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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 HODOM(IMS2), RHTSK
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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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Target 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
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Four Elements in TNCS• Co-ordinates with relevant healthcare
stakeholders • Utilizes protocols to guide nurses’ clinical
decisions• Links with the Clinical Management System
(CMS)• Utilizes ‘High Risk Elderly Database & Alert
System’
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CommunityNursing Service
Hospital Service
NGOsDistrict Elderly
Care Center
GPs
Volunteers
TNCS
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GP can contact TNCS to enquire patient’s medical history
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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
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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 18/05/2005
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Average Workload per Month
• No. of patients registered in the TNCS high-risk database in March 2006: 2414
• No. of calls made/month: 365• Average duration/call: 19.3 min.• Time for heavy co-ordination work and data
retrieval have not been counted.• No. of calls initiated by nurse: 270• No. of consultation calls from clients: 95
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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 groupsCongestive 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• Results at 2 months after TNCS service
– AED attendance– Number of admissions
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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 call Asks 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
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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
All Comparable (p>0.05)
4.754.8No. of regular medications (mean)
9092Patients with medical diagnoses >=3
46:5152:49Sex M:F
78.4(65 – 93)
78.1(65 – 91)
Age
TNCS Group(n = 97)
Control Group(n = 101)
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Outcomes Decreased Total AED Attendance
85
54
0
10
20
30
40
50
60
70
80
90
No
of e
piso
des
Control Group TNCS Group
Episodes of AED Attendance
p=0.025
36.5%
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OutcomesReduced Multiple AED Attendance
24 25
19
8 8
40
5
10
15
20
25
No.
of
pati
ents
Once Twice >= Threetimes
Frequency
No. of Patients Attended AED
ControlTNCS
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OutcomesDecreased Total Emergency Admissions
67
43
0
10
20
30
40
50
60
70
No.
of
Epis
odes
Control Group TNCS Group
Episodes of Emergency Admission
p=0.05
35.8%
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OutcomesReduced Multiple Emergency Admissions
2224
15
85
10
5
10
15
20
25
No
of P
ati
ents
Once Twice >= 3 Times
Frequency
No of Patients with Emergency Admission
ControlTNCS
*
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Overall OutcomesDecreased Usage of Hospital Services
Usage of hospital services
24
6785
17
4354
0102030405060708090
AED E Adm C Adm
Hospital services
No
of A
ED a
tten
danc
e /
adm
issi
ons
ControlTNCS
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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
of A
dvic
e
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Referred out to Different Services
18
1
66
02468
101214161820
Community AlliedHealth
Community NursingService
Volunteer Service District Elderly CareCenter
No
of r
efer
ral
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OutcomesPatient 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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100 10095.56
81.82
100 100
0
10
20
30
40
50
60
70
80
90
100
Sati
fact
ion
Rat
e (%
)
ReduceWorries
Improve HealthKnowledge
Improve SelfManagement
on the disease
Assist DailyLife Adaptation
Refer toAppropriate
Health Service
OverallSatisfaction
Survey Questions
Patient / Carer Satisfaction Survey
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ConclusionsTNCS Package can….
• Identify high-risk elders• Monitor their health needs proactively• Provide timely interventions• Bridge service gaps• Improve service interfacing• Empower elderly clients and their care-givers
for self-management
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ConclusionsTNCS Package can ….
• Improve Community Health• Reduce Unnecessary Usage of Hospital
Services• Save Money
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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), RHTSKCollaborators:• 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– 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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Thank You
TNCS