Development of Community

Nursing Service (CNS) in

HK:

Penny Wong
Community Nurse
Sept 2017
Learning outcome:
1st session:
1. Development of Community
Nursing Service (CNS) in HK
2. Case sharing in CNS: from Hospital to home
care
3. ICM/ICDS
4. Primary healthcare in HK
2nd session:
Nursing practice in diverse settings
Development of Community
Nursing Service (CNS) in HK:
Community Nursing Service
 UCH, CNS (Hospital without Walls)

Community
Nursing was introduced
in 1967, first through the
Yang Memorial Social
Services Centre…

Start from 1970, community

nurse training was first
carried out by Alice Ho Miu
Ling Nethersole Hospital
1977 – Government Hospital CNS started
1991 – Hospital Authority took over all
Community Nursing Service
1994 – Decentralized to 11 Hospitals
2002 – Extended to 14 Hospitals covering
Cheung Chau & Lantau Island
Home Care
Age Home
 Community Nursing was recognized to be an
integral part of the medical & health services from
1979, since then the service was support by the Hong
Kong Government

“… To shift the emphasis from inpatient to ambulatory and community

care.. ”
 CNS under HA after 1991
 Decentralized the management to 11 hospitals in 1994
 Extended to 14 Hospitals covering Cheung Chau & Lantau Island
in 2002
 Practice of nursing in patient’s home
 Continuing care for discharge patients
 Referrals typically for wound care or other nursing procedures
 building a strong and
To support patients cohesive network of
within the Seamless integrated
Health Care System rehabilitation

Maintenance care for patient in the community

Service boundaries
 Hospital Community
care Care
Pre-
discharge NGO/ Home
Pre-discharge
assessment CNS & Home Care
planning &
by Liaison CGAT Carer Nursing
education
nurse

Referrer: Case Care

Discharge OAH
Medical/ Manager Provider /
planner Coordinator
allied Educator
health

“to reduce avoidable hospital use if it is to deal with the future

demands of the ageing population and with chronic health
conditions…”
The changing context
Health care context
➢ Patients discharge from hospitals quicker and
sicker; requiring considerable interventions in the
community
➢ Frequent unplanned admissions
➢ Resources maximization
➢ Changing roles of nurses
➢ Era of evidence-based practice
 Three Levels of CNS Care in HK
CNS contribution to a stratified
chronic disease population
Virtual Case management
& complex care
Ward
Patient / carer
empowerment on chronic
Enhanced CNS disease management

General CNS Episodic Care

 Key Challenge
“Enhanced Roles of Community
Nursing and Effective Mode of
Service Delivery in face of Growing
Service Demand?”
 Principles of Action

1. Engaging consumers & community as partners

2. Helping people stay healthy & out of hospital
3. Advocating hospital without walls
4. Enabling transformation & improving care
 Modernization of
Community Nursing
1. Hospital-at-home: Virtual Ward
2. Enhanced CNS Program
3. Estate-based Community Nursing Centres
1.Virtual Ward
was effective reducing
unplanned readmissions and
improving patients’ quality of
life…
(Leung et al. 2015)
Interventions @PMH Virtual Ward
COPD fast-track clinic & clinical admission for
specialist consultation

Patient/Carer empowerment on symptoms

control

Advanced nursing practices BiPAP & home

ventilator care
Protocol-driven hospital-at-home investigations and
medication adjustment Standby emergency drug kit
for COPD exacerbation

Daily ward round and weekly case

conference for continuous quality care

Referrals to allied health professionals for

maintenance therapy PMH COMMUNITY NURSING SERVICE
社康精神服務人群積極參與事在必行
2. Enhanced CNS Program
Support for Patients with Chronic Disease &
Early Discharge from Hospital
Modernization
of community
Nursing
 Chronic disease management
Patient/carer Empowerment scores

Diabetes care
Hypertension care

COPD care Stroke care

Renal care Cardiac care

Fracture Hip care

 Scope of Service
Post-natal & infant
care Continence care

Wound and drain care, Ostomy care

End of life care Drug

management &
supervision
Counselling
Scope of Service
Rehabilitation counseling
 -Utilization of community resources
 -Nutrition counseling and feeding tube care
 -Medication management
 -Home safety assessment / home adaptation
 and exercise
 -Home infection control education
 -Community health education
3. Estate based Community Health Centre
Foster Community Partnership &
Promote Ageing in Place

Modernization of Community Nursing

 Objectives
Continuous FU on
Health Risks
Self Awareness
of Own Health
Platform for
Public Private Interface
Individualized
Health Assessment
Gate – keeping for
Health Services
The Centres provide
1. Walk-in service for health maintenance
2. Nurse consultation spots for care advice
3. Group therapy for care empowerment

Set up in Estates having > 3,500 elders in Hong Kong

 Shui Pin Wai Estate, Yuen Long
 Yue Wan Estate, Chai Wan
 Fu Cheong Estate, Shum Shui Po
 Oi Man Estate, Ho Man Tin
 Community Geriatric Assessment Team
(CGAT)
 Outreach service to frail elders living in RCHEs (Residential
Care Homes for the Elderly) to ensure continuity of care
 Multi-disciplinary approach, designated team
 Outbreak monitoring, training of nursing home staffs…etc
 Advance Care Planning (ACP) and End of Life Care (EOL)
預設護理計劃及臨終照顧
The Past episode care, long-term care

The Present disease management &

transition care
 CNS 2015 (Figures)
7 Clusters
17 Hospital
(YCH set up CNS centre in 2016)

40 CNS Centres
(HAHO 2015)
Advanced nursing practice is
dynamic. The scope of advanced
practice evolves through experience,
acquisition of knowledge, evidence-
based practice, technology
development and changes in the
health care delivery system.

(Nursing council of HK 2015)

 Care management
Clinician
 Liaison role in collaborate with referrers
and preliminary assessment for any high
risk discharged cases
 Manage complex clinical condition and
build up a care delivery system/model,
and allocation of team members (district)

(Woods 2012)
Knowledge & Skill application
Researcher, educator/instructor
 Master specialty knowledge and refine
nursing practice
 Advocate and participate in evidence-
based practice and promote its
implementation

Conservative Sharp Wound

Debridement (CSWD)
Evidence-based practice
Use of current evidence in practice
through the incorporation of clinical
expertise and patient values and
preferences with the systematic search for
relevant scientific evidence to address
clinical problems.
(Melnyk, 2005)

Think out of the box!!!

Centre in-charge – Nurse clinic
To enhance access to care
The practice model of nurse-led clinics serviced by
advanced practice nurses is a global trend. (Shiu et al 2012)
protocol-driven:
- investigation - referral - prescription –
discharge
Reduce avoidable admissions to
secondary care
 Nurse-led Clinic
A NURSE CLINIC is a
formalized and structured health care delivery mode
involving a nurse and a client.

THE CLIENT is an individual and his/her family

with health care needs that can be addressed by the nurse.

THE MOST important and key interventions are

nursing therapeutics which encompass
assessment and evaluation, treatment and procedures, health
teaching/counseling, and case management.

THE NURSE has demonstrated advanced competence

to practice in the specific health area.
Shiu et al (2012)
 Case sharing in CNS:
from Hospital to home
care
 Patient journey ….
Discharge planning at ward

Hospital – referrer inform community

nurse (CN)

Screening and discharge assessment by

Liaison nurse

Case handover (referrer & Liaison nurse)

Case handover (Liaison nurse &

primary nurse/CN)

CN contact patient/family to
arrange home visit within 48
hours
Home visit….. Nursing bag
Enhanced home care – COPD care
77 years old man
Family history
Allergy history
Medical history: COPD, CHF,BPH
Medication review
Mobility (Up & Go test)
Emotion, mental assessment:
Abbreviated Mental Test (AMT)
Physical assessment
(Barthel Index, Braden Scores)
Home environment assessment
Intervention:
Multidisciplinary approach:
➢ Home modification – refer to occupational
therapist
➢ Stand-by emergency drugs (refer to appendix)
➢ Education: empowerment scores – COPD care,
cardiac care, urinary catheter care
➢ Drug management
➢ Stress symptoms control, not disease cure
➢ Financial support - refer to social worker
➢ Phone follow up
Patient/Carer
Empowerment score

Home
modification by
occupational
therapist
Promote quality of life

Oxygen concentrator
Integrated Care Management (ICM)
Integrated Care and Discharge
Support for Elderly Patients
(ICDS)
支援長者離院綜合服務
 ICM/ICDS 支援長者離院綜合服務

Objectives:
1. Care management structure
Set up the Discharge Planning Team for
enhancement of care coordination to high
risk elderly patients and their carers
2. Reduce the risk of unplanned readmission
3. Enhance support and training to caregivers
Home-based Community Support

Direct Care services

 Personal care
 Elderly sitter service
 Home modification
 Home-making services
 Provision of meals
 Transportation and escort services
Residential / Centered – based
Respite Service
Aim
 To relief pressure of the carers
 To train up the client’s functional abilities
 Day Care Centre for the Elderly,
Private OAHs with day-time respite service
Patient Support Call Center (PSCC)
•Aging Population needs
more community support
•Better health promotion
and education
•Early detection and
intervention
Patient Support Call Centre (PSCC)

 Telephone triage
 Referrals to appropriate community resources
 Provides Home Care Instructions
 Gives advice on disease management

2996 2333
Nurse & Allied Health Clinic
Nurse & Allied Health Clinic