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) :
Cheng MLV (2)(5), Kan CK (1)(5), Cheng PYI(1)(5), Wong YYR (2)(5), Ng KKP(2)(5),
Lee WKS(3) (5), Cheung CY(3)(6) Chan SK(4)(7), Wong LY (4)(7)
Affiliation :
(1) Department of Psychiatry (Psy)
(2) Community & Patient Resource Department (PRC)
(3) Department of Occupational Therapy (OT)
(3) Medical Social Service Unit (Psychiatry) (MSSU)
(4) Transitional Support Service (TSS)
(5) Pamela Youde Nethersole Eastern Hospital (PYNEH)
(6) Social Welfare Department
(7) Baptist Oi Kwan Social Service (BOKSS)
Introduction :
A pilot project on Transitional Support Service for persons in mental recovery aims at supporting psychiatric patients of PYNEH during rehabilitation stage, who are potential service users of half-way house (HWH), by early intervention to facilitate better transition and community discharge
in their coming recovery journey.
Objectives :
1.To develop a referral mechanism to TSS project from hospital to community
2.To enhance better understanding of recovery, HWH and TSS for community reintegration
3.To sustain longer length of stay in HWH upon discharge
Methodology :
1.A Work Group of Cross Sectors has been formed since Aug 2022 to design, monitor
the care model of TSS and review its effectiveness.
2.Use of multi-disciplinary approach.
•Cases identified by Psy, would be assessed by MSSU and eligible patients with
their consent would then be referred to BOKSS TSS team for case management upon
patient discharge.
•Empowerment program, jointly organized by Psy, OT, PRC, TSS and HWHs, was
conducted to render orientation of rehabilitation journey and transitional
support service. Peer workers and ex-residents were invited to share practical
tips and on-line site visit of HWHs was included.
Result & Outcome :
•During Oct 2022 to December 2023, 62 eligible patients were referred to BOKSS TSS
team while 280 patients & carers attended 8 sessions of empowerment programs.
•Overall 100% satisfaction for those who returned the questionnaires from TSS
service users and 100% positive feedbacks were collected from empowerment
programs.
•Over 16% increasing rate of length of stay of users in HWH after receiving the
services.
•The project is launched as a pilot by 2022-2025 to serve total 90 cases. The
referral rate has been met the requirement of the 1st year. It is a remarkable
result under medical-social collaboration to enhance patient reintegration in the
community.
