Authors (including presenting author) :
Tsang MW, Lee K, Lee LS, Wong KM Mona, Kwok CM, Tong MH, Chim CK, Kwok ML Angela, Leung KW Maria.
Affiliation :
Community Outreach Services Team(COST), New Territories East Cluster(NTEC)
Introduction :
The Community Outreach Services Team(COST) identified a service gap that 15% of high-risk patients declined post discharge support because of financial constrain. Unfortunately, they were also not supported by social security service. They could not afford the outreach visit fee and/or medical consumables. Consequently, their repeated hospital admission noticed, and their physical conditions got deteriorated. To address the need of this underprivileged group, a patient centric care initiative was then implemented in cluster level including PWH, AHNH and NDH since 2019 to enable these patients accessing the specialized community care.
Objectives :
- To fill the service gaps for underprivileged group
- To subsidize home visit; and /or medical consumables
- To improve quality of life
- To keep patients healthy in the community
Methodology :
- Patients with financial difficulties and not receiving government subsidy, suffering from chronic wound; or chronic/terminal illness are eligible to be recruited in the project.
- Advanced dressing material; or Intra-Pleural Catheter(IPC) drainage bottle; or Continuous glucose monitor(CGM) were freely provided to these patients;
- The patients would receive four to ten coupons to waive community nursing service(CNS) visit. Post discharge transitional support would be provided freely to these high-risk underprivileged patients.
Result & Outcome :
Outcomes
From 2019 to December 2024, a total of 760 patients benefited from the project. Age ranged from 60-92 with mean age 75.
The project sponsored 2651 CNS visits to (1) empower patients and their carers on chronic disease self-management, or self-drainage of pleural fluid via the IPC system; (2) detect unaware hypoglycemia by CGM with early intervention, (3) improve wounds’ condition either healed or in good healing progress 86% patients successfully kept in the community without hospital readmission within 28 days. All recipients highly appreciated the project.
Conclusion
The patient-centered care initiative improves not only the accessibility of underprivileged high-risk patients to specialist outreach services, but also promotes and restores their health through empowering their skills to better manage their diseases, improve their quality of life with win-win situation to patient, career and hospital.
It is highly acknowledged the funding supported from donation by the PWH Charitable Foundation, NDH Charitable Foundation and AHN Charitable Foundation.
