Authors (including presenting author) :
SUEN D (1)(3), HEUNG LW (1)(3), CHAN MWM (1)(3), WONG YFB (1)(3), LAW CB (2)(3), TONG BC (2)(3), CHENG S (3)(4), LEUNG C (3)(5)
Affiliation :
(1), Community Nursing Service (CNS) (2) Department of Medicine & Geriatrics (M&G), (3) Princess Margaret Hospital (PMH) (4) Occupational Therapy Department (5) Physiotherapy Department
Introduction :
PMH was facing various challenges with ageing problem. A lot of community care programs were under different structures with diverse practices coordinated by different community teams. Also, there was lack of interface and access to information of community services by frontline staff, and this might lengthen the diagnosis and discharge process. Having considered that appropriate post-discharge support could facilitate early discharge and alleviate the pressing demand for in-patient service, PMH had integrated Community Nursing Service (CNS) and Integrated Care Model (ICM) in providing coordinated discharge planning and post-discharge support services for targeted elderly patients in October 2017.
Objectives :
1.To develop an integrated and patient-centered model in community care to enhance efficiency, effectiveness and service 2.To better manage growing service demand and meet the challenge of ageing population
Methodology :
Riding on the direction from PMH Strategic Plan 2017, two community care teams - CNS and ICM were integrated with effect from October 2017. Principle of actions was to keep the cost neutral and the deliverables unchanged. Key actions on service integration were: (i)formed a hospital-based Community Care Coordinating Committee to govern and steer the development of community care programs (ii)co-located CNS and ICM teams into the same office (iii)enhanced interface for discharge planning by ONE discharge planning team to triage patient care needs (iv)reviewed service statistics then re-defined targets by disciplines and optimized members’ roles and responsibilities (v)developed agreeable service pledge for effective customer service communication (vi)enhanced medico-social collaboration by monthly team meeting and a single point of contact (vii)developed KPI for PMH ICM i.e. specialty-based Unplanned Readmission Rate (URR) for service monitoring and continuous quality improvement. After the integration, ICM had service coverage during long holidays, especially on high pressure areas and surge periods, so as to provide discharge planning and early interventions for high risk elderly patients living at home.
Result & Outcome :
After the integration, PMH ICM had service coverage during long holidays, especially on high pressure areas and surge periods, so as to provide discharge planning and early interventions for high risk elderly patients living at home. From October 2017 to October 2018, PMH ICM had provided case management for 1,320 post-discharge elders. 58% (769) of them were female. The mean age was 79 ranging from 60 to 105. Concerning re-admission risks, the mean HARRPE score was 0.34 ranging from 0.2 to 0.74. 59% of the cases were referred by the frontline clinical staff - the referral diagnoses were fracture, stroke, respiratory disease, cardiac disease and fall while the requests were post-discharge community support, rehabilitation and chronic disease management. In general, the URR of the ICM cases in October 2017 was 21% and the URR in October 2018 was 13.5%. There was a reduction of unplanned readmission by 36% comparing the same month in 2017 versus 2018. More importantly, stakeholders experienced better logistics arrangement on the discharge planning as well as post-discharge services. Frontline staffs had improved knowledge on the latest provision for discharge. Cross-team cross-sectoral communication was enhanced as a result. Conclusions: A key direction in the coming years is to enhance the access and efficiency of care through strategies that re-orientate and transform our services, with a strategic focus promoting integration and patient-centered care.
Co-location with:
