Proposed Topic (Most preferred): :
Enhancing Partnership with Patients and Community (Projects initiated to engage patients / carers / community to improve efficiency / quality of care)
Proposed Topic (Second preferred): :
Clinical Safety and Quality Service III (Projects aiming at quality service to patients and their carers)
Authors (including presenting author) :
Lee LS,Tong MH,Chim CK,Lee K,Kwok ML Angela,Ho PY Becky,Leung KW Maria.
Affiliation :
Community Outreach Services Team(COST),New Territories East Cluster(NTEC)
Introduction :
Tele-Health is in rapid development since COVID pandemic. Some community patients are reluctant to nurse visits due to infection concerns. In order to provide better support to community elderly, Tele-iSMART pilot project has been implemented in PWH Community Nursing Service(CNS) since 2022.
Objectives :
1. To develop a new model of care delivery via Tele-Care
2. To empower patient self-care ability via Tele-Care
3. To provide continuous monitoring via Tele-Visit
Methodology :
Recruitment:
Patients referred for Foley, feeding tube care or chronic diseases management and are familiar with smartphone WhatsApp’s functions, would be recruited in the project.
Design:
Tele-Care includes elderly-friendly empowerment videos and Tele-Visits. Videos are forwarded to patients/caregivers via WhatsApp. They are characterized by slow narration with short-content divisions which facilitate elderly to revisit easily. Video-calls are used to conduct Tele-Visit for continuous monitoring and empowerment to patients.
Process:
• Conduct 1stempowerment score of related care as baseline
• Send educational video to patients/caregivers via WhatsApp before 1stvisit and encourage them to watch at least twice
• Conduct Tele-Visits via video-calls to:
o Empower patients’ care skill on home care and knowledge
o Evaluate caregivers’/patients’ self-care competency by return demonstration
o Continue monitoring patients’ condition and progress
• Evaluate empowerment score for Pre-/Post-visit, nursing time, visit frequency, traveling time and patients’/caregivers’ satisfaction
Result & Outcome :
From April-December 2023, 47 patients(37male/10female)aged 63-97 were recruited for Foley care(68%,n=32), feeding tube care(21%,n=10) and congestive heart failure(CHF)care(11%,n=5). Result showed that the crucial points of empowerment score was improved by 37.6%. ALL recruited patients had NO readmissions within 28 days after intervention. 540 minutes traveling time was saved. Nursing time for patient empowerment during Tele-visit is similar as usual home visit. ALL patients/caregivers are satisfied and agreed to continue Tele-mode of care as they commented that education video is simple with easy understanding and they could review anytime/anywhere for practice of care at home.
Conclusion:
Tele-iSMART project incorporated elderly-friendly videos and Tele-care model in delivery of community care with smart idea. It is effective and alternate mode in empowerment, monitoring and providing ad-hoc support with high acceptability among patient/caregivers with good results in keeping patient healthy in community and preventing hospital admissions. Therefore, Tele-Care is a safe adjuvant way to supplement onsite visit in coming operation model in service.
