Authors (including presenting author) :
Fu ML, Ng YB, Leung MW, Hung YL, Sze-To WY, Choi YW
Affiliation :
Department of Medicine & Geriatrics, United Christian Hospital
Introduction :
The increasing aging population with high service demand added strain to our healthcare system in Kowloon East Cluster. The capacity of in- patient service is limited which requiring us to develop a new service model to facilitate patient discharge and reduce unplanned readmission. A pilot program of Discharge Coordinator was implemented.
Objectives :
1.To improve quality of care & facilitate patient discharge back to community
2.To enhance health care workers’ awareness and knowledge on discharge planning and better utilizing community service
3.To enhance patients/ caregivers knowledge & confidence on their discharge
4.To increase the efficiency on convalescent bed utilization & reduce the wastage
Methodology :
Training
1. Two RN were selected as discharge coordinator in acute medical ward 12A & 12B.
2. One-week training in CNS and Integrated Care & Discharge Support (ICDS) unit were provided.
Selection Criteria
Discharge coordinators proactively screened every new admitted patient using Reported Edmonton Frail Scale.
Target patients were those: (1) HARRPE > 0.2, (2) repeated readmission <28 days, (3) poor social support with activity of daily living (ADL) impairment. We also reviewed those patients with length of stay >3days.
Early Multidisciplinary Collaboration
Once patients were admitted, apart from face-to-face patient assessment & education, discharge coordinators earlier collaborated with nurses, doctors, Allied Health, SPTT, ICDS, MSW, community service institutions and convalescent bed coordinator to streamline the discharge process and formulate an early discharge care plan.
Result & Outcome :
From 23/12/2019 to 31/7/2021 (total 8 months due to the suspension of the epidemic of COVID-19), the data showed that:
1)Increase the utilizing of community service, including CNS (35%), Enhanced CNS (14%), Case manager (9%) & Home support team (11%)
2)38% non-HARRPE cases required post discharge service support but not only the patients with HARRPE score >0.2. Our program filled in this service gap to provide post discharge support to those non-HARRPE patients.
3)Reduce the waiting time of Kowloon Hospital to 2.2-2.43 days
4)Reduce the waiting time of Haven of Hope Hospital from 4.5-4.6 to 3.1-3.23 days
5)Increase the number of patients discharge to convalescent hospital before 13:00, from 17% to 76%. Thus, more acute medical bed was available in the morning for emergency admission from AED so as to relieve access block.
6)In the satisfaction survey, all healthcare workers showed more effective on discharge planning and improve their communication with patients.
7)Over 95% patients showed satisfaction on the service.
As a result,it is a win-win program for patients and health care worker and hospital service to reduce convalescent bed wastage and relieve AED access block.
