Outcomes of an integrated care model for high risk older patients discharged from acute hospitals in Hong Kong

Background: the Integrated Care and Discharge Support (ICDS) Programme was introduced in 2012, targeting older patients discharged from acute medical wards in a major teaching hospital in the north-eastern part of Hong Kong. The catchment area has a population 0.7 million, of which 11% or 77,000 are aged over 65 years. A statistical model that predicts the early (28-day) unplanned readmission rate in older patients is applied daily to all acute medical admissions. Those predicted to have > 30% chance of readmission will be assessed by a Link Nurse who will formulate discharge plans and assign post-discharge supporting services including intensive support by clinical case managers, home and personal care provided by social services and rehabilitation at the Geriatric Day Hospital. The above services are not mutually exclusive, and patients will spend on average 8 weeks in the programme

Acute care · Health care · Integrated care · Medical emergency · Political science · Chronic Disease Management Strategies · Healthcare Systems and Practices · Healthcare Systems and Reforms · Medicine