Engaging Medical and Rehabilitation Support forTWGHs Wong Cho Tong Enhanced Home & Community Care Services :

the KWH Experience

Dr. Lorna Ng, SMO, Dept of Family Medicine, KWHDr. M.H.Chan, COS, Department of Medicine & Geriatrics, KWH

Ms. Mariana Wong, Superintendent, TWGHs Wong Cho Tong Social Service BuildingMr. Eva Liu, Executive Manager, Dept of Allied Health & Community Support, KWH

Mr. Lawrence Fung, Department Manager (Physiotherapy), KWHMs. Florence Lee, Department Manager (Medical Social Service), KWH

Any Best Practice and Service Model?

• No. of clients seen = 120• Sex :

Female = 83

Male = 37

• Mean Age = 81

Demographics

Male31%

Female69%

61-65 66-70 71-75 76-80 81-85 86-90 91-95 96-100

4

10

20

3229

14

11

10

5

10

15

20

25

30

35

Age Distribution

Res

ult

s:F

M C

lin

ic -

EH

CC

S (

Oct

05

to J

ul

06)

Clinic Statistics

No. of Clinic Visits>/= 3 visit

27%

< 3 visit73%

Res

ult

s:F

M C

lin

ic -

EH

CC

S (

Oct

05

to J

ul

06)

Total no. of sessions 52

No. of clinic visits per patient < 3 visit = 86

3 visit = 32

Total no. of patient consultations 252

Clinic StatisticsR

esu

lts:

FM

Cli

nic

- E

HC

CS

(O

ct 0

5 to

Ju

l 06

) Referral to other clinical specialties 9

Referral to Allied Health Services 4

Referral to other clincal specialties

Surgery, 2Orthopaedics, 1

Psychiatry, 1

ENT, 1

Skin, 2Geriatrics , 2 Geriatrics

ENT

Orthopaedics

Psychiatry

Surgery

Skin

Referral to Allied Health Services

Podiatry, 3

SpeechTherapy, 1

Podiatry

SpeechTherapy

Clinic StatisticsR

esu

lts:

FM

Cli

nic

- E

HC

CS

(O

ct 0

5 to

Ju

l 06

)

Investigations done 65

Most Common Investigations Done

CXR, 8RFT, 7

CBP, 5

SP

UT

UM

c/c

st, 5

XR

AY

, 5 ECG, 4

LFT, 2

MSU/CSU, 19

0

2

4

6

8

10

12

14

16

18

20

MSU/CSU CXR RFT CBP

SPUTUM c/cst XRAY ECG LFT

Health Status

Res

ult

s:F

M C

lin

ic -

EH

CC

S (

Oct

05

to J

ul

06)

Top chronic diseases presenting at clinic visit :

CVA 73 Musculoskeletal disease

32

HT 70 Dementia 31

IHD 47 Depression 21

DM 32 COAD 15

Total no. of active clinical problems 543

Average no. of active problems per patient 4.6

Physical Status

Res

ult

s:F

M C

lin

ic -

EH

CC

S (

Oct

05

to J

ul

06)

No. of clients dependent in functional mobility 65

No. of clients totally dependent in ADL 9

No. of clients totally dependent in IADL 28

Hospital Admission

Res

ult

s:F

M C

lin

ic -

EH

CC

S (

Oct

05

to J

ul

06)

Baseline Period(Oct 04 – Sep 05)

Intervention Period(Oct 05 – Jul 06)

No. of pat with hosp adm 14 7

No. of hosp adm episode 28 12

Prevalence rate of hosp adm 11.6% 5.8%

Res

ult

s:F

M C

lin

ic -

EH

CC

S (

Oct

05

to J

ul

06)

Res

ult

s:F

M C

lin

ic -

EH

CC

S (

Oct

05

to J

ul

06) Performance Indicator 1 : Fall-related Injuries

Res

ult

s:F

M C

lin

ic -

EH

CC

S (

Oct

05

to J

ul

06)

Res

ult

s:F

M C

lin

ic -

EH

CC

S (

Oct

05

to J

ul

06)

Res

ult

s:F

M C

lin

ic -

EH

CC

S (

Oct

05

to J

ul

06)

Reasons Led to Unplanned Hospital Admission

Prevent Unplanned Hospital Admission / Prevent Hospital Admission(Oct 2005-July 2006)

Res

ult

s:F

M C

lin

ic -

EH

CC

S (

Oct

05

to J

ul

06)

ReasonsPrevent Hospital

AdmissionPrevent Unplanned Hospital Admission Total

Chest infection and other respiratory problems

5 4 9

Stroke & neurological problems 2 2Cardio-vascular problems 3 1 4Urinary tract infection 8 8GI illness (eg. Diarrhea/GI bleeding) 1 1Arthritis/non-injury musculoskeletal illness

3 3

Other infection/sepsis 1 1Fall-related injuries 1 1

Total 22 7 29

Total consultations for acute problems: 132

Prevent hospital admissions/unplanned hospital admissions: 22%