Proposed Topic (Most preferred): :
Clinical Safety and Quality Service II (Projects aiming to enhance clinical safety and outcomes, clinical governance / risk management)
Authors (including presenting author) :
Lin OY (1), Yung SY (2), Chan WK (3), Kwong WF (2), Leung KC (2), Luk KH (1)
Affiliation :
(1) Medicine and Geriatrics, Fung Yiu King Hospital
(2) Orthopedics and Trauma, Queen Mary Hospital
(3) Community Care Services, HKWC
Introduction :
‘Revolving door syndrome’ was a phrase coined by Gordon in 1995 to describe the problem of recurrent return of older people to hospital shortly after discharge. Readmission is common among medical patients, especially the elderly population, and is a poor outcome for the health care system. Integrated Care and Discharge Support (ICDS) a HAHO and Government supported program implemented in all 7 clusters aiming to provide post discharge support to the elderly discharging from medical ward to reduce their unplanned readmission. ICDS has rolled out in HKWC Medical ward and AED Emergency (EM) ward since 2012. Lead geriatrician and link nurses would identify the patients with high readmission risk in these wards. Then these patients would be offered post discharge support of either home visits by case managers or community support by NGO such as meal delivery, household cleaning, respite care, and home assessment and modification etc. In Oct 2023, with funding support from the Governm
Objectives :
To provide post discharge support to hip fracture patient in HKWC
Methodology :
In June 2023, working group “ICDS implementation for Geri hip fractured patients” was formed. Work flow of case referral and recruitment in QMH, FYKH and MMRC was established in Aug 2023. Two identical road shows of ICDS introduction to orthopedics doctors and nurses were performed in QMH and FYKH/MMRC on 30 Aug 2023 and 28 September 2023 respectively. The ICDS service was then implemented in orthopedics ward hip fracture patients on 1 Oct 2023.
Result & Outcome :
The ICDS service was then implemented smoothly in orthopedics ward hip fracture patients on 1 Oct 2023. 31 patients have been recruited to receive post discharge service since then. Depends on patient need, these patients may be allocated to receive home visits with home base rehabilitation by case managers or community support by NGO to receive meal delivery, household cleaning, respite care, and home assessment and modification etc.
