Free Paper Presentation I Success & Failure

The United Front – An Integrated Collaborative Model for Community Services Dr CP Wong Cluster Service Director (Community)

Outline Previous collaborations -- drawbacks Enhanced new model Strategies Evaluation

Service No of unitsService collaboration Communication Platform Elderly Service63 *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 Team *Elderly Neighborhood Centres *Elderly Social Centres *Elderly Day Care Centres *Elderly Homes *Service Purchase Scheme *Community Rehabilitation Practitioner *Shared care in PT *Carer Training Courses *Service Promotion in SOPDs / GOPCs *Patient & Carer Empowerment 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 0 60Service 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 *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 80Service Collaboration Communication Platform *Family Service Centre *Centres for Special needs *Nursery *Residential Services *Family Education & Support Services *Joint Project on community support *Case referrals *Project meetings Youth Service6161 *Youth and Children Centres *Services for Drug Abuser *Community Support Services *After School Care Services *School Social Work Service *Joint Project on volunteer service *Case referrals from school social workers *Project meetings *TWGH Drug abuse Centre joined liaison meeting already Others 13 Total277 Previous Collaborations

Status of HKEC Community Services April 2005 HospitalCommunity Specialists NGO

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 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 Workshop Partnering with Community Care Providers Hong Kong East Cluster Hospital Authority 13 August 2005 TSKHACC

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 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 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 Disable Elderly 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)

Resources

“UNITED FRONT” 統一戰線 Patient/ Carers CPRD AHCP Drs & Nurses Political System Environment Education Legal System Cancer Housing NGOs Prevention Psychiatry Volunteers CPNS Others DB Others Elderly Family Chronic Diseases Disability Welfare Economy Health $ O&T ONC PSY PAED MED CNS Geri

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 – Involvement of Clinical Services in HKEC” Share your views on Successes & Failures Obstacles & Opportunities Saturday 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”