Authors (including presenting author) :
Ho WH(3), Cheng PL(2), Lee CM(3), Kwan WY(3), Siu TS(3), Po MY(2), Wong CW(1), Wan MC(1), Chan YYR (4), Leung KC(4)
Affiliation :
(1) Division of Geriatrics, Department of Medicine & Geriatrics, Ruttonjee & Tang Shiu Kin Hospitals (2) Community Healthcare Services, HKEC (3) Community Geriatric Assessment Team, Ruttonjee & Tang Shiu Kin Hospitals (4) Department of Medicine & Rehabilitation, Tung Wah Eastern Hospital
Introduction :
Integrated Discharge Support Programme for Elderly Patients (IDSP) under the Integrated Care Model for High Risk Elders (ICM) has been implemented in HKEC since 2011, aiming at “building up an integrated system & service delivery model for transitional care for high risk elderly patients through better discharge planning & post discharge support services thereby keeping patients stable in the community & preventing avoidable hospital admission”. In view of increased service demand on inpatient discharge support due to the ageing population, increased complexity of chronic diseases & social support needs in the community, the extension of ICM service was rolled out in all clusters in 4Q2023 along with Government’s direction. Under this occasion, in additional to service extension in RTSKH, the coverage of ICM/IDSP would be extended to inpatient of TWEH in order to maximize the coverage among HKEC.
Objectives :
1. To illustrate the process of ICM extension in TWEH to facilitate discharge planning & post-discharge support. 2. To evaluate the 1-year outcome after the extension.
Methodology :
Patients aged >60 years admitted to TWEH would be assessed by RH ICM Link nurse under the following criteria: i) Inpatient clinical referral to RH ICM Link Nurse (LN) ii) HARRPE Score >0.2 without assessment in PYNEH. iii) Proactive on-site screening by RH ICM LN, especially patients with recent hip or fragility fracture & stroke. Onsite assessment and discharge planning was performed in TWEH 3 times per week. Suitable patients would be advised & referred to different community support services on discharge such as RH ICM Case Manager (CM), NGO Home Support Team (HST), transitional respite (TR) bed, CNS, GDH etc. An on-line survey was launched in Dec 2024 to collect feedback from TWEH clinical staff on the service extension.
Result & Outcome :
1126 patients were assessed by LN onsite in TWEH from 10/2023-9/2024: 149 patients (13.2%) were proactive assessment by LN, 492 patients (43.7%) were recruited under HARRPE score >0.2, & 485 patients (43%) were by clinical referral. Among all the assessed cases, a total of 401(35.6%) cases were recruited to provide home support after discharge, in which 324 (80.7%) cases were new referred to HST, 77 (19.3%) cases were referred to CM for further management. For the Staff Feedback Survey, total of 52 TWEH clinic staff (Drs, nurses & MSW) returned the online survey. 98% of respondents agreed that LN’s onsite assessment in TWEH could effectively assist in patients’ discharge & all of them agreed that this ICM/ICDS extension helped in facilitating patients’ discharge in TWEH. Among all kinds of discharge supports, discharge planning & HST were rated as the best services in facilitating patient’s discharge.
