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Symposium on. Community Engagement II. “Building a Successful Partnership in Community Care”. Free Paper Presentation I. Success & Failure. Symposium on. Community Engagement II. “Building a Successful Partnership in Community Care”.

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Free paper presentation i

Symposium on

Community Engagement II

“Building a Successful Partnership in Community Care”

Free Paper Presentation I

Success & Failure


The united front an integrated collaborative model for community services

Symposium on

Community Engagement II

“Building a Successful Partnership in Community Care”

The United Front –An Integrated Collaborative Model for Community Services

Dr CP Wong

Cluster Service Director (Community)


Outline

Outline

  • Previous collaborations -- drawbacks

  • Enhanced new model

  • Strategies

  • Evaluation


Free paper presentation i

Previous Collaborations


Free paper presentation i

Previous Collaborations


Free paper presentation i

Previous Collaborations


Status of hkec community services april 2005

Hospital

Community

NGO

Specialists

NGO

Specialists

NGO

Status of HKEC Community Services April 2005


Drawbacks of the o ld s ystem

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


Integration of community services

Integration of Community Services

  • Jul 2006: Community-based Services re-structured towardsimproved 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


Free paper presentation i

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


Our vision

Our Vision

“A Healthier Community in Hong Kong East”


Our mission

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


4 strategic areas for enhancement

4 Strategic Areas for Enhancement

  • To strengthen community health infrastructurebyestablishing 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 andcapacity buildingthrough pooling of resources in the cluster and the community


Development of 7 platforms 1

Development of 7 Platforms: 1

  • NewCommunity Network Link Liaison Officewith7 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 witha (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


7 platforms

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, O&G, 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…


Development of 7 platforms 2

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


Free paper presentation i

Elderly

Cancer

Psy

Paed

Chr

Disable

Protocols and Guidelines

Evaluation

Staff Training …

Communication & Data Interchange

An Integrated CS Infrastructure


Liaison office in tskhcacc

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


Free paper presentation i

“UNITED FRONT” 統一戰線

Education

Political System

Family

Elderly

NGOs

Chronic Diseases

Environment

MED

DB

Volunteers

Health $

CPNS

Patient/

Carers

CPRD

Others

PAED

Others

AHCP

Disability

Prevention

Drs &

Nurses

CNS

PSY

Geri

Legal System

O&T

ONC

Economy

Cancer

Psychiatry

Welfare

Housing


Overall approach

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 effectiverehabilitation/ support programs and secondary prevention programs

  • To keep the population healthy by primary prevention programs and early detection of diseases in the community


Integration of cluster community service continuing efforts

Integration of Cluster Community Service: Continuing Efforts

  • Internal dissemination

    HKEC Workshop on“From Hospital to Community – Involvement of

    Clinical Services in HKEC”

    Shareyour views on

    Successes & Failures

    Obstacles & Opportunities

    Saturday 4 March 2006

  • Community engagement seminars

    • HA Convention May 2006

    • Follow-up seminar 23 Sep 2006


Evaluation

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


Evaluation1

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


Public health targets

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)


Conclusions

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


Success stories

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


Our vision1

Our Vision

“A Healthier Community in Hong Kong East”


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