Authors (including presenting author) :
(1)Dr. Eddie Chow, Dr. Savio Lee, Dr. Yukie Tse, Ms. Ng Wai Yung, Ms. Yick Ho Yee, Mr. Lau Chi Ki, Mr. Ho Ping Yeung, Ms. Wong Ka Yi, Ms. Chan Chui Ling, Ms. Lau Nga Yan, Mr. Lau Yuen Pan, Ms. Mok Po Chu, Ms. Lee Tim Yan, Ms. Ho Wai Yu, Ms. Lee Nga Yin, Ms. Ku Oi Shan
(2) Ms. Sherman ZHANG , Mr. Kenji KAM , Mr. Anson CHAN , Ms. Rita CHENG , Ms. Abby AU YEUNG
Affiliation :
(1) M&G Rehab, TMH
(2) NTWC PRC
Introduction :
Stroke is a critical cerebrovascular condition characterized by abrupt interruption of cerebral blood flow, leading to neurological impairments such as hemiparesis and aphasia. The sudden onset of the disease and its long-term consequences often leave families unprepared. An interface programme was established twenty years ago to ensure smooth transition from hospital to home following the commissioning at Rehabilitation Stroke Unit (RSU) of Pok Oi Hospital. The service has been extended to RSU and Acute Stroke Unit (ASU) at Tuen Mun Hospital afterward. Leveraging previous success, the programme has enhanced into a Medical-Social-Collaboration Patient Empowerment Programme (MSC-PEP) to enhance holistic patient care through collaboration with community partners after COVID.
Objectives :
To assess the effectiveness of MSC-PEP in improving stroke management capacity, fostering community resource utilization, and enhancing post-discharge care for patients and caregivers.
Methodology :
Between December 2023 and December 2024, MSC-PEP involved nurses, social workers, community service providers and peer support volunteers was implemented for hospitalized stroke patients preparing for discharge, and their caregivers. The programme consisted of three core elements: capacity building on stroke management, establishment of supportive network, and recognition and utilization of different social services. A self-constructed post-programme evaluation questionnaire was administered assessing the perceived improvement in stroke knowledge, practicability of homecare skills and awareness on community resources.
Result & Outcome :
Results
237 patients and caregivers joined the programme. Among the patients (M=65.06, SD=12.73), 62.6% were male, 81.6% were diagnosed with ischemic stroke, and 53.1% of them required walking aid upon discharge. 90% of attendee reported an improvement on understanding of stroke knowledge. 92.55% of them reported the acquired home-care skills were practical. 92.5% of them reported they found community resources helpful, which helped them to navigate through different social services for stroke rehabilitation. Participants also highlighted the benefits of peer sharing and demonstration of home exercise.
Conclusion
The MSC-PEP successfully enhanced stroke management capacity among patients and caregivers, fostered peer support, and improved awareness of community resources for post-discharge care. By strengthening medical-social collaboration, the programme facilitated smoother hospital-to-home transitions and promoted patient empowerment, enabling timely discharge and reducing reliance on institutional care. This intervention model demonstrates significant potential for replication in pre-discharge support initiatives for other chronic conditions, aligning with the objective of “sustainable healthcare”, which focus on community-based care and resource optimization.
