The Effects of a Health-social Partnership Program for Discharged Non-frail Older Adults

The Effects of a Health-social Partnership Program for Discharged Non-frail Older Adults: a Pilot Study

Previous studies supporting discharged patients are hospital-based which admission criteria tend to include mainly those with complex needs and/or specific disease conditions. This study captured the service gap where these non-frail older patients might have no specific medical problem upon discharge but they might encounter residual health and social issues when returning home.

Objective: To compare the effect of a community-based health-social partnership program with usual care for discharged community-dwelling non-frail older adults on their health-related quality of life, activities of daily living, depressive symptoms, and use of health services.

Design: A randomized controlled trial. Participants: Discharged community-dwelling non-frail older adults from an emergency medical ward in an intervention (n=37) and a control (n=38) group.

Interventions: Discharged older adults were randomized to receive usual care or complex interventions, including structured assessment, health education, goal empowerment, and care coordination supported by a health-social team.

Main measures: The outcomes were measured at pre-intervention (T1) and at three months post-intervention (T2) using the Medical Outcomes Study 12-item Short Form, the Modified Barthel Index and the Geriatric Depression Scale.

Inclusion Criteria:

• resided in the service areas of the study hospital,
• were aged 60 or over,
• were cognitively competent with a score greater than 26 in the Montreal Cognitive Assessment Hong Kong version,
• were living at home before and after discharge from the hospital,
• had scores of <5 on the Clinical Frailty Scale (Note: a patient is considered to be non-frail if they have a score less than 5), and
• were fit for medical discharge

Exclusion Criteria:

• were not able to communicate,
• could not be reached by phone,
• were bed-bound,
• had active psychiatric problems,
• were already engaged in other structured health or social programs, and
• would not be staying in Hong Kong for the three months of the study