Rehabilitation for a Million – Hospital as a Proactive Interface ......F1 F2 A5 C9 CCU/CCL Team 2 ASU A10 B10 C9 GDH Team 3 D9 C10 C10 C9 T10 MB - Acute RB – Subacute Service integration

Rehabilitation for a Million –

Hospital as a Proactive Interface to

Community Rehabilitation

Dr Eddie SL CHOWMBBS(HK), MMED(Syd), MMED(NSW), MRCP(UK),

FRCP(Edin), FHKCP, FHKAM(Medicine)

Consultant Rehabilitation Physician

Department of Medicine and Geriatrics, Tuen Mun Hospital,

Hospital Authority, HKSAR

The Work-Force

Tuen Mun Hospital Rehabilitation Block (TMHRB)

• A designed capacity of 520 beds.

• Current M&G Beds : 319 beds

The Workforce

• Designated Rehabilitation Team with Specialists in

rehabilitation

• A diverse spectrum of expertise collaboration:

1. Rehab Specialists with expertise in exercise physiology,

acupuncture, osteoporosis, sex therapy & work rehab.

2. Collaboration with

• Geriatricians/ Cardiologist/Resp Physician/Renal

Physician/Neurologist /Rheumatologist etc..

• Neurosurgeons

• Orthopaedic Surgeons

• Paediatricians

• AH professionals

New Territories West Cluster

Service Demand in NTWC新界西聯網服務需求

In Tuen Mun, Yuen Long & Tin ShuiWai

• Population– ~1.1 million

服務屯門、元朗及天水圍

• 1,100,000 人口

• A HUGE in-patient medical rehabilitation

demand

Requiring …..

• A close service linkage, and

…….. to sustain the “high output”.

The System

Acute In-patient

RehabCommunity

Rehab

9/F Visceral 9/F Visceral 9/F Visceral 9/F Visceral RehabRehabRehabRehab

10/F Neuro 10/F Neuro 10/F Neuro 10/F Neuro RehabRehabRehabRehab

11/F 11/F 11/F 11/F Musculoskeletal Musculoskeletal Musculoskeletal Musculoskeletal

RehabRehabRehabRehab

Floor–Based Rehabilitation

Team 1

F1

F2

A5

C9

CCU/CCL

Team 2

ASU

A10

B10

C9

GDH

Team 3

D9

C10

C10

C9

T10

MB - Acute RB – Subacute

Service integration : Stroke/ NeuroReh

GDH

NeuroSur

R10 NeuroReh Floor

Team 1

F1

F2

Cardi

C9

CCU/CCL

Team 2

B6

A10

B10

C9

GDH

Team 3

Resp

Renal

C10

C9

T10

MB - Acute RB – Subacute

Service integration : Visceral Rehab

(Card/Resp/Renal)

GDH

In-patient programs

Integrated patient care plans (IPCP)

• COPD care program (CCP)

• COPD rehabilitation program (PRP)

• Rehabilitation Stroke Unit (RSU)

• NeuroSurgical-Med-Rehab Collaboration (Pilot)

• A HUGE in-patient medical rehabilitation

demand

Requiring …..

• A close service linkage, and

• an extensive community support network

…….. to sustain the “high output”.

Community Rehab

The System

Acute In-patient

RehabCommunity

Rehab

Community Rehab

Community Rehab

Community Rehab

Community Rehab

The Hardware

Day rooms and Integrated Rehab Areas at

each RB floor

17

Integrated Rehab Area(PT & OT)綜合治療室綜合治療室綜合治療室綜合治療室

((((物理治療及職業治療物理治療及職業治療物理治療及職業治療物理治療及職業治療))))

Day Activity Room 活動室活動室活動室活動室

The Hardware

Day rooms and Integrated Rehab Areas at

each RB floor

• For rehabilitation services catering both in-patient and

out-patient rehab patients.

• As an interface activity centre for in-reaching community

partners

• For multi-disciplinary training and patient meetings.

The Software –

As a Platform for Community Rehabilitation

For In-patients to transit to the community …..

– To facilitate community partners to join in

– Community partners as a team member

– Multi-community partner collaboration

TMH RB

Community

Rehab

Community

Rehab

Community

RehabCommunity

Rehab

Community

Rehab

Advanced Rehabilitation

Vocational Rehab (VRRC)

CRN 社區復康網絡社區復康網絡社區復康網絡社區復康網絡Stroke

Interfacing Program中風分享會中風分享會中風分享會中風分享會

NAAC鄰舍輔導鄰舍輔導鄰舍輔導鄰舍輔導會會會會Community

Rehabilitation Day Center社區日間康復中心社區日間康復中心社區日間康復中心社區日間康復中心

YOT 仁愛堂仁愛堂仁愛堂仁愛堂In-reaching

Acupuncture Service結合針灸服務結合針灸服務結合針灸服務結合針灸服務

TMH Rehab Centre

Patient visiting Program

by previous Stroke Patients/ Patient self-Help groups

PLK / NAACHome Care Service

Our Community Rehabilitation Partners Our Community Rehabilitation Partners Our Community Rehabilitation Partners Our Community Rehabilitation Partners

• Cardiac Rehabilitation

• Neuro-Rehabilitation

NTWC Cardiac Rehabilitation Program

24

Acute Hospital

HospitalIn-Patient

Rehab (CRP1)

HospitalDay-patient

CRP2

CommunityCRP3/4

Emergency Dept

CommunRehab CRP3/4

Heart Attack

26

Traditional Hospital-based

Cardiac Rehabilitation

• Classical

• Simple

• Safe

• Control

• Treatment Compliance

• Established effectiveness

Hospital Rehab CRP 2

27

Drawbacks

• Cost

– Hospital manpower Vs facilities

– Patient fees

• Priority

• Safety Issues: Infection Control

• Accessibility (time, place, person)

• “Patient” role

• Treatment Vs Habits/Hobbies/Enjoyment

• Post-’treatment’ maintenance

Traditional Hospital-based


Hospital Rehab CRP 2

29

TMH Cardiac Rehabilitation

NTWC Cardiac Rehab Program

• CRP Phase 1 (CCU):

Preventive education and rehabilitative services to hospitalized patients following an index CVD event, such as an MI/acute coronary syndrome;

• CRP 2 (Hospital-based Day-patient Supervised Training)

Medically-supervised Exercise-based training and education.

• CRP 3 (Community-based Supervised Training)

Professionally-supervised Exercise-based training in the community setting

• CRP 4 (Community-based Long-term Maintenance Unsupervised Training)

The incorporation of exercise into daily lives with long-term maintenance

30

31

“OUR BIG FOUR”

NTWC Cardiac Rehab Program

• CRP Phase 1 (CCU):

Preventive education and rehabilitative services to hospitalized patients following an index CVD event, such as an MI/acute coronary syndrome;

• CRP 2 (Hospital-based Day-patient Supervised Training)

Medically-supervised Exercise-based training and education.

• CRP 3 (Community-based Supervised Training)

Professionally-supervised Exercise-based training in the community setting

• CRP 4 (Community-based Long-term Maintenance Unsupervised Training)

The incorporation of exercise into daily lives with long-term maintenance

32

33

Drawbacks

• Cost


– Patient fees

• Priority






Hospital-based rehabilitationThe use of partial hospital

resources to run the full service

Patients pay the same fees and

then lower fees afterwards

34

Drawbacks

• Cost


– Patient fees

• Priority






Hospital-based rehabilitationHospital can maintain priority

services without jeopardizing CRP

services

Less infection risk in the

community

35

Drawbacks

• Cost


– Patient fees

• Priority



• “Sick” role



Hospital-based rehabilitation

Enhanced accessibility:

Opening hours (staff/Gym) /

locations (city centre)

Elimination

36


• Does it work? the medical parameters …

Leung KC, Chow E et al 2006

Chow E, Chung MC, Fong CH et al 2007 and 2010

39

Summary (c/w other reports)

• SBP ↓ 6mmHg (Vs ↓ 3-4mmHg)

• DBP ↓ 1mmHg (NS) (Vs ↓ 2-3mmHg)

• BP targets (140/90) achieved in 75%/91%.

• Quit Smoking 87% � 96% (Vs 76% � 92%)

• Mood and QoL Improved (inconsistent)

Risk Factor control 2

Match (or exceed) international

audit practice/ requirement /

standards

41

What afterwards ……

• The medical parameters seemed acceptable…..

• Can we do better?

– Patient Behaviour Parameters

– the incorporation of healthy life style into daily lives –Exercise Habits / DM Mx / BP Mx.

42

“Psycho-Cardiac Rehabilitation”

活出新“心”– Collaboration with NGO (Community Rehabilitation

Network)

– Cognitive-Behavioral Therapy

– Self-Disease Management (CDSMP)

44

“Psycho-Cardiac Rehabilitation”

活活活活出出出出新新新新““““心心心心””””

45

What afterwards ……

• The medical parameters seemed acceptable…..

• Did we do better?

– Patient Behaviour Parameters

– the incorporation of healthy life style into daily lives –Exercise Habits / DM Mx / BP Mx.

48

Drug Survey (post CRP)

90%90%90%90%

80%80%80%80% 80%80%80%80%

93%93%93%93%

85%85%85%85%

96%96%96%96%

94%94%94%94%

95%95%95%95%

60%60%60%60%

80%80%80%80%

100%100%100%100%

antiplatelet agentantiplatelet agentantiplatelet agentantiplatelet agent lipid lowering agentlipid lowering agentlipid lowering agentlipid lowering agent Betablk or ACEI/A2RBetablk or ACEI/A2RBetablk or ACEI/A2RBetablk or ACEI/A2R

UK-benchmarkUK-benchmarkUK-benchmarkUK-benchmark NTWCNTWCNTWCNTWC UKUKUKUK

(IHD) (CHF)(IHD)

97.3% 97.3% 97.3%

54

Expected Outcomes

1. Drug Therapy � Better coverage

2. Exercise Capacity

3. BP � Home BG Monitoring

4. Lipid Profile

5. DM � HBGM / DM Screening

6. Body Weight

7. Smoking

8. Mood and QoL

9. Physical Activity Time � More

NTWC Cardiac Rehabilitation Program

A Multi-NGO Collaboration Model in Cardiac Rehabilitation

• Safe• cost-effective• good outcome quality.• sustainable.

58

Acute Hospital

HospitalIn-Patient

Rehab (CRP1)

HospitalDay-patient

CRP2

CommunityCRP3/4

Emergency Dept

CommunRehab CRP3/4

Hobbies / Habit

Neuro-Rehabilitation

Neuro-rehabilitation

• Close Liaison and service flow with acute neurology units

• Community Rehab starts in in-patients

• Close & Extensive Community Rehab Support.

Acute In-patient

RehabTMH RB

Community

Rehab

Community

Rehab

Community

RehabCommunity

Community

Rehab









TMH Rehab Centre




InInInIn----patient Rehabilitation patient Rehabilitation patient Rehabilitation patient Rehabilitation Starts with Community Rehab

Starts with Community Rehab









TMH Rehab Centre

InInInIn----patient Rehabilitation patient Rehabilitation patient Rehabilitation patient Rehabilitation




Community Programs – Collaboration

with NGOs

Stroke Interfacing Program

Partnership with Community Rehab Network (NGO) & HK

Stroke Association (Patient Group)

• Sharing the rehabilitation experience by volunteers of

stroke victims and their carers.

• Introduction of Community Rehabilitation Resources

Introduction of Community Rehabilitation to in-patients

To the pt/family and the team

• In-patient rehab is the initial part of rehabilitation

ONLY….. . NOT the whole process.

• To prepare our patients to enter the next stage of

rehabilitation ….. in the community.

Introduction of Community Rehabilitation to in-patients

To our patients…

• “You are not dying, You can survive & go home”

• “You can recover ….. Just like those who come back today.”

• “Later when you go home, you can (and are expected to) contribute to the society ….. ….. Just like those who visit you today.”









TMH Rehab Centre

Community Rehabilitation Community Rehabilitation Community Rehabilitation Community Rehabilitation Starts in inStarts in inStarts in inStarts in in----patient phasepatient phasepatient phasepatient phase




TMH-YOT Integrated Acupuncture Service

for Rehab patients

• To provide a safe platform for trial of TCM acupuncture service for rehab patients.

• Expertise (in Chinese and Western Medicine Acupuncture)

• Screening and Triage

• Continuous Communication

Safe Transition to

Community TCM Acupuncture Services


Vocational Rehab (VRRC







TMH Rehab Centre

Community Rehabilitation Community Rehabilitation Community Rehabilitation Community Rehabilitation





Vocational Rehab (VRRC







TMH Rehab Centre





Out/Day-Patient Rehab Service門診及日間病人康復服務

M&G Rehab Ambulatory Service 內科及老人科日間服務

Rehab Specialist Clinic 康復專科門診• Brain Injury Clinic (BIR) 腦創傷診所• Visceral Rehab Clinic (VIR)官能康復診所• Spasticity, Musculoskeletal and Pain Rehab Clinic

Extended Rehab Centre (ERC) 延展康復中心• Cardiac Rehab Program / Visceral Rehab Program 心臟/官能康復計劃• Work rehab service for cardiac patients 心臟病人職能康復服務

• Osteoporosis, Exercise & Rehabilitation Clinic (OER)

骨質疏鬆運動及康復診所• Special Rehab Clinic (SPR) 特別康復診所

Advanced Rehab Services

• Cognitive / Work Rehab Services

• Driving/Work Rehab Services

HA Support after Discharge

• Geriatric Day Hospital

• CGAT – Community Geriatric Assessment Teams

• Integrated supported discharge program (IDSP)

• Community Nurse/ Physio/ Occupational services

• Out-patient Allied Health services.









TMH Rehab Centre













TMH Rehab Centre













TMH Rehab Centre





The Neighbourhood Advice-Action Council (NAAC)

NT West Community Rehabilitation Day Center

(CRDC)

75Email: [email protected]









TMH Rehab Centre




Thank YouThank YouThank YouThank You

To Our Team Of Community Rehab PartnersTo Our Team Of Community Rehab PartnersTo Our Team Of Community Rehab PartnersTo Our Team Of Community Rehab Partners

Documents

Rehabilitation for a Million – Hospital as a Proactive Interface ......F1 F2 A5 C9 CCU/CCL Team 2 ASU A10 B10 C9 GDH Team 3 D9 C10 C10 C9 T10 MB - Acute RB – Subacute Service integration