Frail elderly individuals often face complex medical issues requiring intensive care. The Integrated Discharge Support Program (IDSP) currently offers limited community nursing (CNS) and allied health services, lacking on-site medical support. This gap leads to increased attendance at Accident and Emergency Departments (AEDs) and frequent hospitalizations.
To address these needs, the Community Care Division (CCD) of the New Territories West Cluster (NTWC) launched the Integrated Care at Home (ICAH) Clinic for Frail Elderly with Chronic Diseases in 2018. The ICAH program involves home visits by geriatricians and nurses, in collaboration with the Allied Health Team, to provide medical consultations. This initiative helps alleviate the caregiving stress of family members and caregivers in the community.
During the COVID-19 pandemic, on-site visits became challenging, prompting the adoption of teleconsultations via Zoom. In 2020, the E-smart Vital program was piloted within the NTWC CCD. This program provided patients with sphygmomanometers, thermometers, and oximeters. Community nurses trained patients and caregivers to measure vital signs and upload the data to the Clinical Management System (CMS) for remote monitoring. Despite weak signals in some areas, the feedback was positive.
From February 2018 to February 2025, the ICAH clinic recruited 102 frail elderly individuals. Diabetes mellitus (DM) is a common chronic disease among this population, and 39 patients (38%) with DM participated. These patients frequently sought medical advice due to fluctuating blood glucose levels. Community nurses used structured triage questions to assess the severity of health issues and determine whether to recommend further medical consultations or continue monitoring. The results showed a significant decrease in mean AED attendance from 0.97 to 0.44 and a reduction in mean hospitalization days from 9.51 to 1.64, largely due to better DM management.
In conclusion, the ICAH program effectively addresses service gaps and enhances community care for frail elderly individuals. Future advancements in telehealth, such as electronic patient-reported outcome measures (ePROMs) via HA GO or other applications available 24/7/365, could further improve patient care by enabling timely interventions and facilitating closed-loop communication.
