Pilot Community Cardiac Rehabilitation Program

Abstract Description

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Authors (including presenting author) :

Wong WH(1), Lee MM (1), Chan YH (2), Chan SC(2), Kwok FY(1), Lui TM(1), Yip LK(1), Cheung WM(1), Wong PL(1), Lam YM(1), Kwok WY(1)

Affiliation :

(1) Community Care Division, New Territories West Cluster,(2) Department of Medicine and Geriatrics, Pok Oi Hospital

Introduction :

Congested heart failure is an increasing public health problem. Poor control of Congestive Heart Failure (CHF) results in raise in emergency admission rate. Fatigue, dizziness, shortness of breath, exercise intolerance and fluid retention strike them in both physical and psychological aspects. Patient and their family members experienced poor quality of life for frequent casualty attendance. A clinical pathway was developed as to provide a comprehensive disease management including knowledge consolidation, life style modification, self-monitoring education and direct medical consultation by community nurse and cardiac team, in order to deliver a close loop network of care from hospitalization to community.

Objectives :

1. To establish a guideline based clinical pathway to manage patient with CHF from hospital stay to home care. 2. To reduce hospital stay and unplanned readmission rate with home support. 3. To create a close loop caring model for CHF patient, updated home based patient condition to cardiac team as to deliver treatment timely. 4. To arrange ad-hoc follow up or clinical admission when deterioration as to avoid redundancy. 5. To empower patient and carer knowledge in CHF.

Methodology :

1. Recruit suitable cases by Medical team and Community team. 2. Introduce the program by cardiac nurse or community nurse in hospital. 3. Empower knowledge in symptoms management, medication knowledge and facilitate coping and rehabilitation at home from community nurse by providing regular home visit and act as a case manager. 4. Closely monitor patient’s condition by community nurse with home visit or phone consultation. 5. Advocates for patient via case conference, HA Chat and phone consultation. 6. Arrange advance consultation or clinical admission by team if necessary.

Result & Outcome :

1. From February 2017 to November 2018, 15 cases were being recruited. 2. Accident & Emergency Department attendance rate (6 months) was drop from 62 episodes to 14. 3. Knowledge in CHF was improved, as Cardiac Rehabilitation Care Empowerment Score was increased for both patient and carer from 8.2 marks to 14.1 marks. 4. Patient’s activity tolerance improved. The distance of Six Mins Walk was improved from 150 meters to 230 meters. 5. All results shown the collaboration was successful in promoting patients’ quality of life and health in the community.