Free Paper Presentation I

Success & Failure

The United Front –An Integrated Collaborative

Model for Community Services

Dr CP WongCluster Service Director (Community)

Outline

• Previous collaborations -- drawbacks

• Enhanced new model• Strategies• Evaluation

ServiceNo of

units

Service collaborationCommunication

Platform

Elderly Service 63

*District Elderly Community Centre (DECC) Including services for frail elderly / Carer Support Centre / Support Team for the Elderly

*Enhanced Home Care Team*Integrated Home Care Service Tea

m*Elderly Neighborhood Centres*Elderly Social Centres*Elderly Day Care Centres*Elderly Homes

6

2 9 820 612

*Service Purchase Scheme*Community Rehabilitation

Practitioner*Shared care in PT*Carer Training Courses*Service Promotion in SOPDs

/ GOPCs*Patient & Carer Empowerme

nt Program*Community Care Volunteer

Networks*Case referrals

*HKEC Elderly Service Liaison Committee (Quarterly meeting, 7 major NGO service providers invited)*Project Meetings*As advisors to elderly service in SWD District platform or NGO’s Liaison Meetings

Previous Collaborations

Rehabilitation Service 060 Service Collaboration

Communication Platform

*Community Rehabilitation Network*Mental Health Link*Community support*Training and Activity Centre for Mentally Ill*Services for Disabled (adults)*Sheltered Workshops & Supported Employment*Services for Disabled (children)*Hostels / Half way houses

1 313

1 815 514

*Patient & Carer Empowerment Program*Service Promotion in SOPD*Case referrals

*3 Liaison Meetings for Community Partners of chronic illness, psychiatric and, cancer respectively*Project Meetings*Case conferences

Previous Collaborations

Family & Children Welfare Service

80 Service Collaboration

Communication Platform

*Family Service Centre*Centres for Special needs*Nursery*Residential Services*Family Education & Support Serv

ices

12 42923 12

*Joint Project on community support

*Case referrals

*Project meetings

Youth Service 61

*Youth and Children Centres*Services for Drug Abuser*Community Support Services*After School Care Services*School Social Work Service

22 6 31119

*Joint Project on volunteer service

*Case referrals from school social workers

*Project meetings*TWGH Drug abuse

Centre joined liaison meeting already

Others 13

Total 277

Previous Collaborations

Status of HKEC Community Services April 2005

Hospital Community

Specialists

Specialists

NGO

NGO

NGO

Drawbacks of the Old System

• Piecemeal approach• Incomplete and disorganized comm

unication• Duplications/omissions• Development and outcome dependen

t on attitude and efforts of clinicians and specialties

• No overall governance

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

Community Health Service Planning WorkshopPartnering with

Community Care Providers

Hong Kong East Cluster Hospital Authority

13 August 2005TSKHACC

Our Vision

“A Healthier Community in Hong

Kong East”

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

• 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

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

7 PlatformsElderly

Geriatrician, Ortho, Psychiatry, SAGE, TWGH, SJS, Methodist, HKFWS, YWCA…Psychiatry

Psychiatrist, Nursing, Allied Health, BOKSS, Fu Hong, Richmond, SRACP, TWGH…

Children & FamilyPaediatrician, 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…

DisabledPaediatrician, 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

• 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

……ChrPaedPsyCancer DisableElderly

Protocols and Guidelines

Communication & Data Interchange

Evaluation

Staff Training …

An Integrated CS Infrastructure

Liaison Office in TSKHCACC• Organizational Liaison

• Team headed by a social worker • Patients Liaison

• Extension of Telephone Nursing Consultation Service (TNCS)

S tru ctu re o f C om m u n ity S erv ices in H K E C

L ia iso n O ffic e E x e c u tiv e G r o u p

R e fe r r a l & P r o to c o ls C o m m u n ic a tio n /In fo r m a tio n /D a ta b a se

R e so u r c e s D e v e lo p m e n t T r a in in g O u tc o m e D e fin it io n &E v a lu a tio n S tu d ie s

7 P la tfo r m s

E ld e r ly F a m ily C h r o n ic D ise a se s D isa b le d C a n c e r P sy c h ia tr y P r e v e n tio n &H e a lth P r o m o tio n

C N S /C G A T /T N C S /E H C /IH C S T

P a e d ia tr ic s &C h ild H e a lth

F a m ily M e d ic in e /G O P C

H o sp ic e /P R C /C R N /C H a p la in c y

O & T /C o m m u n ityR e h a b ilita tio n N e tw o rk

P G T /C P N S H R C /P R C /C om m u n ity H ea lth C en tre

E x a m p le s

5 W o r k in g G r o u p s

C o m m u n ity S e r v ic eM a n a g e m e n t C o m m itte e

C o m m u n ity S e r v ic eS te e r in g C o m m itte e

P P I C o m m itte e

C lu ste r M e d ic a l C o m m itte e

Resources

“UNITED FRONT” 統一戰線

Patient/Carers

CPRD

AHCP

Drs & Nurses

Political System

Enviro

nm

e

nt

Education

Legal

Syst

em

Cancer

Housing

NGOs

Pre

venti

on

Psychiatry

Volunteers

CPNS

Others

DB

Oth

ers

Elde

rly

FamilyChronic D

iseases

Dis

abili

ty

Welfare

Econom

y

Healt

h $

O&T ONC

PSY

PA

ED

MED

CNSGeri

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

Integration of Cluster Community Service:

Continuing Efforts• Internal dissemination

HKEC Workshop on“From Hospital to Community – Involveme

nt of Clinical Services in HKEC”

Share your views onSuccesses & Failures

Obstacles & OpportunitiesSaturday 4 March 2006

• Community engagement seminars• HA Convention May 2006• Follow-up seminar 23 Sep 2006

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

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

• Rate of smoking / alcohol / fat consumption

• Obesity / exercise / breast-feeding

• Population incidence of stroke, falls, AMI, accidents, etc

Stroke among Age 40+ (2003)

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• 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 Vision

“A Healthier Community in Hong

Kong East”