa Hoa Binh

province province

Vinh Loc district Kim Boi district

Vinh Phuc Vinh Tien Vinh Tien Tu Son

commune Commune Commune Commune

Bai Don Van Xua

Pho Tho Vo Dong Thao Que Bai Ha
Xua g Han n
Moi Phu Coi Ngoai Ca Kho Chao Son
n Minh h Gia
vill- vill- villa- villag villag villag villag villag
vill- vill- vill- vill-
age age ge e e e e e
age age age (With (With age (With (No (No (With (No (With
(With (With (With ISHC) ISHC) (No ISHC) ISHC) ISHC) ISHC) ISHC) ISHC)
ISHC) ISHC) ISHC) ISHC)
2. The community-based long-term care pilot model
forInput
the OP Activity
Expected
outputs
Training The
courses Setting up case Capacity of
Comm CMs, CMAs,
and management system: CMs,
unity- CMAs, Caregivers, DCCCC/ Caregivers,
technical
support for
Based sub-DCCCC at commune and relevant
Long- stakeholders
CMs,
Term Training on CM & caregivers is built
CMAs,
Caregivers Care Case
Pilot Model
, and local Pilot managemen
stakeholde Model t system is
Monitoring and technical
-rs set up and
support
managed
Remunera for Cases are
t-ion and CM quarterly meetings at
the added into
equipment the district (DCCC)
older the system
support peopl CM monthly meetings at the and
e commune and village managed
3. Stakeholder mapping ADB
DHI - MoH
and structure in the
pilot Model National & Instruction/
+ CM HAI International support flow
monthly Consultants
meeting at DOLISA PAE DoH
village level Reporting
+ CM flow/
monthly partnership
meeting at
DCCCC (DPC, DAE, DHC, Disitrct
commune Sharing
DOLISA, etc)
level information
+ DCCCC
quarterly CPC 1 – Sub-DCCCC CPC 2 – Sub-DCCCC
meeting

2 Case Managers 2 Case Managers

(CHS + CAE) (CHS + CAE)

Village 1 Village 2 Village 3 Village 4 Village 5 Village 6

2 CMAs 2 CMAs 2 CMAs 2 CMAs 2 CMAs 2 CMAs

5 Caregivers 5 Caregivers 5 Caregivers 5 Caregivers 5 Caregivers 5 Caregivers

Frail OP Frail OP Frail OP Frail OP Frail OP Frail OP

4. Resources in the Case Management
System
Utilize
 Case existing
Managers human
(CMs):resources
staff
of commune Association of the
Elderly (AE) and Commune
Health Station (CHS)
 Case Manager Associates
(CMAs): staff of CHS, village
AE; Village Head; Village
Health Worker; Chairperson of
ISHC Management Board
 Care Volunteers: ISHC home
care volunteers (in 8 villages
with ISHCs); Women’s Union
(WU), Red Cross’s (RC), or
mass organizations’ village-
level staff (in 4 villages without
4. Resources in the Case Management System
Utilize existing human resources

 CM: 8 (2 CMs per commune * 2 communes * 2 provinces)

 CMA: 24 (2 CMAs per village * 6 villages * 2 provinces)
 Caregiver: 60 (5 Caregivers * 6 villages * 2 provinces)
 OP in the CMS:
 Cumulative number: 75 (Thanh Hoa - 37, Hoa Binh – 38)
Current number: 59 (Thanh Hoa - 30, Hoa Binh - 29)
 Ratio:
1 CM oversees 3 CMAs
1 CMA oversees 2-3 Caregivers
 1 Caregiver takes care of 1 frail OP
4. Resources in the Case Management System
Financial support

 CM: 300,000VND per month

(12 USD)
 CMA: 50,000 VND per month
(2 USD)
 Community Caregiver:
50,000 VND per month (2
USD)
The advantage of using
existing HR of mass or people’s
organizations, CHSs, mandate
of whom are also to provide
4. Resources in the Case Management System
Support equipment/ Care kits
5. Case Management Process
Care service
• Nursing • BADLs (feeding, washing
• Physical face, combing hair,
therapy bathing, etc.)
• Rehabilitation • Help with house chores
• Vaccination • House repair
• Drug reviews • Help with cooking
• Communicati • Help with shopping/
on about self- marketing
care • Help with paying bills
• Nutrition • Communication support
• Advise • Help with taking medicine
• Palliative care
• Make friend
• Help participate in interest group activities/Associations
(Poetry Club, Women’s Union, AE, Teachers' Association,
etc.)
• Companionship (taking OPs to the market/shopping,
medical examination, going to the temple/temple, etc.)
3 main Pillar Collaboration Model
Health care (clinical,
nursing, medicines,
rehabilitations, Health
rehabilitation, health sector
education, nutrition, etc.)
Fathe
r land
Front
Privat
eDono
rs Local Wome
authorit n’s
Union
y-
Social
protection
LTC
AE – ISHC Social care
(rights, Social – BADLs,
Affairs Communi
entitlements, Associati
on for the ty IADLs
Red
social Protectio
n of the Cross
pensions/ Disabled
Processes of a Case Management

• Documentatio • Keeping an eye and

n keeping track
• Managing the • Adjusting our care
Recording/
• What are Workload operations
plans accordingly
their managem
needs? e-nt • Action

Case Implementing Following up/

Screen Assessi Plannin
finding/ / Monitoring/
i-ng -ng g
intake Coordinating Reviewing

Stratifyi Referr
• Where are
-ng/ al/
the seniors? Discha
Prioritiz
• How should -ger
i-ng • How do we
we engage
them? meet their
• Who need Case • Escalate or
needs?
Management? stand-down
responsibly
Step 1 – Case finding
Output: List of OP
# Full name YOB Sex Background Health
situation

Village: ……………………………………. Commune: ………………………………..

Step 2 - Stratifying/ Prioritizing
Step 2 - Stratifying/ Prioritizing
Output: List of OP with CFS
# Full name YOB Sex CFS

Village: ……………………………………. Commune: ………………………………..

Step 3 – Comprehensive Need Assessment (CNA)
How would I like to be addressed?

Ask the older person directly. Otherwise, ask

the close family member

What people appreciate about

me?

Ask the older person something about himself

that he is proud of, as if asking for a biography,
e.g. Interest, hobbies, life’s accomplishments,
joys, personal history: educational level;
occupation; knowledge and skills; other life
history of potential relevance

What is important to me?

Ask the seniors/ caregivers about his values

and priorities in life e.g. family, religion, security

How to support me?

Ask the seniors/ caregivers about the seniors’

ideas, concerns and expectations related to
care e.g. symptoms of pain/ breathlessness;
financial strain; loss of independence etc
 Step 4a – Care planning
Date
CM

Care plan for : ……………………………..

………………………………….
# Care Foci Target Interventions/ In charge Time/
Activities of Frequency
An example of a care plan for Mrs. Nguyen Thi Thuong
Step 4b – Implementing/ Coordinating
Step 4b – Implementing/ Coordinating
Step 4b – Implementing/ Coordinating
Care service provided by Community Caregivers
Regular health check at home by CHS
staff
Resource mobilization

CM groups and AEs

at all levels
proactively mobilize
money, goods,
equipment, etc. to
provide additional
support for OP in the
CMS
 Step 5 – Following up/ Monitoring/ Reviewing

Village –
Commun
e–
District
meetings
6. Initial achievement
- To OP and their families: Help OP feel happier, less lonely, think positive
and often smile; Improve the health of OP, detect diseases early (high
blood pressure) and refer to CHS/invite medical staff to visit; Improve
the living environment of OP; reduce stress for the OP's family; change
the awareness of family members about the responsibility of caring for
their grandparents/parents
- To communities: Spreading motivation and meaning of care, kindness,
and compassion across the villages; the villagers are also very
supportive
- To CMS: CMs, CMAs, and Caregivers are trained, and provided with
technical support, and equipment, helping Caregivers to be confident
and provide increasingly better quality care activities; CMs, CMAs, and
Caregivers are enthusiastic, responsible, coordinate well, and support
each other; Through meetings, village-level issues are brought up to
commune and district levels
- To local authorities: Proactively coordinate stakeholders to support the
7. Gaps and challenges
 Existing services and resources are hard to meet the complex
and comprehensive care needs (rehabilitation, health care,
assistive devices, mental health, cash and in-kind needs, etc.)
 Capacity to provide care services by health care facilities and
social welfare staff; staff workload
 OP and their family’s expectation management
 How to meet ongoing technical support needs (when a change
in HR, new care topics, etc.)
 Personnel in the CMS hold multiple positions in villages and
communes, leading to overlapping work
 Financing after the project end
 Challenges in maintaining the CMS after the Project
Lesson learnt
 Utilizing existing resources (HR, physical materials) is important and
possible in the low resource settings
 Technical support (training, technical support trips) is needed and should
be continuous; digitalized care training materials (video) are helpful.
 Consultation with communities and related stakeholders would help
design a more feasible model
 Important role of AEs and ISHCs in taking the lead in care services
provision and pushing for collaboration and integration; continue after the
project ends;
 Villages with ISHCs easily provide care services compared to villagers
without ISHCs; to improve their role, proper investment (technical and
financial) is needed
 Taking advantage of rapid aging to address challenges of aging: trained
healthy OPs to provide care for frail OPs
 Care kits including assistive devices are needed to improve care quality
9. Recommendations
 Strengthen model documentation and dissemination to national
and local stakeholders
 Consult more with local authorities about financing (fundraising
by the local authority, fundraising for local Fund Care, and
Promoting the role of OP to be partly used for the care model,
etc.)
 There needs to be a national and provincial project that clearly
states the focal party, the role of the focal party, and
coordination to maintain and replicate the model
 Improve and push for implementation of MOU between AE and
Health sectors to ensure integration of health and care services
for frail OPs
 TOT training with materials and video
9. Recommendations (cont.)
 Embed the model into
existing ISHCs (new
version of ISHC, or
ISHC+) - need a new
project to have a
bigger showcase for
policy influence
 Invest in ISHC, train
ISHC volunteers to
support 3 groups of
OP (levels I, 2, 3), and
improve the quality of
Thank you!
Appendix – Analysis of OP situation in 12 villages in Thanh Hoa and Hoa Binh

OP are taken care in the CMS

Appendix – Analysis of OP situation in 12 villages in Thanh Hoa and Hoa Binh

Frequency of care foci among 75 OP

Appendix – Analysis of OP situation in 12 villages in Thanh Hoa and Hoa
Binh

OP vs Care foci
Appendix – Analysis of OP situation in 12 villages in Thanh Hoa and Hoa Binh

Data of OP in 12 villages
Appendix – Analysis of OP situation in 12 villages in Thanh Hoa and Hoa Binh

OP in the CMS vs all OP in the 12 villages