Authors (including presenting author) :
WOO CW, CHAN BKS, CHEUNG GCM, CHUNG RKF, CHAN JSP, CHAU RMW
Affiliation :
Physiotherapy Department, Kowloon Hospital
Introduction :
ICDS for Elderly Patients is a HAHO program launched in 7 clusters since 2011 to 2012. It is a multi-disciplinary team approach to provide comprehensive discharge planning and collaborate the discharge support services for the high risk elderly. The success of the program was seen with evidenced on various platforms. With time, congested medical wards and AEDs emerged, especially during winter surge. Without ICDS, it would have been worse. It will be opportune time to review the characteristics of these high-risk elderly to find out their potential discharge needs, so that a better service matching can be established within the limited resources of ICDS program.
Objectives :
(1) To document the characteristics and discharge needs of high risk elderly referred for PT under ICDS (2) To well understand home care problems (3) To review the “case Management Planning Form” for PT
Methodology :
It was a retrospective review of ICM data from January 2013 to December 2019
Result & Outcome :
996 cases were reviewed. There was no significant difference in age(80.9±7.8) and gender(66.3% male) across the years. There was an overall decreasing trend for HARRPE score, with the lowest point in 2017 and significant between-year difference was observed between 2014 and 2017 (p < 0.05). Ten categories of discharge needs were established. The top 5 high percentages of the discharge needs found were (1) unable to manage health care needs after discharge (28.5%), (2) mobility assessment (25.6%), (3) fall management (14.0%), (4) meducation problem (11.7%) and (5) inadequate family/ social support (7.7%). For functional outcomes, the initial modified Barthel Index showed significant increasing trend (p < 0.05) even for this frail elderly clientele. Data analysis showed that the medical team support to be the greatest need in transitional care from hospital to home. The need for social support cannot be undermined. There is relative decreasing risk as reflect by the HARRPE score and increasing less dependency in physical functioning among this group of high-risk elderly. Increasing efforts to accelerate step down care to NGO through cohesive medical-social collaboration may free up the tight resources within ICDS to take up those with higher risk. This may shed light and be part of relieving the congested medical wards and AEDs.
