Authors (including presenting author) :
Lau LW(1), Yao PKJ(2), Wong WM(4), Chan HSM(4) ,Wu WCA(3), Cheng PPP(3)
Affiliation :
(1)Community Nurse Service, (2)Specialist Out-patient Department, (3)Central Nursing Division, Yan Chai Hospital, (4)Family Medicine, Kowloon West Cluster
Introduction :
In Hong Kong, Chronic Obstructive Pulmonary Disease (COPD) is the 6th leading cause of death and the 4th of admission rates in Hospital Authority. Patient engagement on COPD Care is essential to improve quality of life and reduce burden to patients and community. However, the effectiveness of care varies due to different care practices and education materials used among Community Nurse Service (CNS), Specialist Out-patient Department (SOPD) and Family Medicine (FM).
Objectives :
1)Strengthen the collaboration by aligning care practices and education materials of CNS, SOPD and FM 2)Evaluate the effectiveness of the program in term of patient engagement
Methodology :
In 2019, a workgroup from CNS, SOPD and FM were formed to standardize the patient education materials and assessment tools which was based on the HA-COPD Care Booklet. The recruited COPD patients who were under CNS home visit or face-to-face education by SOPD / FM on care empowerment program were receiving the standardized assessment tools and education materials e.g. Self-monitoring of COPD Care & Action Plan, Inhalation Technique Evaluation Score Sheet. Besides, a QR Code Sheet was tailor-made to facilitate them watching Inhalation Technique Video for revision at home. Phone support and coordinated clinical support to patients with clinical problems were arranged among CNS, SOPD and FM. Concerning the effectiveness, Breathlessness Severity and Quality of Life were assessed by Modified British Medical Research Council (mMRC) Questionnaire and COPD Assessment Test (CATS) respectively. Also, the compliance of Inhalation Technique and Hospital Utilization were evaluated.
Result & Outcome :
Having piloted from August to November 2019, 30 COPD patients were recruited with mean age at 73(83% male, 17% female). The CATS Score were improved by 23.8% (from 11.6 to 8.9); the mMRC Grade were improved from 2 to 1; Inhaler technique was improved by 25.7% (from 8 to 11.3). The pre/post A&E attendance (< 28days) and unplanned hospital readmission (< 28days) were dropped by 66.7% (12 to 4) and 70% (12 to 3) respectively. The program had demonstrated great benefit in patient engagement and enhancement of their quality of life. Last but not the least, it lined up the standardized care practices and education materials through the collaborative teams in community setting.
