Authors (including presenting author) :
Tam EMYY(1), Ho KS(1), Lau CC(1), Ng MF(1), Kwan YK(1), Chao FW(2), Kwok WY(2), Chan FC(2), Chan SM(2), Chu WY(2), Ho KL(2), Ip MF(2), Lau YM(2), Leung MH(2), Li YC(2), Ngai ON(2), Pang WS(2), Wong MHC(2), Yiu WKD(2)
Affiliation :
(1)Department of Medicine and Geriatrics, Tuen Mun Hospital (2)Community Care Division, New Territories West Cluster
Introduction :
Caring for community-dwelling frail elderly is challenging because of their complicated medical backgrounds. The lack of timely on-site medical support often leads to low threshold for AED attendance, frequent hospitalizations and discharge problems.
Objectives :
ICE program aims to support aging in place by establishing an on-site, need-based, integrated model to facilitate community frail elderly care. Secondary objectives include reducing AED attendance and hospitalization, empowering caretakers and relieving caretaker stress.
Methodology :
This geriatrician-led multidisciplinary program is carried out under close collaboration with CNS. Inclusion criteria include home-dwelling frail elderly with supportive caretakers, bedridden and functionally dependent, in need of intensive medical and nursing care, and preferably with frequent admissions or prolonged hospitalization. Regular community nurse visits and on-site medical follow-up by geriatricians are provided. Ad-hoc nursing phone consultations are available, supported by medical tele-consultation for acute medical problems if needed. On-site interventions such as subcutaneous fluids infusion and intravenous antibiotics are supported. Caretakers are empowered to perform procedures like oro-pharyngeal suction or use of narcotics in palliative care. Clinical admissions to dedicated geriatric wards and early post-discharge support are provided if necessary. Medical-social collaboration is involved to liaise for community support. Case conference is held regularly to review the progress of each case.
Result & Outcome :
From Feb 2018 to Dec 2021, 60 cases were recruited with a median age of 89. Median Clinical Frailty Scale was 8. 70% were female. 90% had advanced dementia. 30% had deep pressure injuries. 43% had recurrent sepsis within the past year. 4.7 nursing visits and 0.8 medical visits were provided per patient-month. In 3-month and 6-month pre- and post-program, mean AED attendance per patient decreased from 1.1 to 0.6 (P=0.001) and from 2.0 to 0.9 (P<0.001) respectively, while mean hospitalization days per patient decreased from 27.4 to 6 (P<0.001) and from 49.5 to 8.3 (P<0.001) respectively. Median Relatives’ Stress Scale decreased from 28/60 to 17/60 (P<0.001). To conclude, ICE program is able to fill the service gap to facilitate community care for very frail elderly.
