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1HA - HONG KONG EAST CLUSTER
TNCS
Telephone Nursing Consultation Service
Improving the Health of High Risk Elders in the Community with a
Collaborative Community Health Care Program
A Joint Project by HKEC CGAT & CNS
Joan HODOM(IMS2), RHTSK
2HA - HONG KONG EAST CLUSTER
TNCS
Background
• Ageing Population• Chronic diseases predominant• Elderly constitutes 38.6% of patient days
in Hospital Authority• Inefficient handling of acute crisis of
patients in the community except AED• Lack of a good interface across different
stakeholders in health care service
3HA - HONG KONG EAST CLUSTER
TNCS
Telephone Nursing Consultation Service
(TNCS)• Telephone triage• Referrals to
appropriate community resources
• Provides Home Care Instructions
• Gives advice on disease management
4HA - HONG KONG EAST CLUSTER
TNCS
Three Critical Elements in TNCS
1. Co-ordinates with relevant healthcare stakeholders
5HA - HONG KONG EAST CLUSTER
TNCS
CommunityNursing Service
Hospital Service
NGOsDistrict Elderly
Care Center
GPs
Volunteers
TNCS
Community Allied Health
GOPCs
6HA - HONG KONG EAST CLUSTER
TNCS
GP can contact TNCS to enquire patient’s medical history
7HA - HONG KONG EAST CLUSTER
TNCS
Critical Element in TNCS
2. Utilizes protocols to guide nurses’ clinical decisions
8HA - HONG KONG EAST CLUSTER
TNCS
28 Telephone Triage Protocols Developed• Abdominal Pain• Appetite Loss• Back Pain• Black / Bloody stool• Chest Pain• Confusion• Constipation• Cough• DM• Diarrhoea• Dizziness• Falls • Fatigue• Fever
• Headache• Hemorrhoids• Hypertension• Hypotension• Insomnia• Itching• Joint Pain/ Swelling• Leg Pain / Swelling • Numbness and tingling• Rash• SOB• Skin Lesions• Swallowing Difficulty• Weakness
9HA - HONG KONG EAST CLUSTER
TNCS
10HA - HONG KONG EAST CLUSTER
TNCS
11HA - HONG KONG EAST CLUSTER
TNCS
Critical Element in TNCS
3. Utilizes IT support– Links with the Clinical Management
System (CMS)– Utilizes ‘High Risk Elderly Database
& Alert System’
12HA - HONG KONG EAST CLUSTER
TNCS
13HA - HONG KONG EAST CLUSTER
TNCS
14HA - HONG KONG EAST CLUSTER
TNCS
15HA - HONG KONG EAST CLUSTER
TNCS
16HA - HONG KONG EAST CLUSTER
TNCS
TNCS utilizes ‘High Risk Elderly Database
& Alert System’ to capture high-risk elders
and follows up them actively.
17HA - HONG KONG EAST CLUSTER
TNCS
18HA - HONG KONG EAST CLUSTER
TNCS
17/05/2005 18/05/2005
19HA - HONG KONG EAST CLUSTER
TNCS
Study Population• Patients discharged from Department
of Medicine & Geriatrics in PYNEH & RHTSK and fit 2 out of 3 of the following criteria:– Frequent hospital admissions
>= 3 acute medical admissions in one year
– Multiple pathology>=3 co-morbidities
– Special diagnostic groupsCongestive Heart Failure, COAD, Chronic
Renal Failure, Malignancy
20HA - HONG KONG EAST CLUSTER
TNCS
Exclusions
• Living at old age homes• Under the care of Enhanced Home &
Community Care Service / Integrated Home Care Service
• Receiving intensive community programs e.g. Post Discharge Home Follow-up Program
21HA - HONG KONG EAST CLUSTER
TNCS
Methodology
• 230 patients recruited from 12 Sept 05 to 27 Jan 06
• Randomly assigned to– Control group (conventional, no TNCS)– TNCS group
• Demographic Data were compared• Evaluates the outcomes after a period
of two months– AED attendance– Number of admissions
22HA - HONG KONG EAST CLUSTER
TNCS
TNCS Group Invites to become members of TNCS and flags the case in the High-risk database
TNCS nurse makes phone follow-up to members+ Member initiates call to the TNCS Center
Consults relevant health care professionals for further information and support if necessary
Offers advice•Designates to appropriate health resources•Makes referrals to CNS, volunteer, DECC etc. if necessary•Explains health condition & disease management •Provides home care instruction
Phone follow-up within 24-48 hrs. to assess the effectiveness of the advice
Evaluates the outcomes after a period of two months.
Asks for caller’s feedback before ending the callAsks caller to call back if problem worsened
Advices base on clinical judgment if protocols are not available.
TNCS nurse identifies problem by performing assessment via phone
Client fits the TNCS inclusion criteria
Chooses appropriate protocol to guide the decision
Operational Flow on Telephone Nursing Consultation Service
Control Group Receives the conventional community support if necessary
23HA - HONG KONG EAST CLUSTER
TNCS
Results• Out of the 230 recruited cases, 32
dropped out from the program due to the following reasons:- 29 died- 3 moved to OAHs
• The final TNCS samples were 97 and control samples were 101
24HA - HONG KONG EAST CLUSTER
TNCS
Results - Demographics
All Comparable (p>0.05)
Control Group
(n = 101)
TNCS Group(n = 97)
Age 78.1(65 – 91)
78.4(65 – 93)
Sex M:F 52:49 46:51
Patients with medical diagnoses >=3
92 90
No. of regular medications (mean)
4.8 4.75
25HA - HONG KONG EAST CLUSTER
TNCS
Triage Advice
0 0
4
1213
0
2
4
6
8
10
12
14
Go to AED Arrangedirect
admission
Book earlyF.U. appt
See GP See GOPC
No o
f A
dvic
e
26HA - HONG KONG EAST CLUSTER
TNCS
Referred out to Different Services
18
1
66
02
46
81012
1416
1820
Community AlliedHealth
Community NursingService
Volunteer Service District Elderly CareCenter
No
of r
efer
ral
27HA - HONG KONG EAST CLUSTER
TNCS
Home Care Advice Given
0
50
100
150
200
250
300
EnvironmentalAdvice
Health Education DrugManagement
Communityresources
No.
of Adv
ice
*
28HA - HONG KONG EAST CLUSTER
TNCS
OutcomesDecreased Usage of Hospital
Services
8567
24
5443
170
10
20
30
40
50
60
70
80
90
AED Emergency Adm Clinical Adm
No. of
att
endance/adm
issio
ns
Control
TNCS
35.8%36.5% p=0.05
p=0.025
29.2%
29HA - HONG KONG EAST CLUSTER
TNCS
OutcomesPatient Satisfaction
Survey• Phone survey, conducted by a
volunteer• 46.4 % response rate• 31% respondents were patients and 69% were relatives/carers
30HA - HONG KONG EAST CLUSTER
TNCS
100 100
95.56
81.82
100 100
0
10
20
30
40
50
60
70
80
90
100
Sati
fact
ion R
ate
(%
)
ReduceWorries
Improve HealthKnowledge
Improve SelfManagement
on the disease
Assist DailyLife Adaptation
Refer toAppropriate
Health Service
OverallSatisfaction
Survey Questions
Patient / Carer Satisfaction Survey
31HA - HONG KONG EAST CLUSTER
TNCS
TNCS Package can….
• Identify high-risk elders through IPAS經病人資訊系统識別高危長者
• Monitor & follow-up their health健康監察及跟進
• Empower clients for self-management授權長者及照顧者,以增加他們的自理能力
• Serves as a good platform for service collaboration聯繫各醫療服務的平台
• Improves the accessibility to health care service增加醫療服務的可近性
護訊鈴計劃可以… ..
32HA - HONG KONG EAST CLUSTER
TNCS
TNCS Package can….
• Reduce Unnecessary Usage of Hospital Services減少醫院服務的使用,有明顯的成本效益– Cuts over 1/3 AED attendance & E admissions– Longer service period that the patient joined
TNCS, the better the effect (need to be further studied to confirm the assumption)
護訊鈴計劃可以… ..
33HA - HONG KONG EAST CLUSTER
TNCS
Thank You
TNCS
34HA - HONG KONG EAST CLUSTER
TNCS
Team Members• Dr CP WONG, Director (Community Service), HKEC• Dr Bernard KONG, Dep CSD/Consultant (CGAT), HKEC• Joan HO, DOM(IMS2), RHTSK• Anna NG, SNO(CNS), PYNEH• Karence TO, WM(CGAT), RHTSK• See Mun CHEUNG, WM(CNS),PYNEH• Sabrina HO, NO(CGAT),RHTSK• Kwai Heung NG, APN(CNS),PYNEH• Chi Hang FUNG, RN(CGAT),RHTSK• Tina WONG, RN(CGAT), RHTSK• Sau Yung CHAN, RN(CNS), RHTSKCollaborators:• Mr CK LAW, Executive Manager (Community & Allied Health), PYNEH• Ms Daisy WONG, Cluster Service Co-ordinator (Community &
Volunteer Service), HKEC
35HA - HONG KONG EAST CLUSTER
TNCS
Acknowledgements• Senior Management, HKEC
– Dr Loretta Yam, CCE, HKEC– Dr H C Ma, HCE, RHTSK– Ms Civy Leung, CGMN, HKEC
• NGO Partners– Methodist Centre for the Seniors, Wan Chai
DECC– SAGE, Eastern DECC– SAGE, Chai Wan DECC– St James Settlement, Continuing Care (DECC)– TWGHs, Fong Shu Chuen DECC– YWCA, Ming Yue DECC
• HAHO IT Team