Authors (including presenting author) :
Ma J (1), Li MT (1), Ko CM (1), Wong WK (1)
Affiliation :
(1) Department of Medicine, North District Hospital
Keyword 1: :
Early Rehabilitation
Keyword 2: :
New Service Model
Keyword 3: :
Multidisciplinary
Introduction :
Hospitalized elderly are at risk of functional and cognitive decline with prolonged stay and use of convalescence beds. Early rehabilitation is cost-effective in preventing hospitalization-related deterioration. Currently, patients with low Hospital Admission Risk Reduction Programme for the Elderly scores may not be proactively screened by the Integrated Care and Discharge Support Programme. The Early Rehabilitation for the Aged (ERA) Programme aims to address this service gap.
Objectives :
1) To prevent deconditioning of hospitalized elderly through a proactive, protocol driven, and multidisciplinary approach with emphasis on early rehabilitation once medically fit. 2) To create a culture of early and direct discharge to the community through early initiation of discharge planning and arrangement of post discharge services.
Methodology :
All patients admitted to the acute medical ward were screened to identify groups at risk of prolonged hospitalization. Inclusion criteria include age > 65, marginal social support and admitted for stroke. Flagged patients would be referred to allied health (AH) professionals for rehabilitation on day one of admission. Suitable patients would also have mobility exercises preemptively arranged over weekends and holidays, where AH services are not routinely available. Exploration of discharge planning with family by nurses and doctors was also done within day one of admission to expedite referrals to relevant post discharge services including social workers, community AH team, day rehabilitation centers, and specialty nurse services.
Result & Outcome :
Between March and August 2023, a total of 959 patients were recruited across 10 medical wards under the ERA Programme. Of these, 59% received physiotherapy care and 20% received occupational therapy care. Apart from the first month, patients under ERA consistently demonstrated a shorter length of stay compared to the overall medical ward population (May 2023 ERA group 6.6 days vs overall medical 6.7 days, June 2023 6.5 days vs 6.7 days, July 6.1 days vs 7.1 days, Aug 2023 4.9 days vs 6.5 days). In addition, 91% of patients were directly discharged home rather than transferred to convalescence beds. The ERA Programme was effective in the early identification of high-risk elderly patients, delivering targeted rehabilitation interventions, and facilitating smoother patient transitions. By maximizing the role of multidisciplinary professionals and adopting protocol-driven services, ERA offers a promising new service model to improve patient pathways, reduce hospitalization burden, and enhance discharge outcomes.
