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Establishment of an innovative CHCC in Hong Kong to prevent avoidable hospitalisations Print E-mail
The Quarterly 2011

 
Introduction

The Hong Kong Hospital Authority is the principal public health service provider which delivers over 90% of secondary and tertiary care in the territory. With a rapidly ageing population and significant rise in service demand, the Hospital Authority (HA) has been developing measures that could better support its patients to reduce avoidable hospitalisations. With over 67% of unplanned emergency readmissions attributed to those aged 65 and above, there has been particular focus on developing innovations to support elderly people during the transitional phase of care. The establishment of a HA Community Health Call Centre is one of the successful initiatives.

What is a health call centre?

A "health call centre" is a health service that enables integrated delivery of health care to connect patients and professionals using information and communications technologies that have the capacity to handle high volumes of transactions for large catchment areas. It provides a platform to provide a range of services including information, triage, advice, referral, counseling, assessment and disease management.

The use of a "health call centre" service to triage and coordinate the appropriate use of healthcare resources has been widely adopted in the United Kingdom, Australia, New Zealand and the United States. Studies in these countries have found various successes in curbing the rise of emergency department visits and hospital admissions compared to similar patients not receiving such services.

A different type of health call centre – the Hong Kong experience

Unlike other countries where the health call centre service is predominantly inbound (patients initiate contact to provider), Hong Kong has had successful experiences in using a targeted approach in providing an outbound service (provider initiate contact to patients) to those at the highest risk of emergency readmissions since 2003. This nurse-led CHCC service provides home care advice and referral to appropriate care resources via protocols within 48 hours after discharge from hospitals. Because the patient was discharged from the Hospital Authority, the nurse is able to provide relevant advice specific to the context of the patient’s history and situation.

Our experience suggests successful development of this service innovation depends on appropriate set-up and a timely service response system. The key components are:

  1. A validated risk prediction tool (‘HARRPE’) has been developed locally to screen elderly patients discharged from medical wards who are at risk of emergency readmission within 28 days of discharge. The tool integrates multiple socio-demographic, clinical and healthcare utilisation factors by accessing patient’s clinical information and computes the probability of readmission by a "HARRPE score". The higher the HARRPE score, the higher the risk of emergency readmission. Given the large volume of patients being discharged from hospitals, the tool allows administrators and nurses to auto-generate patient lists so those who are most vulnerable are targeted for assessment and timely interventions can be initiated.
  2. The targeted patients are contacted within 48 hours of discharge by nurses at the CHCC who have direct access to up-to-date patient and care information through Electronic Patient Records. Access to patient’s up-to-date clinical problems and past medical history allows health professionals to attend to issues critical for patient’s return to the community. Specifically, discharge medication and follow-up arrangements are vital information to ensure the service is relevant. A new IT application and telephone system provides interface and support to facilitate workflow and documentation.
  3. During the phone assessment, some patients may be deemed to require earlier follow-up appointment and prompt reviews. Networking and referral arrangement with community healthcare partners have also been established to enable a rapid service response system. The CHCC will co-ordinate fast track GP or specialist clinic appointments, outreach services or even direct hospital admissions if clinically appropriate. The development of a comprehensive service directory facilitates this critical referral system.

Results

In total, 36,072 patients were identified by the risk predictive HARRPE score as high-risk elderly patients and referred to the CHCC between April 2010 and March 2011. A total of 77,633 calls were made through the CHCC. After initial assessment, 137 patients (0.4%) were arranged for direct admission to hospitals, another 2262 patients (6.3%) were referred for follow-up in public and private primary care clinics and 231 patients (0.6%) were given priority specialist appointments. A further 429 patients (1.2%) were provided with outreach nursing and allied health services. Overall, the CHCC provided key advice for patients on two aspects of post-discharge care: information on community resources were given to 19,444 patients (53.9%) and advice on medication management were given to 18,451 patients (51.1%).

The service has redesigned service delivery within the system and has proven to be cost-effective in reducing unnecessary usage of hospital services. The results show that the service provided by CHCC plays a key role in provision of advice especially in relation to information on community resources or patient’s medication management. Only a minority of calls resulted in more direct follow-up such as outpatient appointments and community nurse visits. A study of 678 patients has demonstrated the service to be effective for high-risk elderly patients. There was a relative risk reduction for patients who have received the CHCC service of 27% and 26% respectively in the 90-day utilisation rate of A&E attendance and A&E medical admission.

Progress and Way forward

With success in piloting the initiative at different hospital clusters, the Hospital Authority established a business case and in 2009 set up a centralized centre at Hong Kong Island East Cluster. Under the direction of a robust organisation-wide Steering Committee, an incremental approach has been adopted to build the sophisticated components of the centralized CHCC. The service is run by dedicated staff at the Hospital Authority and has been covering all regions of Hong Kong since the beginning of 2011. The CHCC is open every day of the year and provides a 12-hour service (8am to 8pm) from Monday to Friday and an 8-hour on weekends and public holidays. In addition to the outbound service, elderly patients who are at high risk of hospitalisations and their carers are welcome to initiate contact to the nurses at the CHCC for advice should they have queries in the future.

The establishment of the CHCC is in line with one of the Hospital Authority’s strategic directions, to better manage the growing service demand arising from population ageing, increasing chronic illnesses and technological advances. The service has proven to enhance discharge management, thereby reducing avoidable A&E attendance and hospitalization by improving their access to available healthcare services, thus promoting preventive care and early intervention. Furthermore, with the support of private primary care providers and non-government organizations (NGOs), the CHCC could help HA divert demand for high volume, low complexity services to appropriate care partners.

The HA plans to leverage the CHCC as a centralized profession-led platform to target other at-risk patients, including those with chronic diseases and mental health illness, to further improve care for patients in the community.


Dr Bennie Ng
Senior Manager,
Strategy and Planning Division, Hospital Authority, Hong Kong


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