Authors (including presenting author) :
Wong CL(1), Lam KM(1), Lui WY(2), Yip KF(1), Cheng SY(1), Tang WK(1), Chan SWA(1), Ng YB(1), Tsang WY(1), Sim TC(1), Sha KY(1)
Affiliation :
(1) Department of Medicaine and Geriatrics, United Christian Hospital, (2) Social Welfare Department, HKSAR
Introduction :
Inefficient and ineffective discharge plans are usually directly related to long hospital stays and poor patient satisfaction with the overall discharge process. The medical-social collaborative discharge coordinator in acute hospital can play an important role in improving the overall discharge experience for patients and families.
The purpose of this quality improvement project is to describe and address the implementation and evaluation of a medical-social collaborative discharge coordinator in United Christian Hospital. Improved outcomes, including decreased length of hospital stay and increased patient satisfaction with the discharge process are demonstrated through implementation.
Objectives :
To demonstrate how the medical-social collaborative discharge coordinator plays an important role in supporting elderly patients and their families when discharge from acute hospitals.
Methodology :
The medical-social collaborative discharge coordinator adopted the case management model to provide a series of services for the elderly patients in the target units. In 2018, a registered nurse was appointed as medical-social collaborative discharge coordinator, who participates in different patient meetings and ward rounds to formulated discharge plans with multi-disciplinary professionals in various units, such as ASU, rehabilitation unit and orthopedics department.
The coordinator also collaborative with Social Welfare Department (SWD) and multiple NGOs, routine case conference with SWD social worker was held once per week. The team does follow up on patient’s post-discharge situation. The services plan can be modified according to the patient’s needs. Ensure the patients and their families can be obtained adequate services through appropriate community service providers.
Result & Outcome :
The medical-social cooperative discharge coordinator was implemented in February 2018, and since implementation, the average length of stay of the target patients was 7 days. It has shown a gradual decrease when compared with the unstructured discharge process. During the period, the coordinator participated in 96 Geri-orthopedic ward rounds, 36 ASU nursing rounds and 28 rehabilitation ward conferences. Total 266 patients were evaluated. 77% (n=206) of the elderly patients were successful to provide transitional care and support. 54% (n=146) of the patients were referred to Transitional Residential Care (TRC) Services. Meanwhile 25% (n=60) were referred to Day Care Centre (DCC) Service and Transitional Community Care (TCC) Service. The average referral time of Day Care Centre (DCC) Service and Transitional Community Care (TCC) Service was 2.8 days. 90% (n = 54) of patients can be discharged within 7-10 days with TCC support. Conclusion As the healthcare system continues to evolve and the complex medical problems of elderly patients increase, it is important that healthcare professionals and hospitals continue to develop and test new healthcare models to improve the quality and efficiency of the discharge process. Compared to unstructured discharges, these models lead to improvements in the discharge process. All stakeholders, including physicians, multidisciplinary professionals, patients, and families, agree that the Medical Social Cooperative Discharge Coordinator improves the overall discharge process.
