Utilizing Computer Technology & Data Analytics in Supporting Patients in the Community An Innovative Health Service Model to Support Discharged High Risk Elderly Patients Ms KH Ng (APN) Hospital Authority Patient Support Call Center 1 Avoidable Unplanned Admissions Study on medical specialties inpatients 603 unplanned admission 40.8% are avoidable A retrospective analysis Carrie HK Yam et al(2007) Avoid readmission in Hong Kong- sys, clinician, patient or social factor? 2 BMC Health Serv Res. 2010; 10:311. Common Problem of Frail Elderly in Community Unstable Health Condition Poor Drug Compliance Default FU Caring Problem 3 Immediate Post D/C Follow Up Triage Advice Education Assessment Referral Chronic Disease Management 4 Patient Support Call Center (PSCC) Venue TSK CACC Working hour 08:00-20:00 (Mon-Fri) 08:00-16:00 (Sat, Sun, PH) Size (m2) Computer terminals Call operators Active cases (HRE) 458 64 60 67,358 (As at Sept 2014) 5 An Innovative Health Service Model Medical Informatics Information Technology TeleNursing Practice 6 Proactive Approach 7 Target Patients     MED patients Aged 65+ Discharged alive HARRPE score ≥ 0.17 8 Hospital Admission Risk Reduction Program for the Elderly 9 10 Automatic Daily List of Discharge Patient • Screen of patient recruit list 11 Preparation Before Making a Call 12 Standardized Practice Standard Outbound Call Protocol 1. 2. Same conversation script  Ensure Quality  Focus on patient’s post discharge condition and nursing care  Consent 3. 4. 5. Greeting Show concern and follow up physical condition on discharge Check compliance and competency in medication management Show concern of social support network Introduction of telephone health advice service 13 Perform Triage for Inbound Call  Identify the nature and urgency of client’s health care needs  Determine & advice on appropriate disposition  Not making diagnosis 14 Rapid response ………………. 20 Seconds Service Level 15 Immediate Health Assessment Standard Inbound Call Protocol 1. 2. 3. 4. 5. 6. • Screen of member profile Greeting 你好，我係陳姑娘。有咩嘢我可以幫你？ Procedure of identification Assessment on patient’s need 姑娘！我覺得個肚子痛！ Conclude on the problem Decision making on disposition Provide follow up call PRN 16 Immediate Access to ePR 17 Build in Clinical Protocol for Triage 18 Triage Category Prompt Automatically Emergency Ambulance to AED Urgent Consultation within 24 to 48 hrs Non-urgent GP/GOPC & Home care instruction 19 Triage Category Prompt Automatically Emergency Ambulance to AED Urgent Consultation within 24 to 48 hrs Non-urgent GP/GOPC & Home care instruction 20 Triage Category Prompt Automatically Emergency Ambulance to AED Urgent Consultation within 24 to 48 hrs Non-urgent GP/GOPC & Home care instruction 21 92 Clinical Protocols 1 ABDOMINAL PAIN 2 ABDOMINAL SWELLING 3 ABRASIONS 4 ALLERGIC REACTION 5 ALTERED LEVEL OF CONSCIOUSNESS 6 ANKLE PROBLEM 7 ANXIETY 8 APPETITE LOSS 9 ARM or HAND PROBLEMS 10 ASTHMA 11 BACK PAIN 12 BLACK or BLOODY STOOLS 13 BONE, JOINT and TISSUE INJURY 14 BRUISING 15 BURNS, THERMAL / ELECTRICAL 16 CHEST PAIN 17 CHOKING 18 CHOKING EMERGENCY PROCEDURE 19 CONFUSION 20 CONSTIPATION 21 COUGH 22 DECREASED GENERAL CONDITION 23 DECREASED ORAL INTAKE 24 DEHYDRATION 25 DEPRESSION 26 DIABETES MELLITUS PROBLEM 27 DIARRHOEA, ADULT 28 DIZZINESS 29 DOMESTIC ABUSE 30 EAR RINGING 31 EARACHE, DRAINAGE 32 EYE INJURY 33 EYE PROBLEM 34 EYE, FOREIGN BODY 35 EYE, PINK 36 EYE, VISUAL PROBLEM 37 FACIAL PAIN 38 FAINTING 39 FALLS 40 FATIGUE 41 FEVER, ADULT 42 FINGER and TOE PROBLEM 43 FOOD ALLERGY 44 FOOT PROBLEM 45 GAS / FLATULENCE 46 HEAD INJURY 47 HEADACHE 48 HEARING LOSS 49 HEARTBEAT, RAPID 50 HEARTBEAT, SLOW 51 HEARTBURN 52 HEMORRHOIDS 53 HICCUPS 54 HOARSENESS 55 HYPERTENSION 56 HYPOTENSION 57 HYPOTHERMIA 58 INSOMNIA 59 ITCHING 60 JAUNDICE 61 JAW PAIN 62 JOINT PAIN / SWELLING 63 KNEE PAIN / SWELLING 64 LEG PAIN / SWELLING 65 MOUTH PROBLEM 66 MUSCLE CRAMPS 67 NAUSEA / VOMITING 68 NECK PAIN 69 NOSEBLEED 70 NUMBNESS and TINGLING 71 OVERDOSE 72 RASH, ADULT 73 RESCUE CPR 74 SCABIES 75 SEIZURE 76 SHORTNESS OF BREATH 77 SHOULDER PAIN 78 SKIN LESIONS 79 SORE THROAT 80 SPEAKING DIFFICULTY 81 STOOL, ABNORMAL 82 SWALLOWING DIFFICULTY 83 SWELLING 84 TONGUE PROBLEM 85 TOOTHACHE 86 URINATION, DIFFICULTY 87 URINATION, PAINFUL 88 URINE, ABNORMAL COLOR 89 URINE, INCONTINENCE 90 WEAKNESS 91 WHEEZING 92 WOUND HEALING and INFECTION 11 Knowledge Database 23 Power of Medical Informatics More than 20 years of corporate data In 9.6 million persons Most current medical information Immediately at a Glance No geographical boundary through ePR 24 HKEC NTWC HKWC Cluster Service Response Team NTEC KWC KCC KEC 25 Evidence Based Outcome 26 Study for 90 Days HARRPE Outcome (2007-2009) Significantly reduced in:  AED attendance (Med) 25.4%  Unplanned readmission (Med) 25.5%  Unplanned LOS (Med) 25.6%  Mortality Rate 49.6% 27 Consistent Result with Study for EC@HOME Program Significantly reduced in:  AED attendance (Med) 27%  Unplanned readmission (Med)  Acute patient bed days (Med) 25% 30% 28 Key To Success 29 Proactive Intervention: Access to Reliable Advice %age of health advice/ total no. of calls in one year 80% 70% 77% 66% 60% 55% 50% 40% 30% 20% 17% 10% 0% Utilization of community resource Health education in disease management Educate on drug Educate on home management & safety measures check compliance 30 Proactive Intervention: Utilization of Primary Care Service No. of advice for various types of primary care service per year 8000 7373 7000 6000 5000 4000 3000 831 2000 411 159 10 1000 0 GOPC Private GP Community Nursing Service DECC & Home Allied Health Support Team Service 31 Immediate Phone Consultation Through SMS/Pager system High Risk Elderly Call Center Nurse Listen HELP! Assess Consult SMS/ Pager to Specialist PSCC KH NG. Please call back 29962333 Cluster Medical Support Medical Advice 32 Back up on Clinical Care 216 in one year 33 Electronic Referral Letter MAIL VERSION Hospital Authority Patient Support Call Centre (PSCC) Referral to SOPD To ： Medical Officer M&G SOPD From ： PSCC Nurse Tel No. ： 29962333 Date ： 2nd Sep 2014 Client’s personal particulars: Name: Lucky Lam Chinese Name: 李幸福 A123 xxx(x) ID No.: Sex / Age: PSCC Reference number: HKE500123456 Client’s progress on phone follow up: Progress: Client admitted to KWH from 12/6/2014 to 17/6/2014 for skin rash. Norvasc increased from 2.5 mg to 5 mg during hospitalization in KWH. On 18/6/2014, Daughter claimed client felt dizziness and checked BP: 89/51mmHg. P unknown. KWH Dr KK Wong consulted on 18/6/2014, advised to stop Norvasc til FU. keep BP monitoring and record. FU BP on 20/6 & 25/6: 11x/ 5xmmHg. P 7x/min after stop of norvasc since 19/6/2014. Fax successfully sent Remarks: Please contact PSCC nurse for details Save Fax 34 Engage Patient Positive Image Good Rapport Appreciations 35 Standard & Quality Service Level 94% Abandoned Call Rate 4.7% HRE Service Coverage Nursing Standard Compliance 94% 98% 36 37 38 39 40 Hypotension       Self monitoring BP at community elderly center Found BP 90/50mmHg Suggested to AED by elderly center staff Good drug compliance Regular FU to cardiology Next appt in 2 months later 41 Triage      Ensure patient safety by protocol driven assessment Instruction for home care and monitoring Phone consultation to doctor Withhold anti HT drugs Arrange fast track clinic on next day 42 Follow up care Keep monitor of patient on subsequent days  BP stabilized after adjustment of medication  Reinforced home care advice  Follow up as schedule  43 Patient Engagement Keep mobility and exercise  Get a BP machine for self monitoring at home  Good drug compliance  Self initiate to call back for health advice  Follow up as scheduled in Cardiology  Thank You 44 Information Technology Humanity &&Patient Center 45 46