Authors (including presenting author) :
Yau KH(1), Man CHJ(1), Yeung KH(1), Chan YY(1), Yan FP(1)
Affiliation :
(1)Department of Physiotherapy, Yan Chai Hospital
Keyword 2: :
Integrated Care Model
Keyword 3: :
Chronic Disease Management
Keyword 4: :
Secondary Prevention
Keyword 5: :
Carer Empowerment
Introduction :
Effective stroke management requires a paradigm shift from episodic hospital treatment to continuous, seamless care. Aligning with the Hong Kong Government’s Primary Healthcare Blueprint and the Hospital Authority’s strategic direction to enhance community-based support and reduce hospital reliance, our department implemented the PHASE-ABC ([P]revention of [H]ospital [A]dmission (LOS and Re-admission) for [S]troke-survivors via [E]mpowerment - From [A]SU to reha[B], and back to [C]ommunity) model. While traditional discharge pathways often result in "fragmented care" and high readmission risks, this integrated model addresses the critical vulnerability in the patient journey: the transition from the ward to the home.
Objectives :
The primary objective of this project is to bridge the service gap between inpatient discharge and community living. By deploying a dedicated Case Manager, the initiative aims to empower stroke survivors to "age in place" safely. Specific goals include minimizing unplanned readmissions, alleviating caregiver burnout through targeted education, maximizing patients' functional independence in their actual living environments, and ensuring a sustainable connection to long-term community resources.
Methodology :
The framework is structured around the PHASE-ABC pathway: (1) Phase A ([A]SU- Assessment and Triage): Early identification of rehabilitation potential within the acute stroke unit; (2) Phase B (Reha[B]- Bridging ): Intensive inpatient therapy focused on functional recovery; (3) Phase C ([C]ommunity- Cotinuity): This is the core focus of the intervention. Upon discharge, patients are assigned a dedicated ICDS Case Manager. The methodology involves: (a) Home Visits: The Case Manager conducts on-site assessments to modify environmental risks and perform real-life functional training tailored to the patient's home; (b) Caregiver Empowerment: Personalized training on transfer techniques and nursing care is provided to family members to reduce strain. (c) Resource Linkage: The Case Manager actively triages and refers stable patients to District Health Centres (DHCs) and NGOs, ensuring a seamless handover for long-term maintenance.
Result & Outcome :
The PHASE-ABC model demonstrated significant efficacy in stabilizing patients post-discharge. (1) Service Efficacy: The program achieved a high success rate in Discharge Destination, with the majority returning directly home. Notably, the home visit intervention successfully prevented readmissions for stroke-related complications during the service period; (2) Triage Efficiency: The model validated a seamless workflow, with successful handovers of patients to community partners (DHCs/NGOs) upon program completion. (3) Clinical Improvement: Patients showed measurable gains in Functional Mobility and ADL independence following the home-based training [Datasets: MFAC, walking aid, mBI, EMS, BBS, TUAG, FR]; (4) Psychosocial Impact: Interventions successfully managed carer stress [Datasets: DASS, Caregiver Strain index], equipping families with the competence to manage complex care; (5) Service Feedback: Patient feedback highlighted high satisfaction, specifically citing the restoration of confidence in living in the community as a direct result of the Case Manager’s support [Dataset: Questionnaire of Service Feedback].
