Authors (including presenting author) :
CHAN BKS, CHEUNG GCM, CHUNG RKF, CHAN JSP, WOO CW, CHAU RMW
Introduction :
HA is facing escalating demand of services. Enhancing community-based care is one of the strategic directions to improve access and efficiency. Different out-reach rehabilitation service packages have been innovated to address the service needs. Current CPT services in KH include Integrated Care and Discharge Support for Elderly Patients(ICDS), Community Geriatric Assessment Services(CGAS) and Domiciliary Physiotherapy(DPT). ICDS provides comprehensive support to newly discharged patients under case management model, while CGAS target client residing at Old Age Homes(OAH). DPT serves other clientele who are best fit for home-based rehabilitation program.
Result & Outcome :
Total 273 patients(N=273) were referred to CPT. ICDS constituted majority of patients(65.9%,n=180), referred for mobility training(24%), disease management(24%), fall management & home safety(24%), community & social support(9%), drug supervision(8%), carer education(7%) and physical activities(4%). CGAS composited second largest group(25.3%,n=69), with referral for mobility training(33%), fall management(30%), limb mobilizing exercise(14%), assessment for further rehabilitation training (12%), pain management(4%), carer education(4%), and chest PT(3%). In addition, fall prevention workshop to OAH staff, education talks, walking aid screening, transfer skills, wheelchair assessment, fall prevention exercise group and environmental screened by certified Assessor for Residential Care Services for the Elders were also provided. DPT was the small remaining patient group(8.8%,n=24), filling the service gap among different service packages by HA and community partners in empowering patients and carers for continuity of care and community re-integration through individualized own-environment-based rehabilitation. The overall community PT service of KH was 0.06% of total PT OPD attendance of KH which was lower than the HA Allied Health mean (0.13%).
HA resources are limited. The services should target the patients most in need. With the changes in different service packages, CPT should be specific and selective to cater contextual changes. The findings of this explorative service review supported the contemporary service model enhancement with “less to achieve more”, which is in-line with corporate direction of service modeling innovation. Enhanced CPT developed more options for patient care, promote partnership/ collaboration between high risk patients, informal and formal carers in achieving safe discharge facilitation and maintenance in community.
