Authors (including presenting author) :
Chung LH(1), Ko WNW(2), Lui TCN(3), Choy WF(4), Lam WTR(5), Tse SF(6), Man YCR(7), Yan WHE(8)
Affiliation :
(1)Integrated Care and Discharge Support for Elderly Patients, Kowloon Central Cluster (ICDS, KCC), (2)Community Nursing Service, Kowloon Hospital, (3)Occupational Therapy Department, Kowloon Hospital
Introduction :
The aging population related to health service is increasing in demand. Discharged frail elderly and high risk elderly patients’ hospital admission rate is so high. Chronic disease and multimorbidity are the critical challenges to health care services. Kowloon Central Cluster (KCC) - Integrated Care and Discharge Support for Elderly Patients (ICDS) provide post -discharge continued medical and social support to them in the community. Case managers delivered home visits to support the frail and high risk elderly group at home to empower their self- care in community. We found that self- care on medication management is one of the key challenges to them in community. Discharged frail elderly patients with chronic disease and multimorbidity have the risk of poly pharmacy and suboptimal medication adherence. In this joint program, we aim to empower their self- medication management and promote quality of life.
Objectives :
With empowered self- medication management, the discharged frail elderly patients can achieve: 1. Using medication safely and effectively 2. avoid unnecessary hospital admission 3. Treatment and prevention of disease 4. Improving quality of life 5. Improved self- confidence and self- engagement in self- care management
Methodology :
Recruitment criteria: • Discharged frail elderly patients live alone or couple • Medication managed by themselves • With chronic diseases • Polypharmacy. Patient survey and medication compliance are used to monitor the improvement level of the self-medication management. Program duration last for four months, providing eight weeks of support services by Community Nurses and Occupational Therapists. A wide range of improvement measures will be implemented to the target group of frail elderly patients. It includes patient education and counselling, aids provision, social support, and liaison with medical services. We review and evaluate the progress and level of empowerment every four weeks. Patient interview will be held at the end of the program.
Result & Outcome :
Discharged frail elderly reflected on the following: 1. Improved self- confidence on medication management 2. Correct medication storage, preparation and administration 3. Understand own medical condition and related drug effect and side effect 4. Able to follow up own medical condition and medication 5. Improved quality of life Target patients’ self-efficacy and actual performance in managing their own medication are empowered. Improvement measures by case managers of Community Nurses and Occupational Therapists are effective. Target patients’ shows active and responsible self- participation on their self-medication management.
