Authors (including presenting author) :
Ngai ON(1), Ho KL(1), Ho LY(1),Chu WY(1), Yiu D(1), Kwok WY(1), Lam YM(1), Lee MM(1), Kwan YK(1,2), Lau CL(4), Lee L(4), Ong KL(4), Au Yeung TW(1,3)
Affiliation :
(1)Community Care Division, New Territories West Cluster (2)Department of Medicine and Geriatrics, Tuen Mun Hospital (3)Department of Medicine and Geriatrics, Pok Oi Hospital (4)Department of Accident and Emergency, New Territories West Cluster
Introduction :
In winter surge, the admissions of elderly are heavy burden to hospital services. To reduce unnecessary admissions, Geriatric Support in AED (GSA) program can act as the front door by doing the early assessment of patient needs, performing discharge care plan and coordinating with community support.
Objectives :
1. To initiate early geriatric and frailty assessment for targeted elderly 2. To identify their needs of social and community support 3. To conjoint care plan with geriatric and AED doctors 4. To bridge the continuity care from hospital to community for enhancing post discharge support
Methodology :
Refer eligible elderly to geriatric nurse of Community Care Division (CCD nurse) from AED in NTWC.
CCD nurse:
1.Provide multi-domain frailty assessment in AED to identify the physical health, cognitive function, level of independence, psychological state and social relationships of the elderly.
2.Discuss the referred cases with Geriatrician for suitable discharge planning.
3.Introduce appropriate social and community resources. For example, making proper referrals to Community Nursing Service (CNS), Integrated Discharge Support Programme (IDSP) and Community Geriatric Assessment Service (CGAS) nurse, advancing CGAT follow up appointment and booking of Geriatric Day Hospital (GDH) rehabilitation.
4.Liaise with relevant teams e.g. CNS, IDSP, GDH, SOPC and Geriatric wards to provide a post discharge support by case conference in order to offer an effective care delivery for frail elderly.
Appropriate geriatric assessments and discharge support plans are provided to the AED doctors to facilitate his/her on discharge decision making.
Result & Outcome :
From December 2018 to May 2019,
1.99 cases (40 Male and 59 Female) were referred by NTWC AEDs (Average Age: 82, range of age 65 to 101).
2.99 geriatric assessments were provided by CCD nurses in AED Department 3.63 Discharge plans were conducted included 17 cases were referred to CGAS, 27 cases were referred to CNS, 17 cases were referred to IDSP and 2 cases were referred to GDH.
4.47% (n=99) can be discharged on the same date of refer.
Conclusion: The GSA program is an integrated program of collaboration with community care, geriatric team and AED team. CCD nurse provides frail elderly safe alternatives to hospitalization and reduces suffering due to unnecessary admissions. As the elderly is best treated in the community, providing adequate community support is an essential component to promote care in the community.
