INTEGRATED CARE AND DISCHARGE SUPPORT (ICDS) FOR OLDER PATIENTS –

FROM HOSPITAL TO COMMUNITY IN HONG KONG WEST CLUSTER

HA CONVENTION 2015

Dr Felix Hon Wai CHAN JP

HKWC Service Director( P & CHC )

Clinical Division Chief (Geriatrics), University Department of Medicine

FYKH COS(MED) / QMH/TWH CONS(MED) / GH CONS i/c(AGU)

Patient Journey in HKWC

From Admission to Discharge

2/33

Integrated Care and Discharge Support (ICDS) Program 支援長者離院綜合服務

Program funded by the Labour & Welfare

Bureau and the Hospital Authority

Extension of the Community Geriatric

Assessment Service (CGAS)

Main objectives to reduce avoidable hospital service utilization and promote ageing-in-place

3/33

IDSP

HARRPE Score

4/33

HARRPE SCORE

5/33

HARRPE Score (High Admission Risk Reduction Program for Elderly)

6/33

Link Nurses (Inpatient)

DC HOME

GH TWH FYKH

Case Manager (In

Community)

ICDS Geriatrician

QMH

7/33

Link nurse performing

assessment and discharge

planning

Multi-disciplinary Round

ICM Case Manager home visit

8/33

Home Support Service

9/33

Governance

Weekly Case Conference

SD (P & CHC)

HKWC

Steering

Committee Community

Care Services

HKWC

CCE

ICDS / IDSP Sub Committee Meeting 10/33

Objectives

To examine the effectiveness of ICDS on

Accident and Emergency Department (AED) attendance , acute hospital admission, hospital bed days, functional status, and institutionalization

To identify the risk factors influencing AED

attendance within 6 months

11/33

Study Method - Prospective Study

1,184 older patients recruited into

ICDS

1,090 (92%) analyzed pre- & post-six months

12/33

N (%)

Caring situation

Live alone 154 14.1

Live with maid only 24 2.2

Live with 1st degree relative(s) 698 64

Live with 1st degree relative(s) and maid 205 18.8

Live with friend 9 0.8

Daytime alone even with carer 322 29.6

Finance

DA 69 6.3

HAD 7 0.6

CSSA 114 10.5

Depends on family/self/OA 900 82.6

Total N = 1090 Age = 80.4 ± 7.6 (range 60 – 104)

Female 557 (51%)

Social and Demographic Characteristics

13/33

Recruitment and service received

14/33

All

ICM CM

HST

76 days

(10.8 wks)

N=1090

101 days

(14.4 wks)

N= 475

56 days

(8 wks)

N= 615

Average duration of services 75.8 days

15/33

0

0.5

1

1.5

2

2.5

3

3.5

AED attendance

2

1.2

No

pe

r p

ers

on

pe

r 6

mo

nth

s

P<0.001

40% reduction

Pre-6 m Post-6 m

AED attendance 6 months before and after ICDS

16/33

0

0.5

1

1.5

2

2.5

3

1.7

0.9

No

pe

r p

ers

on

pe

r 6

mo

nth

s

P<0.001

47% reduction

Pre-6 m Post-6 m

Acute hospital admission

Acute hospital admission 6 months before and after ICDS

17/33

0

5

10

15

20

25

30

Bed days

16

11No

pe

r p

ers

on

pe

r 6

mo

nth

s

P<0.001

31% reduction

Pre-6 m Post-6 m

Hospital bed days (acute & convalescence) 6 months before and after ICDS

18/33

0

5

10

15

20

25

BI MFAC AMT

16.5

5.7

8.4

17.6

6.38.4

Pre-6 m Post-6 m

p<0.001

At intake At DC P value

BI 16.5 4.1 17.6 4.1 <0.001

MFAC 5.7 1.6 6.3 2.2 <0.001

AMT 8.4 2.1 8.4 1.7 0.15

p<0.001

Change of BI (20) , MFAC and AMT

19/33

Multivariate analysis for factors predicting

AED attendance ≥ 1 in the 6 months after ICDS commencement

599 (55%) had AED attendance ≥1 in the 6 months after ICDS

(Logistic regression )

Factors

(at the time of recruitment)

Odds

95% CI P value

Age 1.02 1.0 to 1.036 0.025

CCI 1.18

1.11 to 1.25 0.001

Albumin 0.96 0.94 to 0.98 0.001

Living alone 0.68 0.47 to 0.97 0.033

20/33

Only 26 persons (2.4%) were institutionalized in RCHEs after 6 months

21/33

書面讚賞紀錄

2012-2013年度

(156)

2013-2014年度

(215)

2014-2015年度 2014-2015年度

22/32

23

23/33

Total expenditure ( HK$ )

6.68M (ICM) + 5.94M (IDSP HST) = 12.62 M

Net cost saved per year ( HK$ )

17.56M x 2 – 12.62M = 22.5M

Notional annual saving of ICDS

24/33

Special Features of ICDS in HKWC

Covered elderly discharged from medical wards

of QMH, and all cluster hospitals Clinical Governance Case Managers are Nurses, MSW, PT & OT Shared evidence-based protocols & care plan Systematic evaluation

25/33

Essential Elements

1) Comprehensive assessment 2) Patient-centred care 3) Evidence-based care plan 4) Care beyond discharge from Hospital 5) Engagement of patients, family & health/

social care teams 6) Multi-disciplinary approach 7) Linked Nurses, Case Managers &

Geriatricians 26/33

Achievements Accreditation of The Australian Council on

Healthcare Standards (ACHS) in October

2014

27/33

Criteria with Extensive

Achievement (EA)

1.1.6 Ongoing Care

1.2.1 Community Information

1.2.2 Access & Communication

1.6.1 Community & Patient

Participation

Achievements

Achievements

28/33

29/33

Publication

Conclusion

Reduction in AED attendance/hospital admission

Reduction in bed-days occupied

Kept elderly in the community, avoiding institutionalization

Improved functional and mobility states among older patients

Met Government’s policy objective of ageing-in-place

30/33

31

HKWC

Integrated Care and Discharge Support for

Elderly Patients (ICDS)

支援長者離院綜合服務

Queen Mary

Hospital

Grantham

Hospital TWGHs

Fung Yiu King Hospital

Tung Wah

Hospital

Aberdeen Kai-fong

Welfare Association

ICDS

31/33

Collaboration with NGO partners

Date: 12 September 2015 (Saturday)

Time: 0900-1300 hrs.

Venue: M/F, Lecture Theatre, HA Building,

Argyle Road, Kowloon

Evaluation Report on Health and Social Integrated

Model in Transitional Care (HSIMTC), conducted by

Sau Po Centre on Aging (COA), The University of

Hong Kong

32/33

“小病在社區，大病到醫院，康復回社區”

33/33

Work in both acute and convalescence hospitals (QMH, GH, TWH, FYKH)

Comprehensive geriatric assessment

Daily round with ICDS Geriatrician Follow-up progress of patients

during hospitalization Formulate discharge planning Select suitable cases for ICM Case

Management and IDSP HST 34

Link Nurses (stationed in strategic locations – QMH, FYKH, TYH, Aberdeen)

Home visit and telephone support Coordinate the post discharge interventions Coordinate the delivery of community health services Transitional rehabilitation at appropriate institutional or home-based setting Arrange other disciplines e.g. PT, OT, Nurse, MSW for assessment and management Arrange fast track clinic follow-up if required Provision of patient and carer empowerment program

ICM Case Manager – responsible for

community service coordination

Provide rapid seamless community care support.

NGO (AKA) Home Support Team (HST) to provide home services such as:

• Home care - meal delivery, drug supervision, household cleansing

• Rehabilitation and therapeutic exercise

• Home assessment and modification

• Respite care

• Care education

• Telephone enquiry

IDSP HST in HKWC

Record for Appreciation of

ICDS Service in HKWC

Year No. of Appreciation

2012/2013 12

2013/2014 14

2014/2015 26