Development of Care Pathways with Collaborative Care in the Management of Diabetes and Chronic Obstructive Pulmonary Disease in Community: a Pilot Study

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Abstract Summary
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Authors (including presenting author) :
Chim CK(1), Karn KY(1), Chan M(1), Ho C(1), Ho N(1), Lam YM(1), Lee KY(1), Lee MM(1), Wong B(1), Mak F(1), Leung Q(1), Mok M(2), Lit M(3)
Affiliation :
(1) Specialty Advisory Group (Community), HA (2) Specialty Advisory Group (Endocrine), HA (3) Specialty Advisory Group (Respiratory),HA
Introduction :
Diabetes Mellitus (DM) and Chronic Obstructive Pulmonary Disease (COPD) are both high volume chronic diseases with burden to the health care system. However, there was variation in care practice and support journey for COPD/DM patients among clusters. In 2016, two cross specialties working groups involving SAGs of Community, Endocrine and Respiratory were formed to formulate standard care pathways in order to provide coordinated care; and to have better support to those patients from hospital to community.
Objectives :
To evaluate the care process and the effectiveness of the pilot after implementation of the care pathways models
Methodology :
1)A prospective multi-center pilot study was implemented in two phases during the period of January 2017 to March 2018. Home patients with DM or COPD, referred to Community Nursing Service (CNS) for care pathway management were recruited. 2)The community nurses supported the patients according to the standardized care pathways focusing on pre-discharge phase, at the point of discharge and post discharge process of care including stratification of patients, using standardized assessment tools and educational materials compatible with respiratory or DM specialties, well defined home visit protocols focusing on empowerment, self-management incorporated with COPD/DM care bundles. Coordinated clinical support to patients with clinical problems was linked between DM/Respiratory nurse clinic and CNS. 3) Outcome evaluation was studied.
Result & Outcome :
In phase 1, 36 DM were recruited, mean age 77, 53 % male, 47% female. Average 13 home visits per patient were provided by CNS. 36 episodes of hypoglycemic were reported; and were referred to DM nurse clinic for support. The average HbA1C was improved from 11.4% to 7.9%. The hospital admission rate was 2.9% (n=1) respectively. The pre/post 28 days hospital admissions comparison was 10 vs 1. In phase 2, 30 COPD patients were recruited, mean age 83, 87% male, 13% female. After CNS support, the mean CATS score were improved by 34% (mean 14.6 to 9.7); the mean Inhaler technique was improved by 44% (mean 8.1 to 12.6). 30 episodes of exacerbation were reported. 6 patients were referred for respiratory nurse clinic /fast track clinic for prompt intervention. The hospital admission attendance rate was 20% (n=6); the pre/post 90 days hospital admissions was reduced by 25.8% (31 to 23). Conclusion: The results of the pilot study showed the effectiveness of the standard care pathways on improving quality of care for those patients from hospital to community with coordinated care provision through cross specialties collaboration.

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