Bridging the Gap: Win-win from Integrated Discharge Support for Elderly Patients

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1 Bridging the Gap: Win-win from Integrated Discharge Support for Elderly Patients Community collaboration project in elderly services HA Convention June 2011 Dr MF NG Dr KY SHA Dr BC TONG Associate Consultant (Medicine & Geriatrics), Tuen Mun Hospital Senior Medical Officer (Medicine & Geriatrics), United Christian Hospital Senior Medical Officer (Medicine & Geriatrics), Princess Margaret Hospital 1

2 譚 伯 (77 歲 ) Medical history: Dementia/HT/Urge UI/Gout Admitted for flare up of gout with elbow & wrist pain Wife tearful and attended A&E for sprain shoulder Patient wet bed and clothes and his wife failed to transfer patient 2

3 What causes repeated readmissions? Elderly most vulnerable group to have discharge problems lack of coordination on transitional care lack of communication during care transfer short length of stay patient discharged with unresolved issues

4 Integrated Discharge Support Program for the Elderly Patients (IDSP) 4

5 IDSP piloted in three districts: Kwun Tong started in UCH on 1-Mar-08 Kwai Tsing started in PMH on 1-Aug-08 Tuen Mun started in TMH on 1-Jul Mar Mar Mar Mar-11 5

6 Program Objectives To establish integrated care teams comprising of medical and welfare staff to plan for hospital discharge and provide community support for frail elderly patients. To prevent hospital re-admission through community-based rehabilitation and / or support services. To enhance support and training to caregivers to relieve their stress from postdischarge care of the elderly. 6

7 Target Patients Elders aged 60 or above HA-wide admission risk prediction score* > 0.2 or by clinical referral High readmission risk [e.g. those diagnosed with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD)] High rehabilitation needs (e.g. those with stroke, proximal hip fracture or falls) High personal care needs (e.g. those with dementia, parkinsonism) * The score is the predicted probability of emergency admission to medical ward of any HA hospital within 28 days after an index episode, including medical emergency admission and A&E attendance for medical condition, in which the elderly patient was discharged alive. 7

8 Process Hospital DPT Screen, assess and recruit high risk elders Conduct multi-dimensional assessments Develop pre and post discharge care plan Home assessment Caregivers training & empowerment (by DPT and/or by the HST) Discharge Home Residential Care Homes (CGAS/CNS) On need basis Clinic visits Rehab at GDH Home visit Telephone consultation Home care support by HST Case conference: review/ discharge from scheme 8

9 譚 伯 Needs identification and progress review Discharge and long term care planning On discharge: Discharge Planning Team to provide: Medical treatment Priority attendance for Geriatric Day Hospital rehabilitation Home Support Team to provide: Home visit for personal and respite care Home based rehabilitation Caregivers training 9

10 譚 伯 Functional improvement Stable condition No hospital re-admission within one year Living at home Quality of life improved can join social events with relatives Wife is less stressed, able to take care of her husband 10

11 Outcome Functional outcome Stress level of caregivers Hospital services utilisation 11

12 Time points for collection of outcome measures Admission to Hospital Discharge Home A. Screening & Recruitment B. Discharge Home C. Case Close (A) (B) (C) Barthel Index 20 Modified Functional Ambulation Category SF12 (12-item Short Form) Relative Stress Scale Collection of measures on Functional Outcome, Quality of Life Measures and Carers Stress Level at different time points.

13 Barthel Index (BI20) (A) Screening & Recruitment (B) Discharge Home (C) Case Close (A) Screening & Recruitment (B) Discharge Home (C) Case Close Among ALL cases (N = 3,091) At (A) Screening & Recruitment Percentage of Moderate-to-mild / No limitation cases increased over time. * The cutoff for severe limitation is based on J. Woo, S. C. Ho, L. M. Yu, J. Lau, and Y. K. Yuen, Impact of Chronic Diseases on Functional Limitations in Elderly Chinese Aged 70 Years and Over: A Cross-Sectional and Longitudinal Survey, Journal of Gerontology: MEDICAL SCIENCES 1998, Vol. 53A, No. 2, MI02-MI06 13

14 Modified Functional Ambulation Category (MFAC) (A) Screening & Recruitment (B) Discharge Home (C) Case Close (A) Screening & Recruitment (B) Discharge Home (C) Case Close Among ALL cases (N = 3,200) At (A) Screening & Recruitment Percentage of Cat. VII increased over time. (A) Screening & Recruitment (B) Discharge Home (C) Case Close Cat. I Cat. II Cat. III Cat. IV Cat. V Cat. VI Cat. VII Lyer Sitter Dependent Walker Assisted Walker Supervised Walker Indoor Walker Outdoor Walker 14

15 SF 12 (12-item Short Form) 3.7* 6.2* Increases in average PCS and MCS from (B) Discharge Home to (C) IDSP Case Close are both statistically significant. * statistically significant at 5% level. (N = 1,726) 15

16 Relative Stress Scale (RSS) (B) Discharge Home (C) Case Close (B) Discharge Home (C) Case Close Among ALL cases (N = 1,322) At (B) Discharge Home Precentage of Low Risk cases increased over time Low Risk Moderate Risk High Risk (B) Discharge Home (C) Case Close Reference: Ulstein, I., Wyller, T. B. and Engedal, K. (2007), High score on the Relative Stress Scale, a marker of possible psychiatric disorder in family carers of patients with dementia. International Journal of Geriatric Psychiatry, 22:

17 Hospital Services Utilisation Change Post-discharge Hospital Services Utilisation HA-wide predicted risk score on elderly A&E admission # No Overall Emergency Admission to Medical Ward * * * Acute patient days in Medical Ward * * * Attendance in Accident & Emergency Department * * * * * statistically significant at 5% level. # The score is the predicted probability of emergency admission to medical ward of any HA hospital within 28 days after an index episode, including medical emergency admission and A&E attendance for medical condition, in which the elderly patient was discharged alive. 17

18 2010 Policy Address: Through collaboration between the welfare and healthcare sectors, the programme has been effective in helping elderly patients discharged from the hospital to recover at home. We plan to make it (IDSP) a regular service and extend its coverage from the current three districts to all districts in two years' time. 18

19 Thanks to our collaborating partners Discharge Planning Teams: Home Support Teams: United Christian Hospital Haven of Hope Christian Service Princess Margaret Hospital Po Leung Kuk Tuen Mun Hospital Evangelical Lutheran Church Social Service Hong Kong

20 What is HARRPE score? HARRPE score is the predicted probability of emergency admission to medical ward of any HA hospital within 28 days after an index episode, including medical emergency admission and A&E attendance for medical condition, in which the elderly patient was discharged alive. The higher the score, which ranges from 0 to 1, the higher is the likelihood.

21 Discharge Planning Team (DPT) Timely assessment and discharge planning Rehabilitation at GDH Telephone nurse consultation service Fast track clinic 21

22 Home Support Team (HST) Home visit Rehabilitation exercise Caregivers training Sharing Electronic Patient Record 22

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