Integrated Care at Home: A Novel Home-Based Medical Care Program for Community-Dwelling Frail Older Adults in Hong Kong.

Abstract

Background: Caring for very frail community-dwelling older adults is challenging because of their complicated medical backgrounds. The lack of timely medical support leads to frequent Accident and Emergency Department (AED) attendance, prolonged hospitalizations, and discharge problems. Integrated Care at Home (ICAH) program aims to support aging in place by establishing an on-site, need-based, integrated medical care model, so as to reduce hospital burden and caregiver stress.

Methods: The ICAH program serves community-dwelling frail elderly who are bedridden, functionally dependent, in need of intensive medical and nursing care, and with frequent or prolonged hospitalizations, by providing regular on-site community nurse and geriatrician visits, ad-hoc consultations and caregiver support. This retrospective observational study included patients recruited to ICAH between February 1, 2018 to August 31, 2023. We reviewed our service provision, patients' demographics, 180-day AED visits and hospitalization days, and caregivers' 3-month Relative Stress Scale.

Results: Seventy-six patients were recruited with a median age of 90 and a median Clinical Frailty Scale of 8. Among them, 92% had advanced dementia, 30% had deep pressure injuries, and 43% had recurrent sepsis within a year; 3.7 nursing and 0.4 medical visits were delivered per patient per month. The 180-day AED attendance rates decreased from 15.3 to 3.2 per 1,000 PD (patient days) (p<0.001). Rates of hospitalization days decreased from 266.4 to 29.7 per 1,000 PD (p<0.001). Median Relative Stress Scale decreased from 24.5 to 16 (p=0.001) at 3 months.

Conclusion: The ICAH program is able to facilitate community care for the very frail elderly, significantly reducing their AED attendance, hospital stay, and caregiver stress.