Authors (including presenting author) :
Sze-To WY, Ng YB, Chau SW, Leung MW, Hung YL, Choi YW, Fu ML
Affiliation :
Department of Medicine and Geriatrics, United Christian Hospital, Kowloon East Cluster
Introduction :
Acute services are facing unprecedented pressures with access block in AM for AED cases and high
occupancy of the reason that always find caring issues upon discharge. To enhance service capacity,
a pilot of new service model is required. A trained ward-based discharge coordinator liaises timely
identification of those complex discharge needs, thus allowing those patients be matched to
appropriate discharge support services and improve overall patient flow for acute medical ward.
Objectives :
(1) To formulate pre-discharge plan for patient with discharge service needs via Multidisciplinary Approach
(2) To coordinate early transfer of patients to priority convalescent beds
(3) To provide health education and timely referrals to Single Point Triage Team (SPTT) for collaboration of community services to facilitate early discharge
Methodology :
Training for ward-based discharge coordinators to identify potential discharge problem patients by Edmonton Frail Scale and those patients with High Admission Risk Reduction Program for Elderly (HARRPE) >0.2 by Integrated Care Model Assessment and Discharge Planning Form.
Optimizing priority convalescent bed arrangement by communicate with case medical officer, team nurse, patients and families to make sure successful morning transfer. Thus, secures beds for AM AED admission.
Collaborating with SPTT to provide pre-discharge education to patients.
Setting up IT system to capture the data of Discharge Coordinator Program in M&G SharePoint. Proposed deliverables are 500 per year.
Result & Outcome :
Pilot period: From 23 December 2019 to 6 January 2020 and ongoing in 1 Male Medical Ward and 1 Female Medical Ward.
156 out of 179 patients were screened. 14 patients were referred to SPTT for complicated discharge problems. 33 patients were supported with discharge services. 48 patients were given health education and psychological support.
10 patients were successfully transferred to priority convalescent bed in the morning around 1030 which about 3 hours earlier than before. No wastage of bed noted.
The pilot study showed that the ward-based discharge coordinators master of timely discharge to enhance service capacity. In addition, pre-discharge education leads a significant positive effect on patient’s self-management and empowerment. Overall, it could be a chance of reduction on length of stay and repeated readmission in the long run.
