Authors (including presenting author) :
CHIU YY(1), LEUNG YL(2), CHAN KY(1), CHAN KH(1)
Affiliation :
(1)Integrated Care and Discharge Support for Elderly-Patients, Kwong Wah Hospital, (2)Gerontology, Central Nursing Division, Kwong Wah Hospital, Kowloon Central Cluster
Keyword 1: :
Collaboration
Keyword 2: :
Cross-Specialty
Keyword 5: :
Accident and Emergency
Keyword 6: :
Kwong Wah Hospital
Introduction :
KWH Geriatric Support in A&E, Geriatric Emergency Medicine (GEM), serviced tackling the densely populated aging community. As a Cross-Specialty Gate-Keeping Service at the Front-Door of Hospital, GEM brings together clinical-expertise and best-practices, applying timely Comprehensive Geriatric Assessment (CGA), the Gold Standard for managing frailty, identifying complex needs early, preventing unnecessary delays, maximizing patient-flow with safe community reintegration and seamless continuum.
Objectives :
(1)Address individual’s specific needs to facilitate conjoint care-planning and A&E direct discharge with community support proactively. (2)Ensure safe-discharge to reduce unplanned A&E reattendance/readmission. (3)Promote elderly-patient-centered-care to enhance quality-of-life.
Methodology :
(1)Rapid CGA and Triage: Conducting prompt screening and personalized discharge-planning for borderline-admission elderly-patients aged 65 or above, diverting them to transitional care and guiding clinical decisions. (2)Community Healthcare Service (CHS) and Medical-Social Collaboration (MSC): Well-coordinated Multidisciplinary Team (MDT) collaboration with regular Case Conferences, providing ongoing evaluation to overcome barriers and empower both elderly-patients and carers for better self-management. (3)Phone-Follow-up (FU) Service on Day-1 and Day-28: 28-Day Post-Discharge-Support along the recovery-phase, reinforcing treatment adherence and educate appropriate resources utilization.
Result & Outcome :
(1)Quantitative Outcome: Total 1506 elderly-patients enrolled (January - November 2025), Direct Discharge from A&E(60.89%); 28-Day without A&E Reattendance/Readmission(80.01%); 28-Day A&E Reattendance/Readmission(17.40%, excluded 2.59% A&E-FU/Call-Back/Transfer-In); Community Support(CHS/MSC Referral: 606; Phone-FU: 859). Analysis: Top 5 Reasons for CGA Referral are Pain(888), Hypertension(640), Limbs Weakness(610), Falls(534) and Syncope/Dizziness(382). Top 5 Same Causes for A&E Reattendance/Readmission are Pain(53), Skin Problems/Herpes Zoster(15), Foley-Catheter Issue(15), Repeated Falls(12) and Syncope/Dizziness(8). (2)Qualitative Outcome: Written Appreciations obtained from elderly-patients, reflecting gratitude and high satisfaction across Patient-Journey upon A&E arrival to returning home with CHS/MSC. In conclusion, systematic widespread collaboration is of paramount importance for meaningful impacts to patients and healthcare services alike. First, professional discretion in initial screening ensures those most in need benefit. Second, holistic MDT input for frequent A&E attenders, raises awareness focusing on addressing the needs for the common causes of A&E Reattendance/Readmission to enables the right-care at the right-setting. Third, strengthen healthcare policies further enhance services efficiency, including Fees/Charges Reforms, and accommodating A&E-FU/X-Ray/Imaging accessibility in Primary Care. Overall, the encouraging outcomes demonstrate service sustainability and highlight the excellent initiative in promoting “Hospital at Home” and helping elderly stay healthy in the community.
