Authors (including presenting author) :
Lee SY, Hui CK, Yeung CH, Leung LM, Kong CY, Lam KH
Affiliation :
Department of Orthopedics & Traumatology, United Christian Hospital
Introduction :
Orthopedics rehabilitation requires a multidisciplinary approach, encompassing various healthcare professionals like physicians, nurses, physiotherapists, occupational therapists, prothesis & Orthosis therapists, and medical social workers. Effective collaboration among these disciplines ensures a comprehensive understanding of the patient's needs and goals, leading to individualized treatment plans and successful discharge scheduling.
Objectives :
Collaboration optimizes patient care by promoting communication and coordination among specialists form the basis of the case conference model. Key aspects include: 1) Review of medical records, clinical progress and relevant investigation results, 2) Physical evaluation by physical therapist or occupational therapist, 3) Cognitive and functional assessments to determine the patient's current abilities & limitations, 4) Social and emotional assessments to identify support systems & potential barriers to discharge. Selected case will hold separate case conference involving patient and family members as well, to explore any hiccups in the discharge process and facilitate the final discharge plan together.
Methodology :
The case conference model, a cornerstone of effective interdisciplinary collaboration, provides a structured platform for the healthcare team to discuss patient progress, identify challenges, and develop a unified discharge plan. Team members have regular meetings to share their perspectives and expertise, facilitating collaborative decision-making.
All the information about the patient's medical history, physical condition, functional limitations, and personal goals are discussed in the case conference. Relevant information from different parties is clearly documented in the standard comprehensive assessment form which act as a tool for tracking progress and communication among our team and patient’s family. Patient's social, emotional, and cognitive needs are covered. Based on the comprehensive assessment, the team formulates a personalized discharge plan, outlining specific goals, interventions, or need for support services to ensure a smooth transition to home.
Result & Outcome :
With the implementation of multidisciplinary partnership in discharge scheduling and planning for orthopedics patients in the Haven of Hope Hospital for one year since October 2023, more than 75% of newly admitted patients had comprehensive discharge planning and with discharge date set during the first meeting. Among those patients with discharge plan, more than 80% of them were able to complete rehabilitation as planned and be discharged according to schedule.
By embracing data-driven insights and continually evaluating the effectiveness of the discharge planning process, healthcare teams can optimize patient outcomes, promote patient well-being, and ensure a smooth transition back to the community for orthopedics patients.
Way forward:
In the future, by further analyzing patient’s demographic & clinical data, critical factors affecting prolonged length of stay, delay & cancellation of discharge can be determined. Furthermore, by using AI: 1) to predict length of stay, 2) optimal clinical resources allocation, 3) early identification of risk factors.
