Authors (including presenting author) :
Lau M (2), Ho KS(2), Kwan YK(2), Lam YM(1), Lee MM (1), Chao FW (1), KL Ko (1), Li YC(1), Ho KL (1), Lau YM(1), Pang WS(1), Wong WH (1), Wong MH(1), Chan FC (1), Lou SF (1)
Affiliation :
(1)Community Care Division, New Territories West Cluster (2)Department of Medicine and Geriatrics, Tuen Mun Hospital
Introduction :
Hong Kong has an aging population with continuing growth in public health care service demand. Elderly with multiple chronic conditions, increasing complexity in healthcare delivery, higher public expectation put significant burden to the healthcare system and families. More and more totally dependent elderly was being cared by family at home base. Elders and their family members experienced poor quality of life with infirmary level of care. Escorting bed ridden elders to out-patient clinic follow up induce their level of suffering due to the difficulties in transporting and long waiting time. A Community Geriatric Collaborative Home Care Program was developed as to provide a comprehensive geriatric management including geriatrician on site clinic and community nurse home care support in order to minimize the caring burden of families, deliver a close loop support of elders from hospitalization to community.
Objectives :
1.To establish a pilot program of Infirmary Care at Home (ICAH) manage the dependent elders with infirmary level of care for better support at home.
2.To reduce the elders times of out-patient clinic follow up.
3.To reduce hospital stay and unplanned readmission rate by home support, ad-hoc follow up and clinical admission.
4.To establish a close loop care pathway for elders with team approach.
Methodology :
1.Recruit suitable cases by Geriatric team and Community team.
2.Introduce the program to families by community nurse.
3.Provide regular and ad hoc consultation by geriatrician at home.
4.Empower knowledge in symptoms management, medication knowledge and facilitate coping on infirmary care at home from community nurse by providing regular home visit and act as a case manager.
5.Closely monitor patient’s condition by community nurse and advocates for patient via case conference, HA Chat and phone consultation.
6.Arrange advance consultation or clinical admission by team if necessary.
Result & Outcome :
From February 2018 to November 2020,
1.40 cases were being recruited (Aged from 60 to 100).
2.Baseline Characteristics: Bed Bound 100%, NG tube 40%, Pressure Injury 20 %, Foley 4%, Waitlist for Infirmary or Nursing Home 80 %
3.Number of Death for the whole period: 22
4.171 geriatrician consultations at home, over 2500 CNS home visits, 521 community nurse phone consultation were provided.
5.89 Ad hoc Medical consultations and 9 clinical admissions provided to prevent the Accident & Emergency Department attendance.
6.Accident & Emergency Department attendance rate (6 months) was drop from 80 episodes to 33.
7.Relative’s Stress Scale (RSS) was drop from average 28.8 to average 17.6 (21 carers).
8.All results shown the collaboration was successful in promoting patients’ and their carers’ quality of life and health in the community.
