Medical & Social Integration : A Community Volunteer Service for

Discharged Frail Elderly Patients in Hong Kong West

Dr. Felix HW CHAN Honorary Clinical Associate Professor University of Hong Kong

Community Support Program

愛心網絡護社區 To enable older people to continue staying in their familiar environment to achieve the policy objective of aging in place To maintain stable health condition and quality of life of community-dwelling older people To enhance post-discharge support to older patients through collaboration with the medical and welfare sector To provide early/ timely support by volunteers in the neighbourhood via an integrated community health network To reduce avoidable unplanned hospital admissions

Kick-off ceremony28.06.2008

Community Volunteer ServiceWard staff, CNS, MSW

refer target client to community volunteer services

CVS manager arranges volunteer matching

Referral arrangement and client follow up

Liaise with neighborhood volunteer groups for coordination of client’s FU care

Refer to district NGOs for FU if client holds an active membership status

Volunteer’s regular visits

Communicate with responsible NGOs to FU the client’s progress and close the file

NGO/SWD community services

NGO partners Aberdeen Kai-fong Welfare

Association Caritas HK Services for the

Elderly HK Sheng Kung Hui Welfare

Council St. James Settlement The C&M Alliance Wah Kee

Church – Christian Chaplaincy Service

The Diocesan Commission for Hospital Pastoral Care

The HK Red Cross The HK Women Foundation

Ho Kwok Pui Chun Social Centre for the Elderly

Volunteers Gathering

• Photos

CVS client triaged by Telephone Nurse for medical consultation

Seek Emergency Care ASAP

Seek Medical Care within 24 hourse.g. GP/GOPC

Seek early appointment in GP/GOPC

SOPC (Med) QMH EAC FYKH

Telephone nurse completed the required form(s) and fax to related partiesMedical Consultation Form and/orTNCS Record and/orLast discharge summary

AED SYP GOPCKTC GOPCABD GOPCALC GOPC

SOPC (Med) QMH FYKH GDH (EAC)

Fax the lower part of the Medical Consultation Form to Telephone Nurse for follow-up

CVS client to be followed-up by Telephone Nurse post medical consultation

Medical Consultation for HKWC Community Volunteer Support Program 愛心網絡護社區

TNCS Support to CVS (1)

Established since Nov 2008 from 09:00 to 17:00 during weekdays;

CNS TNCS Hotline 2855-4037 is responsible for protocol-driven triage to • SOPC in QMH• GOPC in HKWC • EAC of FYKH • AED

51 cases (as at Aug 2009) had contacted CNS TNCS Hotline

TNCS Support to CVS (2)

Outcomes of TNCS No. of Cases (%)

Refer GP 2 (4%)

Arrange early FU 6 (12%)

Refer CNS 5 (10%)

Health education and counselling

29 (56%)

PRN call back for advice 9 (18%)

Total cases 51

1 2

11 9

202325

3640

52

60

4550

47454340

05

10

15

20

25

30

35

40

4550

55

60

65

04/2008 07/2008 10/2008 01/2009 04/2009 07/2009 Month

Cases

Total No. of Cases Referred to NGOs (4/2008 – 8/2009)

n=549

Mean age = 79.8

Male =55.1% (302)

Female = 44.9% (247)

Demographic Data of Referred Cases

Live with (n=549) No. of Cases %

alone 89 16.2%

with spouse 159 29.0%

with children 160 29.1%

with spouse and children 112 20.4%

with domestic helper 15 2.7%

others 14 2.6%

Total 549 100%

Demographic Data of Referred Cases

District (n=549) NO. of Cases %

Central and M-Level 31 5.6%

Western District 165 30.1%

Wah Fu Estate 69 12.6%

Yue Kwong Estate 10 1.8%

Tin Wan Estate 38 6.9%

Ap Lei Chau 55 10.0%

Lei Tung Estate 39 7.1%

Shek Pai Wan Estate 51 9.3%

Southern Other than the above 91 16.6%

Total 549 100.0%

Demographic Data of Referred Cases

Housing Type (n=549) No. of Cases %

Public Housing 294 53.6%

Home Ownership Scheme 16 2.9%

Private 233 42.4%

Missing Data 6 1.1%

Total 549 100.0%

Diagnoses of Referred Cases

Diagnosis No. of Cases %

HT 366 66.7%

Cardiac Related 279 50.8%

DM 190 34.6%

Lung Related 135 24.6%

Stroke 47 8.6%

Over the 90-day FU period Pre Post Diff (%)

a)

No. of A&E attendance

586 280 -305 (52.2%)

b)

No. of A&E admission 479 206 -273 (57.0%)

c)

Length of Stay (Bed-days)

3760 1841 -1919 (51.0%)

n= 401cases

(Cases joined CVS as at May/2009 and 20 cases were deceased.)

Pre- & post 90 days Hospital Utilization

End User Satisfaction Survey (1) 105 user satisfaction surveys collected (as at Aug 2009); Only those cases having 2 times of home visits need to

complete the survey; Overall speaking, 99% of users reported satisfied or

above to the project; All users reported sufficient carers’ information to them; 99% of users reported satisfied or above to the

volunteer’s performance; 93% of users reported the project can satisfy most or all

their post-discharge needs; 94% of users reported the project can match with most

or all their expectations.

End User Satisfaction Survey (2)

General Feedback from End Users:Appreciated volunteers’ caring home visits;Volunteers were very nice and patient;Volunteers gave useful health information;Appreciated the blood pressure measuring;Hope more elderly can be

benefited.

Keys to Collaboration1. Imagine yourself in others' shoes and hear and feel

from their angles.2. Develop a vision and common interests of a group.

It helps glue group members together. Ask questions like "What values and goals do we share?" in order to develop a collective identity and better co-operative atmosphere for all.

3. Have a collaborative attitude. Be open-minded and listen to other's views. If you are intent on winning or debating, you won't listen effectively.

4. Seek others' opinions first rather than asking them to accept your ideas to reach a consensus

Keys to Collaboration

5. After seeking others' views, incorporate theirs into yours but not just persist in your own thoughts.

6. Be creative and try to reach a win-win scenario because this will be beneficial to all parties.

7. In case of any overt conflict, don't assert your ideas too much. Wait until people are calm and receptive to assertion. If you try to assert while others are in anger, you may spoil the situation. 

(HASLINK Sept 2007)