Authors (including presenting author) :
Ip CK (1), Chan F (1), Tai WK (1), Choy YH (1), Tse LYT (2), Leung KK (1), Chan CCE (3), Cheung, WT (4), Chung SM (1)
Affiliation :
(1) Department of Psychiatry, Tai Po Hospital
(2) Occupational Therapy Department, Tai Po Hospital
(3) Clinical Psychology Department, North District Hospital
(4) Physiotherapy Department, Tai Po Hospital
Introduction :
Repeated admissions for residents in the Learning Disability (LD) Hostel or other residential hostels like Halfway houses (HWH) or private hostels is a common issue in psychiatric settings. This trend significantly impacts the community adaption among those with LD. In response, a proactive care coordination trial, an innovative and forward-thinking approach, has been implemented in male LD Settings in Tai Po Hospital since 2/2023. This trial includes assigning a care coordinator to act as a liaison person with the hostels, organising hostel visits to understand the specific challenges such as medication management, behavioural management, and staff training needs, and biweekly case discussions with the whole LD team to enhance case formulation and implementation.
Objectives :
To evaluate the effects of implementing proactive care coordination on hospital utilisation and user experience
Methodology :
A prospective review has been conducted on the recruited participants. The yearly admission and unplanned readmission rates one-year-before and one-year-after index admission have been evaluated. Also, comments from LD hostels and other residential hostels were collected as part of the user experience.
Result & Outcome :
From 2/2023 to 11/2023, 16 male clients have been enrolled in this trial. They have an average age of 37.3 + 10.7 years old, and 81.3% are moderate-grade LD. They resided in 11 different LD hostels, HWHs or private hostels. The preliminary effects are encouraging, as the yearly admission rate dropped from 1.56 times/year to 0.96 times/year (A reduction of 38.5%), and the yearly unplanned readmission dropped from 0.56 times/year to 0.37 times/year (A reduction of 33.9%). Moreover, hostels have identified increasing communication platforms between hospitals and hostels, narrowing the difference in care between hospitals and hostels as the main comments towards the trial. This positive feedback from the users, a testament to the effectiveness of the trial, provides reassurance about the potential of care coordination in LD cases and instils confidence in the approach.
Implementing care coordination has proven effective, feasible and practical in psychiatric settings. With promising outcomes and positive feedback from service users, the trial has been expanded and will benefit more LD patients residing in hostels. This success story provides reassurance about the potential of this approach, instilling hope for the future of care coordination in LD cases.
