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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
Previous Collaborations
Service
Elderly Service
*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
No of
units
Service collaboration
Communication
Platform
63
6
2
9
8
20
6
12
*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
*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
60
Service
Collaboration
Communication Platform
1
3
13
1
8
15
*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
0
5
14
Previous Collaborations
Family & Children Welfare
Service
80
Service
Collaboration
Communication
Platform
*Family Service Centre
*Centres for Special needs
*Nursery
*Residential Services
*Family Education & Support
Services
12
4
29
23
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
3
11
19
*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
Status of HKEC Community Services
April 2005
Hospital
Specialists
Community
NGO
NGO
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 restructured 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-beintegrated) 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
An Integrated CS Infrastructure
Elderly
Disable
Cancer
Psy
Paed
Chr
…
Communication & Data Interchange
Protocols and Guidelines
Evaluation
Staff Training …
…
Liaison Office in TSKHCACC
•
•
Organizational Liaison
• Team headed by a social worker
Patients Liaison
• Extension of Telephone Nursing
Consultation Service (TNCS)
Structure of Community Services in HKEC
Cluster Medical Committee
Community Service
Steering Committee
PPI Committee
Community Service
Management Committee
Liaison Office
Executive Group
5 Working Groups
Referral & Protocols
Communication/
Information/Database
Resources Development
Training
Outcome Definition &
Evaluation Studies
Cancer
Psychiatry
Prevention &
Health Promotion
O&T/Community
Rehabilitation Network
PGT/CPNS
HRC/PRC/
Community Health Centre
7 Platforms
Elderly
Family
Chronic Diseases
Disabled
Resources
Examples
CNS/CGAT/
TNCS/EHC/IHCST
Paediatrics &
Child Health
Family Medicine/
GOPC
Hospice/PRC/
CRN/CHaplaincy
“UNITED FRONT” 統一戰線
Family
NGOs
DB
Volunteers
CPNS
Others
Patient/
Carers
CNS
Drs &
Nurses
CPRD
AHCP
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”