Hospital Avoidance

Road to Success,

United Kingdom and Hong Kong Practice

Ng Yin Yee, APN TKOH Med

Ageing population

In Hong Kong

• 1 out of 4 reach 65 years

of age by 2041

• 68% of all unplanned

Emergency readmission

• 50% of all patient bed

days

In United Kingdom

• Age over 65 will be double

up by 2050

• 2 millions unplanned

admission

• 68% of hospital emergency

bed days

Acute beds ↓↓↓ 1/3 in 25

years Acute beds are increasing

Factors of hospital admission

Availability of

community services

How hospital

services are

managed

Patient attributes

Access to hospital

services

Success indicators in hospital

avoidance

1. Rate of attendance & readmission rate in AED

2. How many of these are avoidable ?

3. Any admission diversion scheme ?

4. Any prediction tools ?

5. Any admission avoidance scheme ?

Useful data about UK & HK in health service

Health Service (2010/11)

UK HK

Public/ Private health

expenditure

84/16% 49/51%

Attributes Fully responsible Nearly fully

subsidized (public)

In/ Out Patient (Public Health Expenditure)

59/41%

55/45%

E attendance rate (Per 1000 population)

312 (London) 314

Avoidable admission 6-20% 41%

LOS (days) 6/ 5.3 (England) 5.6

Readmission rate (28 days)

7% 10.4%

Elements to the success

1. Risk prediction tools

2. Telehealth

3. Case empowerment

4. Case management

5. Hospital alternatives/ mode of admission

6. Early review by senior clinician in AED

UK and HK Practices in Hospital Avoidance

UK HK

AED

Screening by

• Geriatrician • Liaison nurse

Co-joint screening with medical

colleagues in winter surge only

(Individual cluster)

After admission ACE team for early integrated

discharge

Pre-discharge team for early

supported discharge, EDD/ ESD

program

Intermediate care Extended care at care home Rehabilitation & convalescence

hospital

Home

Community supports:

1. 111 hotline 2. Community Matron/ District

nurse

3. Public education

4. Tied GP

5. Case empowerment

6.

a) Virtual ward

b) Community ward

& Acute home visiting

services

c) telephone messaging

services (District nurse)

Community supports:

1. Community health call 2. GOPC/SOPD

3. GPs: GOPC PPP (HA), Elderly

health care voucher (DH)

4. Outreach team: CGAT, CNS &

Palliative care team

5. Public education (DH)

6. Functional support: Cataract/

Joint replacement/ Dental care/

expand drug formulary

7.

8. Transitional respite residential

services

9. Case empowerment : 8765 hours

self empowerment

Case management

Case management

Case Management &/ Telehealth

Promising of

a. Enhance quality of life

b. Reduce avoidable hospital admission &

readmission

c. Shortening length of stay

1. An evaluation of the impacts of “Virtual Wards” on frail patients receiving community nursing services at home : A case-based mixed-method approach (2013)

2. An evaluation of the case management service provided by the community outreach team (2014)

3. Teleconsultation – Airedale NHS Foundation Trust (2011)

Target groups: Individuals &

residents in Nursing Home

Useful data about UK & HK in health service

Health Service (2013) UK HK

GDP 9.4% 5.1% Hospital beds *

(Public & Private)

2.9 4

Nurses & midwives * 7.2 7

Physicians *

2.8

1.8

Public Private

0.76 1.04

Coverage of in-patients

88% 12%

* per 1000 populations

1. Health Facts of Hong Kong 2014 edition

2. 2.15 World Development Indicators: Health systems

3. Food and Health Bureau: Health Care Resources- Hospital beds (Under the definition of OECD Health Data)

4. Public/ private share by in-patient bed day occupied in 2011

Comparisons in Case Management

& Telehealth (HK)

Not on 24 hours support

Partial & limited coverage

Minimal participation of physicians

Mostly Nurse-led

Barriers to the success

1. Cost effectiveness & efficiency ?

2. Shortage of medical staffs in public sector

3. Resources allocation

Recommendations

1. Explore existing programs on case management &

telehealth in terms of cost effectiveness & efficiency

2. Cope with shortage of medical staffs

a) Co-joint with GPs

b) Develop protocols driven pathways

c) Nurse led approach

d) Use of advanced technologies

3. Support of intravenous therapy at home/ nursing

home

Recommendations

4. Expand telehealth service to 24 hours by

experienced nurses on shared electronic health

records

5. Enhance End of Life Care

- Encourage early advanced directives

- 24 hours support

- Under Gold Standards Framework (GSF)

- Encourage die in peace & familiar place

At a glance

2. Case management can effectively reduce hospital

avoidable admission & readmission

1. Hospital admission is not the default option

but last resort to the elderly

4. Use of existing health services & co-joint with GPs

supporting treatments at out-of-hospital places will

be the long run for success

3. 24 hours telehealth can minimize hospital admission

especially out of hours

5. Specialties as advisors to community health

services will fill up the gaps in quality support

Looking forward

Keep

Treat

Die

At Home/

Nursing Home Well

Care Effective

Cost Effective