Free Paper Presentation I

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Free Paper Presentation I
Symposium on
Community Engagement II
Building a Successful Partnership in Community
Care

• Success Failure

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The United Front An Integrated Collaborative
Model for Community Services
Symposium on
Community Engagement II
Building a Successful Partnership in Community
Care

• Dr CP Wong
• Cluster Service Director (Community)

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Outline

• Previous collaborations -- drawbacks
• Enhanced new model
• Strategies
• Evaluation

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Previous Collaborations
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Previous Collaborations
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Previous Collaborations
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Status of HKEC Community Services April 2005
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Drawbacks of the Old System

• Piecemeal approach
• Incomplete and disorganized communication
• Duplications/omissions
• Development and outcome dependent on attitude and
  efforts of clinicians and specialties
• No overall governance

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Integration of Community Services

• Jul 2006 Community-based Services re-structured
  towards improved integration and efficiency
  through enhanced partnership with care-providers
• Well-defined governance
• Steering Committee chaired by CCE to give overall
  directions
• Appointment of Cluster Director (Community
  Service) and deputy as i/c of Management
  Committee
• 1st Workshop with 29 major community partners to
  discuss the future of this Service

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Community Health Service Planning
WorkshopPartnering with Community Care
ProvidersHong Kong East Cluster Hospital
Authority13 August 2005TSKHACC
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Our Vision

• A Healthier Community in Hong Kong East

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Our Mission
To establish and implement a new enhanced
community service model to improve the health of
the community through team-optimal partnership
with care-providers within and outside the
hospitals
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4 Strategic Areas for Enhancement

• To strengthen community health infrastructure by
  establishing a Liaison Office
• To ensure quality of care by defining health
  outcome indicators, setting protocols/
  guidelines, and performing evaluation studies
• To improve networking and communications by
  setting up 7 platforms, improving information
  exchange and engaging community support for High
  Risk Patients
• To enhance staff training and capacity building
  through pooling of resources in the cluster and
  the community

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Development of 7 Platforms 1

• New Community Network Link Liaison Office with 7
  Platforms, including Chronic Diseases, Elderly,
  Family, Disabled, Cancer, Psychiatry and Health
  Promotion
• NGO representatives actively participate in every
  Platform
• All Platforms expected to efficiently function
  through interacting with a (still-to-be-integrated
  ) network of Clinicians, CNS/CPNS, CGAT, Allied
  Health Services, GOPC/IC/FMSC, Health and Patient
  Resource Centres, Volunteers and Chaplaincy
  Services

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7 Platforms

• Elderly
• Geriatrician, Ortho, Psychiatry, SAGE, TWGH, SJS,
  Methodist, HKFWS, YWCA
• Psychiatry
• Psychiatrist, Nursing, Allied Health, BOKSS, Fu
  Hong, Richmond, SRACP, TWGH
• Children Family
• Paediatrician, Allied Health, IFSC ICYSC, SWD,
  SJS, HKFWS, Caritas, Methodist, Baptist, HKPA,
  YMCA, Salvation Army, HKFYG
• Cancer
• Oncologist, Physician, Surgeon, OG, Palliative,
  Cancer Fund, Anti-Cancer Society, New Horizon
  Club, Comfort Care Concern Gp, HK Stoma
  Association
• Disabled
• Paediatrician, Orthopaedics, Geriatrician,
  Physician, Allied Health, Heep Hong, Fu Hong, Po
  Leung Kuk, Caritas, SJC, HKCS, PHAB
• Chronic Diseases
• Physician, Rehab Physician, Allied Health, CRN
• Health Promotion
• HA Hosp PRC, HKTBA, Anti-Cancer Soc, District
  Councils, Dept of Health

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Development of 7 Platforms 2

• 7 Platforms to be supported by Working Groups,
  which will focus on Quality of Care, Management
  Protocols, Communication and Information Sharing,
  Staff Training and Outcome Evaluation
• Key Performance Indicators to be developed, to
  include health services utilization, hospital
  staff and community partners participation, and
  health indicators of the population

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An Integrated CS Infrastructure
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Liaison Office in TSKHCACC

• Organizational Liaison
• Team headed by a social worker
• Patients Liaison
• Extension of Telephone Nursing Consultation
  Service (TNCS)

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Resources
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UNITED FRONT ????
Education
Political System
Family
Elderly
NGOs
Chronic Diseases
Environment
MED
DB
Volunteers
Health
Patient/ Carers
CPRD
CPNS
Others
PAED
Others
AHCP
Disability
Drs Nurses
Prevention
CNS
PSY
Geri
Legal System
OT
ONC
Economy
Cancer
Psychiatry
Welfare
Housing
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Overall Approach

• To enhance safe and early discharge from the
  hospital by establishing a good community support
  environment and utilizing ambulatory care
  services offered by hospitals
• To keep patients healthy and safe in the
  community via effective rehabilitation/ support
  programs and secondary prevention programs
• To keep the population healthy by primary
  prevention programs and early detection of
  diseases in the community

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Integration of Cluster Community Service
Continuing Efforts

• Internal dissemination
• HKEC Workshop onFrom Hospital to Community
  Involvement of
• Clinical Services in HKEC
• Share your views on
• Successes Failures
• Obstacles Opportunities
• Saturday 4 March 2006
• Community engagement seminars
• HA Convention May 2006
• Follow-up seminar 23 Sep 2006

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Evaluation

• Throughput indices
• Before/After Reduction of hospital services
• AED attendance
• AED admissions
• Unplanned readmissions
• Total length of stay
• Continual monitoring of hospital utilization
• Referral / downloading to NGO
• Quality indicators
• Compliance to protocols in community
• Adverse Outcome Incidences in community

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Evaluation

• Post-discharge home follow up program RCT of 209
  high risk patients reduction of 60 AED and 68
  of unplanned readmission rates
• Telephone Nursing Consultation Service RCT of
  230 high risk patients reduction of 36 AED
  admissions
• Visiting Medical Officer scheme up to 22 part
  time / full time VMO serving 68 OAH with 4846
  residents further reduction of 8 AED

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Public Health Targets

• Rate of smoking / alcohol / fat consumption
• Obesity / exercise / breast-feeding
• Population incidence of stroke, falls, AMI,
  accidents, etc

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Stroke among Age 40 (2003)
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Conclusions

• An integrative collaborative model for community
  services was established in HKEC
• Better infrastructure set up
• Mutual trust is being secured
• Better communication channels established
• Less misunderstanding
• Synergism in patient care achieved
• Quality of care is ensured
• Staff training is focussed
• Evaluation is continual in process

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Success Stories

• Enhance Home Care Service Teams conjoint
  bidding by 7 NGOs in HKEC
• TNCS to NGOs to facilitate communication and
  sharing of data
• Sharing of High Risk Patients Database and Alert
  System
• Downloading GDH and mental health patients to
  community rehab centres
• Community Engagement Symposium Sep 23, with 410
  participants (43 from NGO) 47 abstract
  submissions and a TRUE collaborative function

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Our Vision

• A Healthier Community in Hong Kong East