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Population ageing is a global phenomenon and Taiwan is no exception.

Currently, the percentage of older people in Taiwan exceeds 10% of the total population and will rise to 14% before 2020. To cope with the health care impact the Taiwanese government has introduced several policies to promote an age-friendly health care system.

The Veteran Affairs Commission (VAC) has made the greatest effort to face this challenge - the VAC being responsible for providing quality health and social care for all veterans in Taiwan. There are around half a million veterans in Taiwan. The majority were soldiers in World War II and during the Chinese Civil War, who came to Taiwan with the Chiang Kai-Shek’s government. In the sixty years since 1949 many veterans have become dependent and frail. A number of them stayed single for their whole life because of certain conditional restrictions. These people therefore cannot rely on support from a family, the most common form of elderly care support in Taiwan.

To promote better care for elderly veterans, the VAC launched a “Geriatric service development” program to introduce geriatric services for older veterans. The characteristic part of the program is the establishment of geriatric fellowship training program (akin to the specialist registrar level in the United Kingdom), which includes courses taught by experts in their field from, inter alia, the British Geriatrics Society. The first nationwide geriatric fellowship training program was started in 2004 by the National Health Research Institute, which is affiliated to the Mt. Sinai Medical School of New York, who organised the training program. This pilot program stopped 2 years later and was followed by the VAC training program.

Taipei Veterans General Hospital, the biggest public hospital in Taiwan with approximately 3,000 acute beds, established the Centre for Geriatrics and Gerontology (CGG) in 2006 and started the VAC geriatric fellowship training program. Although Taiwan has a renowned National Health Insurance service, the service provision was based on fee-for-service reimbursement and specialty-based practice. This system aimed to provide disease diagnosis and treatment, but not comprehensive and coordinated health care services for older people. Under such circumstances, health care for older people is fragmented and functional emphasis has long been ignored. Therefore, this fellowship training program has multiple objectives, namely to (1) cultivate more experts in geriatric services, (2) pilot geriatric health service models, and (3) to disseminate successful service models in this country. The CGG piloted several innovative geriatric services in Taiwan, including the Integrated Geriatric Outpatient Services, Geriatric Evaluation and Management Unit, Implementation of Minimum Data Set in the Veterans Care Home, and the most important and most recent of all, the Intermediate Care Services.

However, the fee-for-service payment system and sub-specialist based clinical practice intensified the fragmentation of health care service delivery for patients, especially those elderly patients with multiple and complex needs. To overcome the systemic barriers from the National Health Insurance, integration of all necessary services has become most critical to developing a high-quality health care system for older people. The CGG successfully introduced the operation of multidisciplinary teams and providing comprehensive geriatric assessment-based care for older patients.

With the assistance of the British Geriatrics Society and Taiwan Association of Gerontology and Geriatrics, Taipei Veterans General Hospital started the most successful geriatric fellowship training program in Taiwan. This training program recruits teachers from all disciplines related to care for older people as well as the teachers from the British Geriatrics Society who assist teaching in clinical practice. The fellowship training program recruits trainees from family medicine, internal medicine, neurology, physical medicine and rehabilitation, and psychiatry. After their first 3 years training in general internal medicine, family medicine and neurology, they then specialise in geriatric medicine. The training program is composed of 3 months of geriatric ward practice, 1 month in neurology, 2 months in rehabilitation, 2 months in old age psychiatry, 1 month in a palliative care unit, and 3 months in long-term care services. During the whole year, they also rotate to the geriatric outpatient department for at least 3 months and they are provided the opportunity to participate in the research program of the CGG. All fellows are required to participate in research projects and to finish manuscript writing of their own work during the training period. After the training, fellows may take the board examination, which is held by the Taiwan Association of Gerontology and Geriatrics.

To date 12 fellows have completed the fellowship training and all passed the board examinations. They are now playing important pioneering roles in different VAC health care institutes, including the tertiary medical center, community hospitals and Veteran Care Homes. The outstanding performance of their clinical practice has gained extensive support from the government which is placing increasing emphasis on geriatric fellowship training in Taiwan. In addition to the British Geriatrics Society, we also invite teachers from Canada, Japan, United States and Hungary to train the fellows in their clinical skills, research, and in bio-gerontology. Although teachers may come from different countries with different socio-cultural backgrounds, all teachers have demonstrated their passion for the healthcare of older people, which has impressed all fellows, in addition to their expertise in clinical skill training. Moreover, the case-based learning and bedside teaching has been very impressive because it vividly shows how teachers approach patients and demonstrates their expertise to promote better quality of life of older people.

Promoting age-friendly health care services is of critical importance, especially in obviating the risk of, for example, inappropriate prescriptions, in-hospital falls, or decision-making deprivation and the functional decline related to hospitalisations for older people. The development of intermediate care services is deemed an important solution to the current health care system in Taiwan. Traditionally, the health care provided in Taiwan has been strongly influenced by Japan and the United States. For geriatric health care services, we are more and more influenced by the British model and hope this approach will be developed in the future and we strongly believe that experience of the United Kingdom may be applied to Taiwan. Nevertheless, there are still some obstacles in promoting geriatric services i.e. the challenges from colleagues in traditional organ-specific specialties and the lack of adequate social and health care integration. However, we believe, with all our efforts and achievement, geriatric services will be widely accepted into Taiwanese society and by most health care professionals.

Before we end this article, we would like to extend a special word of thanks to Dr David Oliver of the British Geriatrics Society. He is such an enthusiastic person having helped us organise the participation of several outstanding teachers from the United Kingdom, and he also gave us the benefit of his expertise in falls and orthogeriatrics. Moreover, he helps us to set up a short-term exchange program for fellows to learn from their teachers in different hospitals in the United Kingdom. No words can describe how grateful we are for his contribution. We have great hopes for this training program in the future and that geriatric services in Taiwan may lead Asia to provide the best care services for older people.

Liang-Kung Chen
Szu-Ying Chu
Taipei Veterans General Hospital

BGS Newsletter, July 2009
Issue 22 ISSN 1748-6343 22