Authors: (including presenting author): :
Lui WC(1)(2), Chow ESL(1)(2), Lee S(1)(2), Tse PM(1)(2), Tam WL(1)(2), Liang Y(1)(2), Chan LY(2), Cheng HWB(2), Ma YK(2) ,Hong YF(2), Yeung TCG(3)
Affiliation: :
(1) Tuen Mun Hospital Rehabilitation Centre and The WARM Team (2) Department of Medicine and Geriatrics, Tuen Mun Hospital (3) The Hong Kong Society for Rehabilitation and The WARM Team
Keyword 1: :
Motor neuron disease
Keyword 2: :
Transdisciplinary
Keyword 4: :
Rehabilitation
Keyword 5: :
Hospitalization
Introduction: :
Motor neuron disease (MND) is a rapidly progressive, fatal disorder causing severe functional decline and death mostly in 2-5 years. Tuen Mun Hospital (TMH) implemented a cross-specialty MND service in 2010, co-led by neurologists, rehabilitation specialists and palliative-care physicians, with support by respiratory physicians, gastroenterologists, allied health & nursing professionals. Patients under the care had a significantly longer median survival compared to patients who were not (20 months vs 9 months). Building on this foundation, a pilot day transdisciplinary specialist rehab service hub for MND was established in 2023 hoping to further support community rehab to better suits patient/family needs.
Objectives: :
To review and discuss the effectiveness of a local cross-specialty transdisciplinary comprehensive day rehab service hub model for MND patients and families.
Methodology: :
In the new pilot MND day rehab service hub, service redesign emphasized early one-stop rehab specialist comprehensive assessment as early as at the stage of suspected diagnosis, proactive disease course projection paired with anticipatory and tailored rehabilitation, and be supported with the timely provision of assistive technology, nutritional, respiratory and communication intervention, and intensive medico-social and psychosocial support; with regular review and timely rehab adaptation aiming to maintain patient in the community as far as possible. The centre also partnered with NGOs to form a medico-social integrative rehab team [the WARM Team]. On top of physical rehab and medical care, it expedited access to community funding and equipment, and strengthened caregiver/family support network.
Result & Outcome: :
After the implementation of MND day rehab hub in 2023, Institutional inpatient days per MND patient during 2023-2025 were 31.5 days, which was reduced compared to the 56 days for the period 2005–2019 before the implementation of day rehab service hub. While a Neuro-Rehab-Palliative cross-specialty service model showed evidences of a longer MND patient survival in local patients, further service enhancement with a MND transdisciplinary day-rehab hub provided a better support for community living among MND patients, with improved quality of life, reduced hospitalization and associated healthcare cost savings. It also transformed the patient paradigm from simply "living longer" to truly " living to the fullest".
