Authors (including presenting author) :
Law PL(1), Kwong P(1), Wu I(3), Yung CY(8), Wong KL(8), Cheng KY(8), Chan MC(6), Ip LL(7), Yuen HC(5), Chiu S H(5), Chiu C(4), Tam B(4), Mak F(2), Chan M(5), Hui E (9), Law CB(10), Lee M(6), Ha T(3), Kng C(2)
Affiliation :
(1) HA Patient Support Call Centre (2) Department of Medicine and Geriatrics, Ruttonjee & Tang Shiu Kin Hospital (3) Primary and Community Service Department, Strategy & Planning Division, HA Head Office (4) Information Technology and Health Informatics Division, HA Head Office (5) Department of Medicine and Geriatrics, Princess Margaret Hospital (6) Department of Medicine, Queen Elizabeth Hospital (7) Department of Medicine and Geriatrics, Tuen Mun Hospital (8) Cardiac Medical Unit, Grantham Hospital (9) Department of Medicine and Geriatrics, Shatin Hospital (10) Kowloon West Cluster
Introduction :
Chronic heart failure (CHF) contributes to significant hospital readmissions within HA. Evidence supports chronic disease model management can improve heart failure (HF) knowledge, self-care behaviors and patient outcomes.
Objectives :
To pilot feasibility of a novel telephone-based chronic disease management program for CHF patients by PSCC nurses to (a) improve patient knowledge, self-care behavior and monitoring and (b) to facilitate and support early detection of CHF symptoms and timely intervention.
Methodology :
A HA working group (WG) of specialists was formed with representation from Coordinating Committee (Medicine), Central Committee (Cardiac Services), Coordinating Committee (Rehabilitation Services), Specialty Advisory Group (Cardiology), Specialty Advisory Group (Community), PSCC management (HKEC), IT and HI Division, and HAHO subject team. 5 pilot hospitals with clinical support team were selected. The target patients were defined as moderate risk adult patients diagnosed CHF with one CHF-related admission into medical wards within 12 months prior to recruitment period. Intervention protocol was co-designed by the WG for telephone-based delivery for CHF education (10 calls over 6 months covering 7 dimensions). CHF health education booklet was sent to each patient before start of program. Workflows and care pathways focused on early symptoms identification, triage and timely intervention by designated clinical support team such as medication education, diuretic dose adjustment, fast track clinic and telephone follow-up care.
Result & Outcome :
During 17 December 2018 to 2 August 2019, 100 eligible patients aged from 45 to 93 years old were recruited. 77 patients completed the program, with 1165 calls provided. Pre and post comparison on CHF self-reported outcomes showed positive improvements with 67.5% improvement in knowledge, in particular “Understanding HF” (0% to 69%), “Knowledge of red flags” (1% to 77%) and “Measure of daily body weight” (8% to 40%). AED attendances, CHF related hospitalizations and length of stay decreased during 6 months intervention period when compared to pre-intervention, potentially due to early symptom detection which enabled early intervention by PSCC nurse and clinical supports. Conclusion: Co-production of CHF disease management protocol with specialists and PSCC, this pilot study confirmed feasibility for telephone based self-management program to empower patients using a service model which is patient-centred for convenience and user-friendliness and in reducing hospital based usage, may emerge as a sustainable health care model in managing high volume of chronic disease patients.
