Authors (including presenting author) :
KWAN WS(1), LAU LW(1), KO WC(1), CHENG PPP(2), MO KK(3)
Affiliation :
(1) Community Nursing Service, (2) Central Nursing Division, (3) Department of Medicine, Yan Chai Hospital
Introduction :
Ageing population leads to high demand for continuity of care and extended health services. To cope with the emerging healthcare needs, Hospital Authority (HA) established a strategic direction to develop an integrated care model in community. In July 2018, Yan Chai Hospital (YCH) triggered the integration between Integrated Care Discharge Support (ICDS) and Community Nursing Service (CNS) for improving service quality and efficiency, enhancing patient empowerment and strengthening collaboration with other department and community stakeholders.
Objectives :
1) Strengthen service organization and management structure; 2) Increase workforce capacity and sustainability; 3) Enhance the staff competency; 4) Standardize the practice to improve care planning; 5) Promote a well-organized discharge planning; 6) Enhance communication for better coordination and collaboration with community stakeholders.
Methodology :
The existing service delivery model of ICDS and CNS were reviewed comprehensively for months. It was compromised that the patient journey was from hospital to community and standardized the electronic documentation with concerned stakeholders. In July 2018, a “Single contact point” for outreaching service referring mechanism was set up to streamline intake and case stratification. Moreover, community nurses would proactively recruit cases to facilitate early discharge planning during the case conference of acute and rehabilitation units. In addition, a “Staff Training & Rotation Program” was coordinated to standardize the practice and empower the staff. For better resources utilization, ICDS nurses were being incorporated into CNS home care teams for enhancement of staff back-up and supervision, reduction of travelling time, and extension of service hours.
Result & Outcome :
After the integration, the ICDS nurses were allocated into 3 responsible areas in Tsuen Wan to save travelling time. The number of ICDS home visit and Patient Assessment & Discharge Planning were both increased in 13.1% and 4.7% respectively. Total 231 patients were discharged from ICDS. Comparing the unplanned admission and A&E attendance of these completed cases 2 months before and after the service, both unplanned admission and A&E attendance had reduced 46.2% and 44.9% respectively. Lastly, 40 out of 61 selected discharged patients were contacted successfully in a satisfaction survey. All satisfied the new ICDS service provided. The new integrated community care model in YCH had significantly improved both performance indicators and service outcomes in order to meet the increasing demands.
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