Authors (including presenting author) :
Kwan CY , Ho S , Po MY, Mak PK , Kng C
Affiliation :
Integrated Care & Discharge Service (ICDS), Divisions of Geriatrics, Ruttonjee & Tang Shiu Kin Hospitals (RTSKH)
Introduction :
Integrated Care and Discharge Service for the High Risk Elderly (ICDS) has been introduced for 8 years and aimed at facilitate early discharge and reduce avoidable readmission, by means of Case Management or Home support service. In order to improve ICDS service and evaluate its effectiveness and service gap, a post service review was conducted by the link nurse (LN) at the High Risk Elderly (HRE) Clinic about 4 months upon completion of service.
Objectives :
1. Assess patient condition and extend the multidisciplinary and community support if needed
2. Evaluate the services qualities of ICDS to look for further service improvements
Methodology :
From June to August 2019, a two-month review was conducted. Patients were assessed with comprehensive geriatric assessment tools, reported Edmonton Frail Scale (rEFS) and Clinical Frailty Scale (CFS); and provided with individualized patient empowerment education or referral to indicated supports in the community. Other information including service quality, limitations in case management and the Home Support Services were captured for service evaluation.
Result & Outcome :
In the evaluation period, 25 patients were recruited, 14 (56 %) cases turn up and assessed. No deterioration of CFS was observed before receiving ICDS service and 6 months after with mean 4.33 and 4.23 respectively (p=0.337); similar to rEFS with mean 6.4 and 6.1 respectively (p=0.73). Con-joined care plan was developed according to patients’ needs; 1 patient was referred to Spasticity Clinic in Geriatric Day Hospital, 2 to community support, 2 for specialist FU and 1 to Speech Therapist. Recommended that special attention should be paid on the need of social support, complication screening of cardiac patient, mood problem, carer stress as well as medication management. A 9-domain care plan was extended from rEFS and integrated to electronic documentation template in Clinical Management System (CMS). Conclusion Periodic service review boosts continuous service quality improvement. Needs identification and specialized person-centered care plan for the target high risk elderly could enable a superb case management model. The review also triggered betterment in service development and beneficial to patients as well as care givers in a win-win situation.
