Bridging the Gap: Win-win from
Integrated Discharge Support
for Elderly Patients
Community collaboration project in elderly services
HA Convention 2011
7 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
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
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
Integrated Discharge Support Program for the
Elderly Patients (IDSP)
4
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
01-Mar-08
01-Mar-09
started in TMH on 1-Jul-09
01-Mar-10
01-Mar-11
5
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
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
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
Discharge
(by DPT and/or
by the HST)
Residential
Care Homes
(CGAS/CNS)
Home
On need basis
Clinic visits
Rehab at GDH
Home visit
Telephone
consultation
Case conference: review/ discharge from scheme
Home care
support by HST
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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
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
Outcome
 Functional outcome
 Stress level of caregivers
 Hospital services utilisation
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Time points for collection of outcome measures
Discharge
Home
Admission
to Hospital
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.
Barthel Index (BI20)
(A)
(B)
Screening & Discharge
Recruitment
Home
(A)
Screening &
Recruitment
(C)
Case Close
(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
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Modified Functional Ambulation Category
(MFAC)
(A)
(B)
Screening & Discharge
Recruitment
Home
(A)
(B)
Screening & Discharge
Recruitment
Home
(C)
Case Close
(C)
Case Close
Among ALL cases (N = 3,200)
At (A) Screening
& Recruitment
(A)
(B)
Screening & Discharge
Recruitment
Home
Percentage of Cat. VII increased over time.
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
(C)
Case Close
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SF 12 (12-item Short Form)
3.7*
6.2*
(N = 1,726)
Increases in average PCS and MCS from (B) Discharge Home
to (C) IDSP Case Close are both statistically significant.
* statistically significant at 5% level.
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Relative Stress Scale (RSS)
(B)
Discharge
Home
(B)
Discharge
Home
(C)
Case Close
(C)
Case Close
At (B) Discharge Home
Among ALL cases (N = 1,322)
Precentage of Low Risk cases increased over time.
0 – 23
23 – 30
30 – 60
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: 195–202.
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Hospital Services Utilisation
Change
Post-discharge Hospital
Services Utilisation
HA-wide predicted risk score on elderly
A&E admission#
0 – 0.2
No
0.2 – 0.4
Overall
0.4+
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.
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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.
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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
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.
Discharge Planning Team (DPT)
Timely assessment
and discharge planning
Telephone nurse consultation service
Rehabilitation at GDH
Fast track clinic
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Home Support Team (HST)
Home visit
Rehabilitation exercise
Caregivers training
Sharing Electronic Patient Record
22