Authors (including presenting author) :
Cheng JN (1), Leung CP (1), Wong CW (1), Lee P (1), Chan WL (2), Ngan YYJ (3), Leung CS (1)
Affiliation :
(1) Department of Medicine and Geriatrics, Caritas Medical Centre, (2) Department of Physiotherapy, Caritas Medical Centre, (3) Department of Occupational Therapy, Caritas Medicaine
Introduction :
With the rapidly growing ageing population of Hong Kong, more elderly people are residing in the Residential Care Home for Elderly (RCHE). These groups of elderly people are mostly frail and in need of frequent medical and nursing supports, otherwise, they may have frequent admissions to the hospitals due to various problems. In fact, the rate of unplanned readmissions in patients residing in RCHE is high. Our Community Geriatric Assessment Service (CGAS) has a multidisciplinary team, which consists of Geriatricians, Geriatric nurses, Physiotherapists, Occupational Therapists and Social Workers. We work together to provide timely assessment and appropriate management to elderly people in RCHE. In order to tackle the problems of frequent unplanned readmissions of these high risk groups of people, we have launched a pilot program of Multidisciplinary Team Joint Visits, specifically targeting these groups of patients.
Objectives :
1. To provide multidisciplinary assessment and management to frail elderly patients in RCHE through joint visits. To maintain the mobility, function and well-being of our elderly patients by inputs of expertise from different disciplines, 2. To decrease the re-admissions rate of these patients by targeted interventions decided by the multidisciplinary team in joint visits. 3. To educate and reinforce staff in RCHE caring techniques and problems solving skills
Methodology :
Multidisciplinary Team Joint Visits were arranged monthly. Patients residing in the RCHE with frequent repeated admissions were targeted. During the visits, Geriatricians, Geriatric Nurses, Physiotherapists and Occupational Therapists assess the patients at the same time at the RCH. Reasons for the frequent readmissions were explored together, interventions and management plans were discussed and then conveyed to the RCHE staff on site at the same time. Education to the RCHE staff was done when problems identified.
Result & Outcome :
In 13 months’ time, 11 Joint Visits were done in 14 RCHE. A total of 33 patients with frequent repeated admissions to our hospital were assessed by our multidisciplinary team. The patients had an average age of 84.1, 40% of them were male. They had an average of 3.1 admissions (2-7 times) within 3 months before our joint visits, 81% of these admissions were due to respiratory conditions (e.g. chest infections, COAD, sputum retention). Four patients died within 3 months after the Joint Visits. When compared the number of admissions 3 months before and after the joint visit, the wilcoxon signed-rank test showed significant reduction, with median number of admission reduced from 3 to 1 ( Z= -3.4921, p value: 0.00048). It showed that our Multidisciplinary Joint Visits can reduce the repeated admissions of our patients residing at the RCHE.
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