Project “CHEERS”- Innovative Care Delivery Model to Improve Elderly Access to Community Health Care Service: Seven Years’ Experience in Prince of Wales Hospital.

Abstract Description

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Authors (including presenting author) :

Poon WHW, Chim CK, Leung JSW1, Cheng HM1, 1Wong KMM1 , Kwok CM1, Yung SY1, Kwok AML1, Hui EAS2, Ho BPY3, Li PKT1

Affiliation :

Community Outreach Services Team, Prince of Wales Hospital, Hospital Authority

Introduction :

In 2011, the Community Outreach Services Team (COST) of Prince of Wales Hospital identified the service gap that 30% of high risk elderly patients refused post discharge support service even suggested by the health care professionals. They were then suffered from repeated hospital admissions and condition deterioration. It was not surprised that these underprivileged elders had the issue of financial difficulties, not fall into the safety net of social security service; and were unaffordable to the payment fee of outreach visit. In order to fill the gap and improve the elderly patients easy access to the community health care service, the project “CHEERS” (Charitable Project to Enhance the Effectiveness of home Rehabilitation Support) was then proposed with funding support from donation by the PWH Charitable Foundation.

Objectives :

• To subsidize home visits and advanced wound dressing materials for needy elderly patients with financial difficulties • To address the service gaps • To keep patients healthy in the community

Methodology :

Those elderlies with financial difficulties; and suffered from different chronic diseases with complications; or their chronic hard-to-heal wounds were not properly treated in long term, could be recruited in the project. The “Advanced Dressing Bank” was set up to provide dressing freely for patients; and four to ten coupons with fully waived community nursing service home visit were offered to improve elders accessing to the specialist outreach services. Pre-discharge planning and post discharge transitional professional support was provided to these high risk elderly.

Result & Outcome :

By retrospective review of the data from 1st December 2011 to 30 November 2018, a total of 1,383 elderly patients benefited from the project. The age of these ranging from 60-92 with the mean age 75. Among these group, 7% lived alone, 12% lived with elderly spouse and 81% had poor social support. Comorbidities were common as 50% had diabetes, 21% had hypertension, 14% had congestive heart failure and 15% had chronic obstructive pulmonary diseases. The project had sponsored 1,961 home visits to empower elderly patients and their carers on chronic disease self-management. 80% patients had successfully maintained in the community without hospital readmission within 28 days. The “Advanced Dressing Bank” also provided better quality of special dressings to support 877 patients resulting in 94% patients’ either wounds healed or in good healing progress. Conclusion This patient-centered care initiative improves not only the accessibility of elderly patients to specialist outreach services, but also promotes and restores their health through empowering their skills to better manage their diseases in community.