Authors (including presenting author) :
Lam SM(1), Hai MT(2), Pang WS(2), Lai KM(3), Chan TF(1), Wong WT(1),
Yiu PC(1), Chan PC(1), Wong KW(1), Ip HM(1), Liu CY(1), Mak PS(1)
Affiliation :
(1) Palliative Care Unit, Department of Medicine and Geriatrics, Ruttonjee & Tang Shiu Kin Hospitals
(2) Department of Medicine and Geriatrics, Ruttonjee & Tang Shiu Kin Hospitals
(3) Palliative Care, Hong Kong East Cluster
Introduction :
Scope of palliative care (PC) serves for patient with diagnosed as irreversible life threatening illness included malignant and non-malignant. Most of PC patients are stay in community. Therefore, the demand of PC home care nurse support is rapid increasing relatively. Ruttonjee & Tang Shiu Kin Hospitals (RTSKH) PC home care team historically divided in two mega teams and no designated nurse to follow patient’s condition. All PC patients rely on single hotline to contact PC home care nurse (HCN). Thus, time consume as long traffic time on large partition and both patients/ carers are difficult to contact HCN for support immediately.
Objectives :
1. Enhance holistic and maintain continuity of care for PC patient in community
2. Streamline the home care referral and follow up action
3. Improve home visit schedule planning and allocate manpower effectively
Methodology :
Develop 4 main teams by geographic location, 2 sub teams aimed at supervision and supporting role to main teams.
HCN named as case manager, they will provide direct contact no. and information to patients / carers for further enquiry and support.
Buffer zone for HCNs cover and paired up for support other teams, e.g. day off, annual leave or sick leave etc.
Result & Outcome :
Result:
Patient and staff satisfaction survey collected after program implemented 6 months. Patients and carers showed that agreed of easy access to contact HCN is 100% compared with no designed case nurse is 70%. Overall satisfaction rate as 88%.
Otherwise, HCN showed 71.4% agreed of difficult to manage daily home visit schedule before program implementation. 100% agreed of evaluate the risk of patient in particular condition. 85.7% showed satisfy the new arrangement of case management.
Improved time-consuming in schedule home visit and repeated communication for 20%.
Conclusion:
Patients and caregivers can more easily contact designated HCNs, and HCN can rapid response to them directly and effectively, for addressing their health concerns and diminish their worries. Otherwise, the programme improved rapport between HCN and patients, thereby enhancing efficiency in home care services.
In terms of staff, dedicated HCN can coordinately manage the physical, emotional, social, and spiritual needs of patients and caregivers. It saves time and effort to repeated communication, shortens transportation time, schedules home visit or daily operation smoothly, and improves job satisfaction.
For departmental, reduce daily transportation expenses, relief the heavy workload of PC hotline co-ordinator, and enhance home care service quality.
