Seamless transition to the community and a shorter Length of Stay (LOS) at hospitals are considered priorities in many health care systems. In Hong Kong, Hospital Admission Risk Reduction Program for the Elderly (HARRPE)1 - a risk prediction tool has been used by hospitals to facilitate discharge of older patients and minimize the need for hospital or emergency re-admission. Older patients score > 0.2 and present greater social-care needs than medical issues will be followed up by a community NGO, in service partnership with the hospital, through an 8-week, home-based, Intensive Discharge Support Program (IDSP)2. Apart from evaluating the success in admission risk reduction, this study was also to assess the program’s effects on patients’ health status and well-being for both discharged patients and family carers, and to understand the underlying supportive mechanism of IDSP.

A mixed-method approached was used, as establishing control groups was not feasible due to both ethical and practical concerns. Structured interviews integrating standardized instruments were employed to evaluate changes in outcome variables pre-and-post IDSP intervention for both the discharged patients and their carers. To complement the quantitative data, two focus groups involving 9 carers were organized to explore the essential and critical service elements of the discharge program, including their effects on promoting patients’ wellbeing or alleviating caregiver burden.

48 patient-carer dyads were recruited from the discharge program, with 35 pairs (73%) successfully completed both pre-and-post IDSP interviews. 68.6% of the discharged elders had no hospital readmission during the 8-week in IDSP. While there were statistically significant improvement in ADL, IADL (p<0.001), the environment domain of WHOQOL(p<0.05), and 3 other domains measured by the Health Status Questionnaire (HSQ-12), namely social functioning, role limitation due to mental health and level of fatigue (p<0.05) among the patient group, there was only one outcome variable – the environment domain of WHOQOL showed significant improvement (p≤0.01) among carers. Focus group discussions also highlighted the importance of using a family-based approach in providing discharge support.

This Discharge support program which emphasizes hospital-community collaboration seems beneficial to older patients’ timely recovery and smooth transition back to community.