Authors (including presenting author) :
Siu HY(1)(2), Lee KF(2), Law HS(2), O HH(2), Leung YK(1), Ip YW(1), Chao YL(2), Leung YY(1)(2)
Affiliation :
(1) Physiotherapy Department, North Lantau Hospital, (2) Physiotherapy Department, Princess Margaret Hospital
Introduction :
The Integrated Care and Discharge Support program (ICDS) is a transitional support service first launched by Hospital Authority in October 2011 for high-risk elderly patients, facilitating a smooth transition from hospital to home through medico-social collaboration. With a comprehensive interdisciplinary approach, it offers tailored medical, nursing, rehabilitation, and community services to meet individual needs. North Lantau Hospital (NLTH) had launched this program in October 2023, aiming at optimizing discharge planning and post-discharge care for patients residing in NLTH catchment area.
Objectives :
Physiotherapy aimed at (1) enhancing home-based rehabilitation for patients upon discharge and (2) facilitating their transition back to the community within this program. This review aims at evaluating the rehabilitation outcome for patients receiving physiotherapy ICDS services following the one-year implementation of the program.
Methodology :
Suitable candidates were identified by the link nurse based on specific criteria: aged 60 or older, discharged to home, and residing within the NLTH catchment area. Recruits were alternately referred to a Physiotherapist (PT) or another Allied Health (AH) discipline, who served as the case manager and provided personalized home-based rehabilitation for 6 to 8 weeks. If further support was needed, an interdisciplinary approach was implemented for referrals to other specialties, including the Geriatric Day Hospital when necessary. To ensure continuity of care, weekly case conferences involving physicians, nurses, and allied health professionals were held. A fast-track clinic was available for patients requiring immediate medical attention.
Outcome measures included Modified Functional Ambulatory Category (MFAC), Elderly Mobility Scale (EMS), and Modified Rivermead Mobility Index (MRMI). Time-points of evaluation were the in-patient discharge status versus completion of the physiotherapy IDSP service. Data were analyzed using paired t-tests.
Result & Outcome :
From October 2023 to September 2024, a total of 86 cases were recruited to PT as case managers, with an additional of 42 patients referred to PT from other disciplines. 59% of the cases were female. A total of 494 home visits were conducted by physiotherapists.
The median MFAC increased from 4 to 6, indicating a significant enhancement in the ambulation ability from assisted walker to independent indoor walker. While the mean scores of EMS improved from 10.7 to 14.8 (p<0.001) and MRMI from 18.4 to 25.8 (p<0.001). All outcome measures demonstrated statistical significance as well as clinical relevance, indicating that the patients experienced higher independence in their daily activities following the therapeutic intervention.
The present review of the IDCS program after one year of implementation showed that home-based physiotherapy service under the program effectively improved patients’ physical mobility and ambulatory performance.
