Post on 20-Mar-2020
INTEGRATED CARE AND DISCHARGE SUPPORT (ICDS) FOR OLDER PATIENTS –
FROM HOSPITAL TO COMMUNITY IN HONG KONG WEST CLUSTER
HA CONVENTION 2015
Dr Felix Hon Wai CHAN JP
HKWC Service Director( P & CHC )
Clinical Division Chief (Geriatrics), University Department of Medicine
FYKH COS(MED) / QMH/TWH CONS(MED) / GH CONS i/c(AGU)
Patient Journey in HKWC
From Admission to Discharge
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Integrated Care and Discharge Support (ICDS) Program 支援長者離院綜合服務
Program funded by the Labour & Welfare
Bureau and the Hospital Authority
Extension of the Community Geriatric
Assessment Service (CGAS)
Main objectives to reduce avoidable hospital service utilization and promote ageing-in-place
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IDSP
HARRPE Score
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HARRPE SCORE
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HARRPE Score (High Admission Risk Reduction Program for Elderly)
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Link Nurses (Inpatient)
DC HOME
GH TWH FYKH
Case Manager (In
Community)
ICDS Geriatrician
QMH
7/33
Link nurse performing
assessment and discharge
planning
Multi-disciplinary Round
ICM Case Manager home visit
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Home Support Service
9/33
Governance
Weekly Case Conference
SD (P & CHC)
HKWC
Steering
Committee Community
Care Services
HKWC
CCE
ICDS / IDSP Sub Committee Meeting 10/33
Objectives
To examine the effectiveness of ICDS on
Accident and Emergency Department (AED) attendance , acute hospital admission, hospital bed days, functional status, and institutionalization
To identify the risk factors influencing AED
attendance within 6 months
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Study Method - Prospective Study
1,184 older patients recruited into
ICDS
1,090 (92%) analyzed pre- & post-six months
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N (%)
Caring situation
Live alone 154 14.1
Live with maid only 24 2.2
Live with 1st degree relative(s) 698 64
Live with 1st degree relative(s) and maid 205 18.8
Live with friend 9 0.8
Daytime alone even with carer 322 29.6
Finance
DA 69 6.3
HAD 7 0.6
CSSA 114 10.5
Depends on family/self/OA 900 82.6
Total N = 1090 Age = 80.4 ± 7.6 (range 60 – 104)
Female 557 (51%)
Social and Demographic Characteristics
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Recruitment and service received
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All
ICM CM
HST
76 days
(10.8 wks)
N=1090
101 days
(14.4 wks)
N= 475
56 days
(8 wks)
N= 615
Average duration of services 75.8 days
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0
0.5
1
1.5
2
2.5
3
3.5
AED attendance
2
1.2
No
pe
r p
ers
on
pe
r 6
mo
nth
s
P<0.001
40% reduction
Pre-6 m Post-6 m
AED attendance 6 months before and after ICDS
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0
0.5
1
1.5
2
2.5
3
1.7
0.9
No
pe
r p
ers
on
pe
r 6
mo
nth
s
P<0.001
47% reduction
Pre-6 m Post-6 m
Acute hospital admission
Acute hospital admission 6 months before and after ICDS
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0
5
10
15
20
25
30
Bed days
16
11No
pe
r p
ers
on
pe
r 6
mo
nth
s
P<0.001
31% reduction
Pre-6 m Post-6 m
Hospital bed days (acute & convalescence) 6 months before and after ICDS
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0
5
10
15
20
25
BI MFAC AMT
16.5
5.7
8.4
17.6
6.38.4
Pre-6 m Post-6 m
p<0.001
At intake At DC P value
BI 16.5 4.1 17.6 4.1 <0.001
MFAC 5.7 1.6 6.3 2.2 <0.001
AMT 8.4 2.1 8.4 1.7 0.15
p<0.001
Change of BI (20) , MFAC and AMT
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Multivariate analysis for factors predicting
AED attendance ≥ 1 in the 6 months after ICDS commencement
599 (55%) had AED attendance ≥1 in the 6 months after ICDS
(Logistic regression )
Factors
(at the time of recruitment)
Odds
95% CI P value
Age 1.02 1.0 to 1.036 0.025
CCI 1.18
1.11 to 1.25 0.001
Albumin 0.96 0.94 to 0.98 0.001
Living alone 0.68 0.47 to 0.97 0.033
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Only 26 persons (2.4%) were institutionalized in RCHEs after 6 months
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書面讚賞紀錄
2012-2013年度
(156)
2013-2014年度
(215)
2014-2015年度 2014-2015年度
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23
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Total expenditure ( HK$ )
6.68M (ICM) + 5.94M (IDSP HST) = 12.62 M
Net cost saved per year ( HK$ )
17.56M x 2 – 12.62M = 22.5M
Notional annual saving of ICDS
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Special Features of ICDS in HKWC
Covered elderly discharged from medical wards
of QMH, and all cluster hospitals Clinical Governance Case Managers are Nurses, MSW, PT & OT Shared evidence-based protocols & care plan Systematic evaluation
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Essential Elements
1) Comprehensive assessment 2) Patient-centred care 3) Evidence-based care plan 4) Care beyond discharge from Hospital 5) Engagement of patients, family & health/
social care teams 6) Multi-disciplinary approach 7) Linked Nurses, Case Managers &
Geriatricians 26/33
Achievements Accreditation of The Australian Council on
Healthcare Standards (ACHS) in October
2014
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Criteria with Extensive
Achievement (EA)
1.1.6 Ongoing Care
1.2.1 Community Information
1.2.2 Access & Communication
1.6.1 Community & Patient
Participation
Achievements
Achievements
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29/33
Publication
Conclusion
Reduction in AED attendance/hospital admission
Reduction in bed-days occupied
Kept elderly in the community, avoiding institutionalization
Improved functional and mobility states among older patients
Met Government’s policy objective of ageing-in-place
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31
HKWC
Integrated Care and Discharge Support for
Elderly Patients (ICDS)
支援長者離院綜合服務
Queen Mary
Hospital
Grantham
Hospital TWGHs
Fung Yiu King Hospital
Tung Wah
Hospital
Aberdeen Kai-fong
Welfare Association
ICDS
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Collaboration with NGO partners
Date: 12 September 2015 (Saturday)
Time: 0900-1300 hrs.
Venue: M/F, Lecture Theatre, HA Building,
Argyle Road, Kowloon
Evaluation Report on Health and Social Integrated
Model in Transitional Care (HSIMTC), conducted by
Sau Po Centre on Aging (COA), The University of
Hong Kong
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“小病在社區,大病到醫院,康復回社區”
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Work in both acute and convalescence hospitals (QMH, GH, TWH, FYKH)
Comprehensive geriatric assessment
Daily round with ICDS Geriatrician Follow-up progress of patients
during hospitalization Formulate discharge planning Select suitable cases for ICM Case
Management and IDSP HST 34
Link Nurses (stationed in strategic locations – QMH, FYKH, TYH, Aberdeen)
Home visit and telephone support Coordinate the post discharge interventions Coordinate the delivery of community health services Transitional rehabilitation at appropriate institutional or home-based setting Arrange other disciplines e.g. PT, OT, Nurse, MSW for assessment and management Arrange fast track clinic follow-up if required Provision of patient and carer empowerment program
ICM Case Manager – responsible for
community service coordination
Provide rapid seamless community care support.
NGO (AKA) Home Support Team (HST) to provide home services such as:
• Home care - meal delivery, drug supervision, household cleansing
• Rehabilitation and therapeutic exercise
• Home assessment and modification
• Respite care
• Care education
• Telephone enquiry
IDSP HST in HKWC
Record for Appreciation of
ICDS Service in HKWC
Year No. of Appreciation
2012/2013 12
2013/2014 14
2014/2015 26