Authors (including presenting author) :
Yu SM(1), Au YY (1), Chao FW(1), Ng MF (2), Lam YM(1), Kwok WY(1), Yiu WK(1), Lee MM (1), Kwan YK (2)
Affiliation :
(1) Community Care Division, New Territories West Cluster (2) Department of Medicine and Geriatrics, Tuen Mun Hospital
Introduction :
Integrated Care Model has been launched since 2012 in Tuen Mun Hospital. The Model comprises of hospital professional teams and Non-government organizations (NGOs). Both teams work in harmony to provide comprehensive pre-discharge planning and post discharge community supports to elderly who discharged from Medical and Geriatric Wards with frequent hospital admission and complex physical, psycho-social and care needs. In 2018, in view of the high demand of prolonged stay and deconditioned elders, Hospital Authority established Medical Social Collaboration (MSC) program to extend the service for elders with fracture hips and stroke.
Objectives :
To formulate a comprehensive pre-discharge planning to elders during in-patient phase to coordinate the service to attain patient physical, social and care needs.
Methodology :
In order to formulate a comprehensive pre-discharge planning to elders, Liaison Nurse conducts comprehensive assessment either by referral or proactive screening. Comprehensive assessment includes mobility function, cognitive function, self-care ability and social support. Liaison Nurse triages suitable service to the elders according to findings of the comprehensive assessment. Appropriate referral triggered by Liaison Nurse to support elders to keep healthy in the community. The Post-discharge supports by multidisciplinary Teams include Physiotherapist (PT), Occupational Therapist (OT), Social Worker (SW) and community care team of NGOs.
Result & Outcome :
From 1 January 2018 to 31 December 2019, there were 2411 elders who diagnosed with stroke and fracture hips received pre-discharge planning. Among them, 1609 (67%) were suffered from stroke, while 802 (33%) suffered from fracture. Total 812 (34%) cases were recruited into MSC program. Out of 812 cases, 568 (70%) cases were from stroke while 244 (30%) cases were recruited from fracture. 439 (54%) cases were recruited for PT as case manager, 310 (38%) were diagnosed with stroke and 129 (16%) were diagnosed with fracture. On the other hand, 373 (46 %) cases were recruited for OT as case manager, 258 (32%) were diagnosed with stroke and 115 (14%) were diagnosed with fracture. Furthermore, 189 (23%) cases were referred to SW for social supports including respite care and home help supports. In all, 100% cases were beneficial from MSC program with rehabilitation from professional input of PT or OT. To conclude, Pre-discharge planning is crucial to develop continuous cares and supports to elders, their carers as well as their family members to help keeping elder healthy in the community.
