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Dr. Felix HW CHAN Honorary Clinical Associate Professor

Medical & Social Integration : A Community Volunteer Service for Discharged Frail Elderly Patients in Hong Kong West. Dr. Felix HW CHAN Honorary Clinical Associate Professor University of Hong Kong. Community Support Program 愛心網絡護社區.

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Dr. Felix HW CHAN Honorary Clinical Associate Professor

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  1. Medical & Social Integration : A Community Volunteer Service for Discharged Frail Elderly Patients in Hong Kong West Dr. Felix HW CHAN Honorary Clinical Associate Professor University of Hong Kong

  2. Community Support Program愛心網絡護社區 To enable older people to continue staying in their familiar environment to achieve the policy objective of aging in place To maintain stable health condition and quality of life of community-dwelling older people To enhance post-discharge support to older patients through collaboration with the medical and welfare sector To provide early/ timely support by volunteers in the neighbourhood via an integrated community health network To reduce avoidable unplanned hospital admissions

  3. Kick-off ceremony 28.06.2008

  4. Community Volunteer Service Ward staff, CNS, MSW refer target client to community volunteer services CVS manager arranges volunteer matching Referral arrangement and client follow up Liaise with neighborhood volunteer groups for coordination of client’s FU care Refer to district NGOs for FU if client holds an active membership status Volunteer’s regular visits NGO/SWD community services Communicate with responsible NGOs to FU the client’s progress and close the file

  5. NGO partners • Aberdeen Kai-fong Welfare Association • Caritas HK Services for the Elderly • HK Sheng Kung Hui Welfare Council • St. James Settlement • The C&M Alliance Wah Kee Church – Christian Chaplaincy Service • The Diocesan Commission for Hospital Pastoral Care • The HK Red Cross • The HK Women Foundation Ho Kwok Pui Chun Social Centre for the Elderly

  6. Volunteers Gathering • Photos

  7. Medical Consultation for HKWC Community Volunteer Support Program 愛心網絡護社區 CVS client triaged by Telephone Nurse for medical consultation Seek early appointment in GP/GOPC SOPC (Med) QMH EAC FYKH Seek Medical Care within 24 hours e.g. GP/GOPC Seek Emergency Care ASAP • Telephone nurse completed the required form(s) and fax to related parties • Medical Consultation Form and/or • TNCS Record and/or • Last discharge summary SYP GOPC KTC GOPC ABD GOPC ALC GOPC FYKH GDH (EAC) SOPC (Med) QMH AED Fax the lower part of the Medical Consultation Form to Telephone Nurse for follow-up CVS client to be followed-up by Telephone Nurse post medical consultation

  8. TNCS Support to CVS (1) • Established since Nov 2008 from 09:00 to 17:00 during weekdays; • CNS TNCS Hotline 2855-4037is responsible for protocol-driven triage to • SOPC in QMH • GOPC in HKWC • EAC of FYKH • AED • 51 cases (as at Aug 2009) had contacted CNS TNCS Hotline

  9. TNCS Support to CVS (2)

  10. Total No. of Cases Referred to NGOs (4/2008 – 8/2009) Cases n=549 Mean age = 79.8 Male =55.1% (302) Female = 44.9% (247)

  11. Demographic Data of Referred Cases

  12. Demographic Data of Referred Cases

  13. Demographic Data of Referred Cases

  14. Diagnoses of Referred Cases

  15. Pre- & post 90 days Hospital Utilization n= 401cases (Cases joined CVS as at May/2009 and 20 cases were deceased.)

  16. End User Satisfaction Survey (1) • 105 user satisfaction surveys collected (as at Aug 2009); • Only those cases having 2 times of home visits need to complete the survey; • Overall speaking, 99% of users reported satisfied or above to the project; • All users reported sufficient carers’ information to them; • 99% of users reported satisfied or above to the volunteer’s performance; • 93% of users reported the project can satisfy most or all their post-discharge needs; • 94% of users reported the project can match with most or all their expectations.

  17. End User Satisfaction Survey (2) General Feedback from End Users: • Appreciated volunteers’ caring home visits; • Volunteers were very nice and patient; • Volunteers gave useful health information; • Appreciated the blood pressure measuring; • Hope more elderly can be benefited.

  18. Keys to Collaboration 1. Imagine yourself in others' shoes and hear and feel from their angles. 2. Develop a vision and common interests of a group. It helps glue group members together. Ask questions like "What values and goals do we share?" in order to develop a collective identity and better co-operative atmosphere for all. 3. Have a collaborative attitude. Be open-minded and listen to other's views. If you are intent on winning or debating, you won't listen effectively. • Seek others' opinions first rather than asking them to accept your ideas to reach a consensus

  19. Keys to Collaboration 5. After seeking others' views, incorporate theirs into yours but not just persist in your own thoughts. 6. Be creative and try to reach a win-win scenario because this will be beneficial to all parties. 7. In case of any overt conflict, don't assert your ideas too much. Wait until people are calm and receptive to assertion. If you try to assert while others are in anger, you may spoil the situation.  (HASLINK Sept 2007)

  20. Thank You

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