Authors (including presenting author) :
Yam CHK (1), Wong ELY (1), Cheung AWL (1), Chow TY (1), Ip EMY (1), Yeoh EK (1)
Affiliation :
Centre for Health Systems and Policy Research, The Jockey Club of School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong
Introduction :
A “Pilot Scheme on Support for Elderly Persons Discharged from Public Hospitals After Treatment” was implemented by Social Welfare Department in collaboration with Hospital Authority since February 2018 through a medical-social collaboration model to enable elderly people discharged from hospitals in three pilot clusters including Kowloon East Cluster, New Territories East Cluster, and New Territories West Cluster to receive transitional care of not more than 6 months so as to facilitate rehabilitation and prevent premature long-term institutionalization for the elderly which enables ageing-in-place.
Objectives :
This paper is to assess the effectiveness of the discharge support programme in improving the functional status of elderly patients and reducing hospital readmission.
Methodology :
A face-to-face/ telephone longitudinal questionnaire survey were conducted at two time-points among elderly patients/ carers between October 2019 to January 2021. The elderly patients were firstly interviewed within a month following admission to the discharge support programme, and then followed up after completing the discharge support programmes.
Result & Outcome :
199 users had completed both baseline and follow-up questionnaire survey. Most of them were hip fracture (63.3%) and stroke patients (25.1%). Among them, 46.2% received transitional residential care services (TRCS), 40.7% received transitional community care services (TCCS), and 13.1% received both services.
Users’ functional status, in term of modified Barthel Index and Lawton Instrumental Activities of Daily Living (IADL), significantly improved at the follow-up survey. Regarding the Barthel Index, the proportion of “total” and “severe” degree of dependency at the baseline survey decreased significantly from 60.2% to 45.5% at the follow-up (P-value at < 0.001). Lawton IADL’s mean score was improved from 3.99 at baseline to 4.84 at follow-up survey (3.99) (P-value at 0.003) (the higher the score, the better the independency). Multivariate analysis showed that older patients, those with carer, living with carer/ family/ elderly home, and longer duration of services had a relatively less improvement in functional status. Among the elderly patients with records of hospitalization, only a few proportion had an unplanned readmission.
Overall, the discharge support programme is effective in facilitating the rehabilitation of the elderly patients, and providing suitable transitional care and support services to the elderly patients.
We acknowledge Social Welfare Department in funding this project and assisting in the data collection and analysis.
