Patient Support Call Centre: A Territory-wide Structured Telephone Support for HA Patients 護訊鈴 : 醫院管理局全港性的電話支援服務 Kwong Sin Yee Patty ( 鄺倩儀 ) Unit Manager ( 科組經理 ) HA Patient Support Call Centre ( 護訊鈴 ) 23 Jun 2018
HA Community Health Call Centre (CHCC) 社區健康電話支援服務中心 Established in April 2009 ( 於 2009 年 4 月成立 ) Provide telephone advice as an innovative service model to better support elderly patients ( 出院長者 ) with high risk of hospital re-admissions, as well as patients with chronic diseases ( 慢性疾病患者 ) 2
HA Community Health Call Centre (CHCC) 社區健康電話支援服務中心 CHCC Patient Support Call Centre (PSCC) ( 護訊鈴 ) in TSKH Mental Health Direct (MHD) ( 精神健康專線 ) in KCH provides support to high risk elderly patients discharged from HA hospitals ( 高危長者病人 ) and patients with Diabetes Mellitus ( 糖尿病人 ) provide telephone support for patients with mental illness ( 精神病患者 ) 3
PSCC Service 護訊鈴 High Risk Elderly Program 高危長者服務
High Risk Elderly Program 高危長者服務 Target Client ( 服務對象 ): High risk elderly patients discharged from hospitals of the Hospital Authority 醫院管理局轄下醫院出院的高危長者病人 Purpose ( 目的 ): We adopt a proactive outbound call approach to provide one-stop support and continuity of care to postdischarged high risk elderly patients 我們主動透過電話跟進剛出院的高危長者病人, 為他們提供一站式的支援及延續護理 5
High Risk Elderly Program 高危長者服務 Characteristics ( 特點 ): Make use of an advanced information technology system and a risk prediction tool to identify elderly patients with high risk of hospital re-admissions upon discharge 利用先進的資訊科技系統及風險評估工具, 識別出院後有較高風險再次入院的長者病人 Proactively provide outbound calls to high risk elderly patients (or their carers) by professional nurses 由專業護士主動致電高危的長者病人 ( 或其照顧者 ) Clinical advice is given based on more than 90 robust evidence-based protocols 根據超過 90 項富實證的臨床指引, 提供護理指導 6
High Risk Elderly Program 高危長者服務 - Integrated System Support 整合模式的支援 PSCC Nurses: Proactive Outbound Call within 2 days after the day of discharge Target Patient List (HARRPE 0.17) Patients epr Cluster Service Response Teams Referrals Documentation Protocol-guided Advice 7
High Risk Elderly Program 高危長者服務 Facilitate Early identification of problems, prompt advice Health advice on symptom control ( 健康狀況 ) Medication advice ( 藥物管理 ) Community resources ( 社區資源的協助 ) Follow up appointments ( 覆診提示 ) Providing Territory-wide Services, 190,000 calls per year Supporting > 50,000 high risk elderly patients per year 8
PSCC Service 護訊鈴 Chronic Disease Management (Diabetes Mellitus) Program 慢性疾病管理服務
Chronic Disease Management (Diabetes Mellitus) Program 慢性疾病管理服務 ( 糖尿病 ) Target Client ( 服務對象 ): Patients with chronic diseases (Diabetes Mellitus) ( 慢性疾病糖尿病 )under the care of the Hospital Authority Purpose ( 目的 ): We provide support to high risk diabetes mellitus patients through telephone advice to strengthen their selfmanagement ( 自我疾病管理 ) of disease conditions 10
Chronic Disease Management (Diabetes Mellitus) Program 慢性疾病管理服務 ( 糖尿病 ) Engage patients to set goals and plans for disease management 與病人一起訂立個人的疾病管理目標和計劃 Health Eating 飲食 管理風險因素 Reducing Risks Taking Medication 服用藥物 運動 Being Active Monitoring 自我監控 應付病情的技巧 Healthy Coping Problem Solving 處理常見問題 Supporting GOPC in all clusters since 2013, extended to DM patients in Medical SOPCs by phase since 2016/17 Recruited around 10,000 DM patients, providing 95,000 calls yearly 11
Appreciations & Awards Appreciations from patients & carers Won 3 prizes in the Category of Best Innovation and Research in HK Information & Communication Technology (HKICT) Awards Grand Award Gold Award (Postgraduates and Open Stream) Special Mention Commercial Value 12
個案分享 13
個案 ( 一 ) 陳婆婆, 78 歲, 獨居 患有高血壓, 糖尿病 服用阿士匹靈 接受家居照顧服務 家務助理於家訪期間發現廁所內有血跡 立即向個案經理報告 個案經理聯絡護訊鈴護士 14
個案 ( 一 ) 護訊鈴護士 : 依據臨床指引為病人評估, 確保長者安全 電話聯絡醫生作諮詢 : 安排明天到診所候診 聯絡個案經理 : 安排陪診服務 為長者量血壓並密切留意長者情況 15
個案 ( 一 ) 醫生診治 : 安排化驗檢查 建議繼續留意長者情況 醫生檢閱化驗報告 : 處方藥物 16
個案 ( 二 ) 李先生, 68 歲, 獨居 患有高血壓, 糖尿病 因中風入院 護訊鈴護士打電話跟進長者離院之後的情況 發現李先生離院回家之後沒有進食, 因病人中風後不能煮食 17
個案 ( 二 ) 護訊鈴護士即時聯絡地區之社會服務機構 當值社工 立即安排為病人評估, 了解李先生情況 即日安排了送飯服務 因應李先生需要, 安排其他家居照顧服務 18
People & Service Integration People Centred Clinical Information & Telephony Systems Integration Technology 19
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