Proposed Topic (Most preferred): :
Enhancing Partnership with Patients and Community (Projects initiated to engage patients / carers / community to improve efficiency / quality of care)
Authors (including presenting author) :
Lee SC (1), Tang V (1), Lui N (1), Li WH (1), Chung LH (1), Ho KF(1), Fu PC (1), Poon WY (2), Tsoi LF (2)
Affiliation :
(1) Community Nursing Service, Kowloon Hospital, (2) Heung Hoi Ching Kok Lin Association Buddhist Ho Wong Cheong Po Neighbour Elderly Centre
Introduction :
To Kwan Wan District, is one of the poorest district in Hong Kong, where the old tenement are without lifts. Within these buildings, reside many aged people who may have social and health problems, including social isolation and a variety of physical and or mental illness. Traditionally, Community Nursing Service (CNS) provides service to these community people through being referred by hospitals.
In fact, many of these aged people outside these identified by such hospitals are in need of health care and support. They are only brought to the attention at a late stage of their health problems which may get worse to a level causing serious problems. That is not only to themselves, but also a burden of our community and health care system.
Therefore, CNS of Kowloon Hospital has collaborated with a District Elderly Centre identified such ‘hidden elderly’, provide healthcare and education to maintain their health and avoid deterioration of health condition at an early stage.
Objectives :
1. To bridge the healthcare gap among those hidden elderly under social support without healthcare attention
2. To identify ‘hidden elderly’ with immediate needs and or high risks in a proactive intervention and at an early stage through home visit
Methodology :
Through collaboration with a District Elderly Center, Kowloon Hospital’s Community Nursing Service (KH CNS) visits identified targeted elderly jointly with social workers to provide on-site health check and assessment with special emphasis on their health, psychological and cognitive conditions. During the home visitation, early identify the healthcare need of the elderly by
1. Provide health assessment, including blood pressure, blood sugar, nutritional status, skin condition and psychological condition.
2. Home environment assessment and risk identification
3. Provide referral to related clinics and social resources
4. Provide on-going follow-up if needed
Result & Outcome :
Results
From 2021 to 2023, 22 elderly identified from the program. They are 4 men and 18 women, age from 60 to 103, average age 87.3. The most common chronic disease is hypertension, 68.18% (n=15), the second is diabetes, 27.27% (n=6). Among all identified elderly. 18.18% of them are lives alone (n=4), the others are lives with family or domestic helpers. Regarding without any medical support (no recent medical history in Clinical Management System), those elderly do not attend Hospital Authority (HA) any clinics or hospitals from 1 to 15 years, mean period is 4 years. In the 3 years program, 4 elderly were referred to CNS for on-going home care, 5 elderly were referred to GOPCs for related health problems. Health education and home care recommendation were provided to all identified elderly. From those elderly, there are various problem identified, including not understanding HA service, drugs from over-the-counter, misunderstanding own physical illness, risk of fall at home environment, skin problem, carer stress and lack of self-care ability. For the follow-up post 90 days, there are no unplanned admission among those hidden elderly.
Conclusion
Over the past 3 years, KH CNS has collaborated with the District Elderly Center to run the collaboration program, 22 Hidden Elderly were identified. Regarding these hidden elderly, their past negative experiences, inadequate information on health and social services would be the contributing factors and barriers influencing their health-seeking behaviors. However, Community nurses proactively provide nursing care, health assessment and consultation to this vulnerable group, who are lack of medical support and not identified by hospitals. By early health issue identified, proactive intervention and support to these vulnerable group, significantly ensure them to continue live in the community with quality of life and prevention of unplanned admission. They are also re-connected with our healthcare services.
