A Joint Project by HKEC CGAT & CNS Joan HO DOM(IMS2), RHTSK

1. Telephone Nursing Consultation ServiceImproving the Health of High Risk Elders in the Community with a Collaborative Community Health Care Program A Joint Project by HKEC CGAT & CNS Joan HO DOM(IMS2), RHTSK

2. Background • Ageing Population • Chronic diseasespredominant • Elderly constitutes 38.6% of patient days in Hospital Authority • Inefficient handling of acute crisis of patients in the community except AED • Lack of a good interface across different stakeholders in health care service

3. Telephone Nursing Consultation Service (TNCS) • Telephone triage • Referrals to appropriate community resources • Provides Home Care Instructions • Gives advice on disease management

4. Three Critical Elements in TNCS • Co-ordinates with relevant healthcare stakeholders

5. NGOs District Elderly Care Center Volunteers Community Allied Health Community Nursing Service GOPCs TNCS GPs Hospital Service

6. GP can contact TNCS to enquire patient’s medical history

7. Critical Element in TNCS • Utilizes protocols to guide nurses’ clinical decisions

8. Abdominal Pain Appetite Loss Back Pain Black / Bloody stool Chest Pain Confusion Constipation Cough DM Diarrhoea Dizziness Falls Fatigue Fever Headache Hemorrhoids Hypertension Hypotension Insomnia Itching Joint Pain/ Swelling Leg Pain / Swelling Numbness and tingling Rash SOB Skin Lesions Swallowing Difficulty Weakness 28 Telephone Triage Protocols Developed

11. Critical Element in TNCS • Utilizes IT support • Links with theClinical Management System (CMS) • Utilizes ‘High Risk Elderly Database & Alert System’

16. TNCS utilizes ‘High Risk Elderly Database & Alert System’to capture high-risk elders and follows up them actively.

18. 18/05/2005 17/05/2005

19. Study Population • Patients discharged from Department of Medicine & Geriatrics in PYNEH & RHTSK and fit 2 out of 3 of the following criteria: • Frequent hospital admissions >= 3 acute medical admissions in one year • Multiple pathology >=3 co-morbidities • Special diagnostic groups Congestive Heart Failure, COAD, Chronic Renal Failure, Malignancy

20. Exclusions • Living at old age homes • Under the care of Enhanced Home & Community Care Service / Integrated Home Care Service • Receiving intensive community programs e.g. Post Discharge Home Follow-up Program

21. Methodology • 230 patients recruited from 12 Sept 05 to 27 Jan 06 • Randomly assigned to • Control group (conventional, no TNCS) • TNCS group • Demographic Data were compared • Evaluates the outcomes after a period of two months • AED attendance • Number of admissions

22. Operational Flow on Telephone Nursing Consultation Service Client fits the TNCS inclusion criteria TNCS GroupInvites to becomemembers of TNCS and flags the case in the High-risk database Control Group Receives the conventional community support if necessary TNCS nurse makesphone follow-up to members + Member initiates call to the TNCS Center TNCS nurse identifies problem by performing assessment via phone Consults relevant health care professionals for further information and support if necessary Advices base on clinical judgment if protocols are not available. Chooses appropriate protocol to guide the decision • Offers advice • Designates to appropriate health resources • Makesreferrals to CNS, volunteer, DECC etc. if necessary • Explains health condition & disease management • Provideshome care instruction Evaluates the outcomes after a period of two months. • Asks for caller’s feedback before ending the call • Asks caller to call back if problem worsened Phone follow-up within 24-48 hrs. to assess the effectiveness of the advice

23. Results • Out of the 230 recruited cases, 32 dropped out from the program due to the following reasons: - 29 died - 3 moved to OAHs • The final TNCS samples were97 and control samples were 101

24. Results - Demographics All Comparable (p>0.05)

27. *

28. OutcomesDecreased Usage of Hospital Services p=0.025 36.5% p=0.05 35.8% 29.2%

29. OutcomesPatient Satisfaction Survey • Phone survey, conducted by a volunteer • 46.4 % response rate • 31% respondents were patients and 69% were relatives/carers

31. TNCS Package can…. 護訊鈴計劃可以….. • Identify high-risk elders through IPAS 經病人資訊系统識別高危長者 • Monitor & follow-up their health 健康監察及跟進 • Empower clients for self-management 授權長者及照顧者，以增加他們的自理能力 • Serves as a good platform for service collaboration 聯繫各醫療服務的平台 • Improves the accessibility to health care service 增加醫療服務的可近性

32. TNCS Package can…. 護訊鈴計劃可以….. • Reduce Unnecessary Usage of Hospital Services 減少醫院服務的使用，有明顯的成本效益 • Cuts over 1/3 AED attendance & E admissions • Longer service period that the patient joined TNCS, the better the effect (need to be further studied to confirm the assumption)

33. Thank You TNCS

34. Dr CP WONG, Director (Community Service), HKEC Dr Bernard KONG, Dep CSD/Consultant (CGAT), HKEC Joan HO, DOM(IMS2), RHTSK Anna NG, SNO(CNS), PYNEH Karence TO, WM(CGAT), RHTSK See Mun CHEUNG, WM(CNS),PYNEH Sabrina HO, NO(CGAT),RHTSK Kwai Heung NG, APN(CNS),PYNEH Chi Hang FUNG, RN(CGAT),RHTSK Tina WONG, RN(CGAT), RHTSK Sau Yung CHAN, RN(CNS), RHTSK Collaborators: Mr CK LAW, Executive Manager (Community & Allied Health), PYNEH Ms Daisy WONG, Cluster Service Co-ordinator (Community & Volunteer Service), HKEC Team Members

35. Acknowledgements • Senior Management, HKEC • Dr Loretta Yam, CCE, HKEC • Dr H C Ma, HCE, RHTSK • Ms Civy Leung, CGMN, HKEC • NGO Partners • Methodist Centre for the Seniors, Wan Chai DECC • SAGE, Eastern DECC • SAGE, Chai Wan DECC • St James Settlement, Continuing Care (DECC) • TWGHs, Fong Shu Chuen DECC • YWCA, Ming Yue DECC • HAHO IT Team