Authors (including presenting author) :
Wong ELY (1), Lau MC (2), Wu CM (3), Wong R (4), Ma HM (5), Fong F (3)(6), Tam V (7), Chim CK (8), Yip BHK (1), Cheung AWL (1), Tam ZPY (1), Chan STK (3), Chiu M (7), Lee KY(6)
Affiliation :
(1) Centre for Health Systems and Policy Research, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong (2) Shatin Hospital, Hospital Authority (3) Health Resource Centre, Prince of Wales Hospital, Hospital Authority (4) Yale Global Health Leadership Institute, Yale University (5) Medicine and Therapeutics, Prince of Wales Hospital, Hospital Authority (6) Health Resource Centre, North District Hospital, Hospital Authority (7) Medical Social Work, Alice Ho Miu Ling Nethersole Hospital, Hospital Authority (8) Department of Community Outreach Service Team, Prince of Wales Hospital, Hospital Authority
Introduction :
The study aims to expand the capacity of existing volunteer visiting program to equip volunteer to provide integrated medical and social care support so as to strengthen the self-care in older adults in winter and to evaluate the effectiveness of the programme in healthcare delivery provision.
Objectives :
The enriched programme targets on older adult discharged from NTEC who aged ≥65, diagnosed with chronic illnesses, and required HA community nursing service. The volunteer visit starts with the referral from the last of HA community nursing visit to continue the integrated medical and social care to the older adult.. The integrated care consists of six themes of self-care during “WINTER”: “W”arm (physical health), “I”mmunization (influenza vaccination), “N”utrition (healthy diet), “T”ender (emotional support), “E”xercise (prevention from fall), “R”isk of hospital admission. The home visit programme pilots in two study periods (Round 1: Nov 2018 – Mar 2019 & Round 2: Oct 2019 – Apr 2020). Stepped-wedge design and pre-and post-evaluation are adopted.
Methodology :
A total of 99 older adults were recruited in the round 1 with 358 regular home visits and 358 phone calls performed. To reduce potential unnecessary A&E attendance or hospital admission, 64 visits (18%) were identified with clinical/ social problems, health care intervention was given through home visit and subsequent phone follow-up. Among of 64 visits, 21 visits (33%) were identified as inadequate treatment compliance, health education and reinforcement of treatment compliance were provided. To facilitate timely secondary care arrangement, 25 visits (39%) were identified as symptom exacerbation and referral to community nurse for clinical management. To aid the accessibility to financial aid/community social service to support self-care, 18 cases (28%) was referred to medical social worker at Health Resources Centers for follow-up.
Result & Outcome :
A total of 278 older adults were recruited with 752 regular home visits and 1,210 phone calls performed. To reduce potential unnecessary A&E attendance or hospital admission, 147 episodes of the visits (19.5%) were identified with clinical/ social problems, health care intervention was given through home visit and subsequent home visit/ phone follow-up. Among the identified episodes with problems, 73 of them (49.7%) were classified as inadequate treatment compliance, health education and reinforcement of treatment compliance were provided. To facilitate timely care arrangement for symptom exacerbation, 29 of them (19.7%) were referred to community nurse for clinical management. To aid the accessibility to financial aid/community social service to support self-care, 45 older adults (16.2%) was referred to medical social worker at Health Resources Centers for follow-up.
