Authors (including presenting author) :
WONG FONG(1), LEE KY (1), KARN KY (2)
Affiliation :
(1) Community Nursing Service, United Christian Hospital (2) Nursing Services Division, United Christian Hospital
Introduction :
According to the Hospital Authority statistics, the Accident & Emergency Department (AED) attendance rate & the hospital bed occupancy rate are overloaded in winter surge. The attendance of UCH AED was increasing and reaching 75,438 in 2017-2018. As timely and effective discharge requires the availability of alternative and appropriate care options to ensure the patients’ needs are identified and meet, Community Nurse (CN) act as a care coordinator to early identify the patient’s need through a proactive assessment and collaborate with multidisciplinary services to provide ongoing support for the patient and facilitate discharge of patient who would otherwise requires hospitalization. Thus, a collaboration pilot program was launched since Dec 2018 with the aim to generate an early discharge plan by providing a proactive assessment and appropriate supporting resources to the patient to reduce the avoidable admission. The STOP program emphasizes the stratification, triage, optimization and priority, to strength the power of care coordination in helping patients to seek the right care in the right place at the right time.
Objectives :
1.To reduce the repeated & unnecessary admission 2.To fully assess and identify the patients’ clinical and social needs and provide an appropriate community supporting services for them 3.To liaise supportive network with the UCH AED and the Non-Government Organization (NGO) to facilitate a structured discharge plan for the patient
Methodology :
The STOP program was conducted from 16 Dec 2018 to 31 May 2019. Patient who are living at home and aged above 75 of AED Category 3 or 4 with inclusion criteria of 1) frequency of fall, 2) admission diagnose: Dizziness; HT; DM; CHF, 3) discharge problem were recruited. The CN coordinator assessed the high risk patient with a risk stratification and frailty assessment that focused on the elderly’s medical, psychosocial and functional capabilities in order to develop a coordinated and integrated discharge plan. Through the discussion with AED staff and provided alternative options on diverting patient the right community service (e.g. virtual ward program, enhanced community service) instead of hospital admission. Moreover, CN liaised and collaborated with other professionals and community partners such as palliative care (PC) home care team, allied health team, NGO enhanced nursing care team, the home supported service team to seamless discharge plan and link up various components along the patient journey from hospital to community.
Result & Outcome :
Total 783 high risk patients were assessed and 80% (n=623) were discharged. In order to avoid any inappropriate readmission and promote early discharge, 117 (19%) were referred or coordinated with NGO, community partners and other multidisciplinary service. 286 (46%) and 70 (11%) were referred to CNS with intensive home visit and telephone support respectively. As a result, 28-days readmissions had dramatically decreased from 28.1% to 16.4% with a relative risk reduction (RRR) of 42%. In Conclusion, the positive outcomes of this program proved that through a proactive assessment and collaboration with appropriated community resources could provide an alternative care options for the patient on discharge planning. Moreover, adequate coordination of community services upon discharge and intensive clinical post discharge support reduce the avoidance admission.
