Presented by : Shum Nga Fan (APN, Colorectal Specialist Nurse, QMH)

Ms Teresa Lui Y.L. (DOM, Department of Surgery)

Dr Judy Ho W.C. ( Consultant, CRS, SRG)

Professional Law W.L. (Professor and Chief, CRS, SRG)

8 June 2011

� Colorectal Cancer - 2nd most common cancer in Hong

Kong (Hong Kong Cancer Registry, 2008)

� 4018 new cases and 1628 deaths in 2008 ( Hong Kong Cancer

Registry, 2008)Registry, 2008)

� Increased demands and needs for good cancer care

service

Factors

�Increased service demand

�Fragmented patient care lead to

Cancellation of operation due to unpreparedness

No pre-discharge planningNo pre-discharge planning

Inadequate preoperative education

Uncertainty and refusal of discharge

Unnecessary hospital stay

�Increased complexity and needs of patient

�change of role of colorectal nurse

• specialty training

• provide sophisticated cares and skills

• participate in the clinical disease management of patient

Factor

• Increase service demand

• Fragmented patient care

Process

• Reference and expanded on

Outcome

• Patient clinical outcomes • Fragmented patient care

• Increased complexity of

patient needs

• change of role of colorectal

nurse

• Reference and expanded on Neurosurgery case management model

• Developed Colorectal Case Management Model in 2007

• Patient clinical outcomes

• Clinical implications

� Define Case Management Model

� Define the objectives

� Identify target group

� Identify patient needs� Identify patient needs

� Select quality management tools

� Identify, liaise and network with multidisciplinary health professionals

� Identify key deliverables

� Identify Cancer Case Manager

� Design the workflow of the Case Management Model

Coordinated care processes for patients

Assessed patient’s needs comprehensively

Social support assessment and developed service plan

Education and pre-discharge planning

Monitor and review patient care outcomesMonitor and review patient care outcomes

Arranged patient care service

Networking, coordination and collaboration

Advocacy for options and service

Gaps identified for service improvement

Empowerment and involvement of patients in all care planning

Risk managing

EducationEducationEducationEducation

InvestigationsInvestigationsInvestigationsInvestigations

Follow up Follow up Follow up Follow up

Arrange admissionArrange admissionArrange admissionArrange admissionfor operation for operation for operation for operation

Nursing assessment:

Physical, Psychological

& Social

ReferralReferralReferralReferral

Early discharge planning: Early discharge planning: Early discharge planning: Early discharge planning: Counseling and support : Counseling and support : Counseling and support : Counseling and support : Patients and CaregiversPatients and CaregiversPatients and CaregiversPatients and Caregivers

Collaboration & Coordination Collaboration & Coordination Collaboration & Coordination Collaboration & Coordination

�Multidisciplinary approachMultidisciplinary approachMultidisciplinary approachMultidisciplinary approach

�Interdisciplinary approach Interdisciplinary approach Interdisciplinary approach Interdisciplinary approach

�Patient focused Patient focused Patient focused Patient focused

CRT

Surgeon

Case

Manager

Medical

Social

Worker

Patient CRT

Nurses

Enterosto

mal

Therapist Other

professio

nals

Anaesthe

-tist

Physio-

therapist

� No unnecessary hospital stay

� No discontentment or conflicts upon discharged

� 98.56% (478) follow discharge plan to home /convalescent for follow up

care

� 1.44%(7) need transfer to convalescent for social placement/problems

98.56%98.56%98.56%98.56%

(478)(478)(478)(478)

1.44%1.44%1.44%1.44%

(7)(7)(7)(7)

Discharge of patients Discharge of patients Discharge of patients Discharge of patients Follow preop discharge

planning

Need transfer to

convalescent hospital for

social placement

� Hospital level

� Efficient utilization of resources

� Maintain good quality in service provision

� Division level

� Prevent cancellation of operation

� Achieves the clinical outcomes within the promptly time frame� Achieves the clinical outcomes within the promptly time frame

� Avoid misunderstanding on disease management plan

� Better patient service

� Ward level

� Systematic and holistic patient care

� Avoid unnecessary stay related to unknown care plan

� Prevent conflicts in ward when discharged of patient

� Facilitate efficient use of bed and resources

� Nursing perspective

� Acted as the resource person between patient and clinicians

� Organized patient care better

� Enhance autonomy in nursing practice

Physician perspective � Physician perspective

� Reduced workload

� Standardized patient care delivery

� Enhanced doctor- patient relationship for mutual understanding of

disease treatment plan

� Patient perspective

� Individualized and timely treatment care plan

� high level of patient and caregivers satisfaction

� Empowerment and engagement of patient in own disease � Empowerment and engagement of patient in own disease

management plan

� Cancer Case Manager Program Management Workgroup in

HAHO started June 2010

� 4 Cancer Case Managers (Breast / Colorectal) started in 2010 :

◦ PMH ◦ PMH

◦ POH

◦ KWH

◦ TMH

� Colorectal Cancer Case Management Model proven to provide quality

patient-centered cancer care in Queen Mary Hospital

� Met the needs of the colorectal cancer patients

� Highly recommended for other cancer or chronic disease management

� Ms Teresa Lui Y.L. (D.O.M, Surgery, QMH)

� Dr Judy Ho WC (Consultant, CRS/QMH)

� Professor Law W.L. (Professor & Chief, CRS, QMH )

� Mr. Peter Chan W.L. (W.M., Surgery, QMH)

� Staffs of colorectal Surgery Division, QMH