Free Paper Presentation I

1. Symposium on Community Engagement II “Building a Successful Partnership in Community Care” Free Paper Presentation I Success & Failure

2. Symposium on Community Engagement II “Building a Successful Partnership in Community Care” The United Front –An Integrated Collaborative Model for Community Services Dr CP Wong Cluster Service Director (Community)

3. Outline • Previous collaborations -- drawbacks • Enhanced new model • Strategies • Evaluation

4. Previous Collaborations

5. Previous Collaborations

6. Previous Collaborations

7. Hospital Community NGO Specialists NGO Specialists NGO Status of HKEC Community Services April 2005

8. Drawbacks of the Old System • Piecemeal approach • Incomplete and disorganized communication • Duplications/omissions • Development and outcome dependent on attitude and efforts of clinicians and specialties • No overall governance

9. Integration of Community Services • Jul 2006: Community-based Services re-structured towardsimproved integration and efficiency through enhanced partnership with care-providers • Well-defined governance • Steering Committee chaired by CCE to give overall directions • Appointment of Cluster Director (Community Service) and deputy as i/c of Management Committee • 1st Workshop with 29 major community partners to discuss the future of this Service

10. Community Health Service Planning WorkshopPartnering with Community Care ProvidersHong Kong East Cluster Hospital Authority13 August 2005TSKHACC

12. Our Vision “A Healthier Community in Hong Kong East”

13. Our Mission To establish and implement a new enhanced community service model to improve the health of the community through team-optimal partnership with care-providers within and outside the hospitals

14. 4 Strategic Areas for Enhancement • To strengthen community health infrastructurebyestablishing a Liaison Office • To ensure quality of care by defining health outcome indicators, setting protocols/ guidelines, and performing evaluation studies • To improve networking and communications by setting up 7 platforms, improving information exchange and engaging community support for High Risk Patients • To enhance staff training andcapacity buildingthrough pooling of resources in the cluster and the community

15. Development of 7 Platforms: 1 • NewCommunity Network Link Liaison Officewith7 Platforms, including Chronic Diseases, Elderly, Family, Disabled, Cancer, Psychiatry and Health Promotion • NGO representatives actively participate in every Platform • All Platforms expected to efficiently function through interacting witha (still-to-be-integrated) network of Clinicians, CNS/CPNS, CGAT, Allied Health Services, GOPC/IC/FMSC, Health and Patient Resource Centres, Volunteers and Chaplaincy Services

16. 7 Platforms Elderly Geriatrician, Ortho, Psychiatry, SAGE, TWGH, SJS, Methodist, HKFWS, YWCA… Psychiatry Psychiatrist, Nursing, Allied Health, BOKSS, Fu Hong, Richmond, SRACP, TWGH… Children & Family Paediatrician, Allied Health, IFSC & ICYSC, SWD, SJS, HKFWS, Caritas, Methodist, Baptist, HKPA, YMCA, Salvation Army, HKFYG… Cancer Oncologist, Physician, Surgeon, O&G, Palliative, Cancer Fund, Anti-Cancer Society, New Horizon Club, Comfort Care & Concern Gp, HK Stoma Association… Disabled Paediatrician, Orthopaedics, Geriatrician, Physician, Allied Health, Heep Hong, Fu Hong, Po Leung Kuk, Caritas, SJC, HKCS, PHAB… Chronic Diseases Physician, Rehab Physician, Allied Health, CRN… Health Promotion HA Hosp PRC, HKTBA, Anti-Cancer Soc, District Councils, Dept of Health…

17. Development of 7 Platforms: 2 • 7 Platforms to be supported by Working Groups,which will focus on Quality of Care, Management Protocols, Communication and Information Sharing, Staff Training and Outcome Evaluation • Key Performance Indicators to be developed, to include health services utilization, hospital staff and community partners’ participation, and health indicators of the population

18. Elderly … … Cancer Psy Paed Chr Disable Protocols and Guidelines Evaluation Staff Training … Communication & Data Interchange An Integrated CS Infrastructure

19. Liaison Office in TSKHCACC • Organizational Liaison • Team headed by a social worker • Patients Liaison • Extension of Telephone Nursing Consultation Service (TNCS)

20. Resources

21. “UNITED FRONT” 統一戰線 Education Political System Family Elderly NGOs Chronic Diseases Environment MED DB Volunteers Health $ CPNS Patient/ Carers CPRD Others PAED Others AHCP Disability Prevention Drs & Nurses CNS PSY Geri Legal System O&T ONC Economy Cancer Psychiatry Welfare Housing

22. Overall Approach • To enhance safe and early discharge from the hospital by establishing a good community support environment and utilizing ambulatory care services offered by hospitals • To keep patients healthy and safe in the community via effectiverehabilitation/ support programs and secondary prevention programs • To keep the population healthy by primary prevention programs and early detection of diseases in the community

23. Integration of Cluster Community Service: Continuing Efforts • Internal dissemination HKEC Workshop on“From Hospital to Community – Involvement of Clinical Services in HKEC” Shareyour views on Successes & Failures Obstacles & Opportunities Saturday 4 March 2006 • Community engagement seminars • HA Convention May 2006 • Follow-up seminar 23 Sep 2006

24. Evaluation • Throughput indices • Before/After Reduction of hospital services • AED attendance • AED admissions • Unplanned readmissions • Total length of stay • Continual monitoring of hospital utilization • Referral / downloading to NGO • Quality indicators • Compliance to protocols in community • Adverse Outcome Incidences in community

25. Evaluation • Post-discharge home follow up program: RCT of 209 high risk patients – reduction of 60% AED and 68% of unplanned readmission rates • Telephone Nursing Consultation Service: RCT of 230 high risk patients – reduction of 36% AED admissions • Visiting Medical Officer scheme: up to 22 part time / full time VMO serving 68 OAH with 4846 residents – further reduction of 8% AED

26. Public Health Targets • Rate of smoking / alcohol / fat consumption • Obesity / exercise / breast-feeding • Population incidence of stroke, falls, AMI, accidents, etc

28. Stroke among Age 40+ (2003)

30. Conclusions • An integrative collaborative model for community services was established in HKEC • Better infrastructure set up • Mutual trust is being secured • Better communication channels established • Less misunderstanding • Synergism in patient care achieved • Quality of care is ensured • Staff training is focussed • Evaluation is continual in process

31. Success Stories • Enhance Home Care Service Teams – conjoint bidding by 7 NGOs in HKEC • TNCS to NGOs to facilitate communication and sharing of data • Sharing of High Risk Patients Database and Alert System • Downloading GDH and mental health patients to community rehab centres • Community Engagement Symposium Sep 23, with 410 participants (43% from NGO) & 47 abstract submissions – and a TRUE collaborative function

32. Our Vision “A Healthier Community in Hong Kong East”