Authors (including presenting author) :
Man YL(1), Wan J(1), Kwok PH (1)
Affiliation :
(1) Occupational Therapy Department, Pok Oi Hospital, NTWC
Keyword 1: :
Integrated Care Model
Keyword 2: :
Case Management
Introduction :
ICM-CM program is a collaborative initiative between hospital and community services aimed at facilitating safe and timely discharge of high-risk elderly patients. Occupational therapy (OT) optimizes patient-environment-occupation interactions, improving functional performance, enhancing home safety, and reducing caregiver burden. This review examines OT service in Pok Oi Hospital’s Case Management program from October 2022 to November 2025.
Objectives :
The primary objective was to evaluate the effectiveness of OT services by assessing improvement in functional independence, cognitive performance, successful home discharge rates and readmission rates, while identifying common patient characteristics and intervention patterns.
Methodology :
Data were extracted retrospectively from CDARS database and CMS records covering 359 patient entries and 3062 appointment records. Demographics, interventions, and clinical outcomes including Modified Barthel Index (MBI), Lawton IADL, Abbreviated Mental Test (AMT), Montreal Cognitive Assessment (HK-MoCA), and admission rates were analyzed. Paired t-tests and Wilcoxon signed-rank tests were used to compare the initial and final scores for patients with complete data.
Result & Outcome :
The cohort consisted of 359 patients (mean age 81, 47.4% female). Common diagnoses were cardiovascular (24.3%), respiratory (24%) and metabolic (10.1%). Nearly all patients received ADL training (99.7%), cognitive assessment/training (98.1%), home recommendations (98%), fall prevention (97.2%), IADL assessment/training (84.9%). Functional outcomes showed notable improvements across four metrics. The mean MBI score (n= 351) increased from 71.7 to 77.5 (mean gain +5.81). Paired t-test yielding t=12.21, p< 0.001 with Wilcoxon test (p< 0.001), indicating highly significant improved independence in daily activities. The mean Lawton IADL score (n=183) improved from 7.79 to 8.71 (+0.92 points). The highly significant results from the paired t-test (t=5.06, p< 0.001) and Wilcoxon test (p< 0.001) indicate a notable gain in IADL tasks like household management. The mean AMT score (n=297) improved from 6.8 to 6.92 (+0.12 points). The paired t-test (t=2.58, p=0.010) and Wilcoxon test (p=0.010) highlighting a significance gain. In terms of cognitive function, the mean HK-MoCA Score (n=106) rose from 14.93 to 15.16 (+0.23 points). The paired t-test (t=2.23, p=0.028) and Wilcoxon test (p=0.034) confirming significance cognitive gains. Greater OT sessions correlated with higher MBI gains (Low < 5 visits: +1.1; Medium 5-10 visits: +4.9; High >10 visits: +6.5; Kruskal-Wallis test p = 0.0008). Additionally, fall rates decreased from 1.2 to 0.8 per patient. Post program shows a positive effect on reducing half year admission rate (Paired t-test, p=0.016; Wilcoxon signed-rank test, p=0.0004). 49.9% of patients having fewer admission rate in the year post-program. 92.6% of patients was successfully discharged home (83.5% with family/ carers, 9.1% alone). Only 8% had change in living setting (14 to private old age home, 6 to others, 4 not available, 2 to other hospital). This suggests a strong effect of the program in supporting aging-in-place and community living. OT services in ICM program significantly enhance the functional outcomes and home safety. It plays a critical role in the transitional care for elderly patients with complex needs to return home safely, while contributing to a reduction in short-term readmissions.
