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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 HO
DOM(IMS2), RHTSK
HA - HONG KONG EAST CLUSTER
TNCS
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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
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Telephone Nursing
Consultation Service (TNCS)
• Telephone triage
• Referrals to appropriate
community resources
• Provides Home Care
Instructions
• Gives advice on disease
management
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Three Critical Elements in TNCS
1. Co-ordinates with relevant healthcare
stakeholders
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NGOs
District Elderly
Care Center
Volunteers
Community
Allied Health
GOPCs
GPs
TNCS
Community
Nursing
Service
Hospital Service
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GP can contact TNCS to enquire
patient’s medical history
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Critical Element in TNCS
2. Utilizes protocols to guide nurses’
clinical decisions
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28 Telephone Triage Protocols Developed
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Abdominal Pain
Appetite Loss
Back Pain
Black / Bloody stool
Chest Pain
Confusion
Constipation
Cough
DM
Diarrhoea
Dizziness
Falls
Fatigue
Fever
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Headache
Hemorrhoids
Hypertension
Hypotension
Insomnia
Itching
Joint Pain/ Swelling
Leg Pain / Swelling
Numbness and tingling
Rash
SOB
Skin Lesions
Swallowing Difficulty
Weakness
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Critical Element in TNCS
3. Utilizes IT support
– Links with the Clinical Management
System (CMS)
– Utilizes ‘High Risk Elderly Database &
Alert System’
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TNCS utilizes
‘High Risk Elderly Database
& Alert System’
to capture high-risk elders and
follows up them actively.
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17/05/2005
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18/05/2005
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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 groups
Congestive Heart Failure, COAD, Chronic Renal
Failure, Malignancy
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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
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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
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Operational Flow on Telephone Nursing Consultation Service
Client fits the TNCS inclusion criteria
Control Group Receives the
conventional community
support if necessary
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
TNCS nurse identifies problem by performing assessment via phone
Consults relevant health
care professionals for
further information and
support if necessary
Evaluates the outcomes after
a period of two months.
Advices base on clinical
judgment if protocols
are not available.
Chooses appropriate
protocol to guide the
decision
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
Asks for caller’s feedback before ending the call
Asks caller to call back if problem worsened
Phone follow-up within 24-48 hrs. to assess the
effectiveness of the advice
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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
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Results - Demographics
Control Group
(n = 101)
TNCS Group
(n = 97)
78.1
(65 – 91)
78.4
(65 – 93)
52:49
46:51
Patients with medical
diagnoses >=3
92
90
No. of regular
medications (mean)
4.8
4.75
Age
Sex M:F
All Comparable (p>0.05)
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Triage Advice
14
12
No of Advice
12
13
10
8
6
4
4
2
0
0
0
Go to AED
Arrange
direct
admission
Book early
F.U. appt
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See GP
See GOPC
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No of referral
Referred out to Different Services
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18
16
14
12
10
8
6
4
2
0
18
6
6
Community Nursing
Service
Volunteer Service
1
Community Allied
Health
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District Elderly Care
Center
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*
Home Care Advice Given
300
No. of Advice
250
200
150
100
50
0
Environmental
Advice
Health Education
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Drug
Management
Community
resources
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Outcomes
Decreased Usage of Hospital Services
Control
TNCS
No. of attendance/admissions
90
80
70
60
85
p=0.025
36.5%
50
67
p=0.05
35.8%
40
30
54
29.2%
43
20
24
10
0
A ED
Emergency A dm
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Clinical A dm
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Outcomes
Patient Satisfaction Survey
• Phone survey, conducted by a volunteer
• 46.4 % response rate
• 31% respondents were patients and
69% were relatives/carers
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Patient / Carer Satisfaction Survey
100
100
100
95.56
100
81.82
90
Satifaction Rate (%)
100
80
70
60
50
40
30
20
10
0
Reduce
Worries
Improve Health Improve Self
Assist Daily
Refer to
Knowledge
Management Life Adaptation Appropriate
on the disease
Health Service
Overall
Satisfaction
Survey Questions
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TNCS Package can….
護訊鈴計劃可以…..
• 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
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TNCS Package can….
護訊鈴計劃可以…..
• 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)
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Thank You
TNCS
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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), RHTSK
Collaborators:
• Mr CK LAW, Executive Manager (Community & Allied Health), PYNEH
• Ms Daisy WONG, Cluster Service Co-ordinator (Community & Volunteer
Service), HKEC
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Acknowledgements
• Senior Management, HKEC
– Dr Loretta Yam, CCE, HKEC
– Dr H C Ma, HCE, RHTSK
– Ms Civy Leung, CGMN, HKEC
• NGO Partners
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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
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