Proposed Topic (Most preferred): :
Clinical Safety and Quality Service III (Projects aiming at quality service to patients and their carers)
Proposed Topic (Second preferred): :
Clinical Safety and Quality Service I (Projects aiming to improve efficiency and effectiveness of care delivery to meet international standards)
Authors (including presenting author) :
Yam CHK, Wong ELY, Cheung AWL, Chow TY, Ip EMY, Yeoh EK
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 :
The "Extended Pilot Scheme on Support for Elderly Persons Discharged from Public Hospitals After Treatment" was an extension of a successful three-year pilot and aimed to provide transitional home care (THC), day care (TDC) or residential care services (TRC) for elderly patients discharged from public hospitals. Under the new mode of operation, a Transitional Care Team (TC Team) formed by selected NGOs was established in three HA clusters to formulate appropriate nursing, rehabilitation, and care support plans for elderly patients for a maximum period of four months.
Objectives :
This study was to evaluate the effectiveness of the Extended Pilot Scheme in providing transitional care and support services and identify key elements of the design and implementation which affected effectiveness from the interim findings.
Methodology :
A mixed method design was adopted using the Implementation Science approach to identify determinants in the implementation process which affect the effectiveness: (a) administrative data from the TC Teams; (b) two rounds of key informant interviews with policymakers, HA management and TC Teams; (c) focus group discussions and semi-structured individual interviews with elderly patients/ their carers, HA frontline staff and transitional care services providers; and (d) longitudinal questionnaire survey with elderly patients/ their carers.
Result & Outcome :
This study presents an interim analysis of the Extended Pilot Scheme. The administrative data (from Oct 2021-Jan 2022) showed a high participation rate (85.3%) in the three clusters from HA referrals. Most of the service users were hip fracture patients (68.2%) and stroke patients (27.3%). Transitional home services, including rehabilitative services, basic nursing care service and carer support services, were the most frequently used services (62.1%).
The new model of operation demonstrated effectiveness in enabling patients to regain a level of physical functionality to age in place, and providing support to carers and time to make appropriate arrangement for elderly patients. Positive feedback were received on the design of the new model, particularly in contracting TC teams for improved coordination with service providers, service fees, and service delivery. The need for early communication at frontline level, better sharing of clinical and social information, and synchronization of different post-discharge programmes are identified.
Throughout the course of the Extended Pilot Scheme, all parties contributed actively to enhance communication and improve services operational flow. The study highlights the need for a common assessment tool to quantify needs and guide referral, and the importance of developing an electronic medical and social record-sharing platform. To enhance consistency and coordination of services, consideration should be given for Extended Pilot Scheme to be integrated with the Integrated Discharge Support Program to better meet patients’ needs.
We acknowledge Social Welfare Department and Community Care Fund for funding this project and enabling the data collection and analysis.
