Tam Ellen Maria Yuen Yee, Leung Lok Ling, Ho Ka Shing, Lau Chi Cheung Michael, Chao Fung Wah, Lau Yuen Mei, Ng Man Fai, Kwan Yiu Keung
Division of Geriatrics, Department of Medicine and Geriatrics, Tuen Mun Hospital, Hong Kong.
Community Care Division, New Territories West Cluster, Hong Kong.
Ann Geriatr Med Res. 2025 Sep;29(3):352-359. doi: 10.4235/agmr.25.0006. Epub 2025 May 27.
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.
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.
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.
The ICAH program is able to facilitate community care for the very frail elderly, significantly reducing their AED attendance, hospital stay, and caregiver stress.
由于社区居住的极度虚弱老年人有着复杂的病史，照顾他们颇具挑战性。缺乏及时的医疗支持导致他们频繁前往急诊科就诊、住院时间延长以及出院困难。居家综合护理（ICAH）项目旨在通过建立一个现场的、基于需求的综合医疗护理模式来支持老年人居家养老，从而减轻医院负担和照顾者压力。
ICAH项目为社区居住的虚弱老年人提供服务，这些老年人卧床不起、功能依赖、需要密集的医疗和护理，且经常或长期住院，通过定期安排社区护士和老年病医生上门探访、临时会诊以及为照顾者提供支持。这项回顾性观察研究纳入了2018年2月1日至2023年8月31日期间招募到ICAH项目的患者。我们回顾了我们的服务提供情况、患者的人口统计学数据、180天内的急诊科就诊次数和住院天数，以及照顾者的3个月相对压力量表。
招募了76名患者，中位年龄为90岁，临床衰弱量表中位评分为8分。其中，92%患有晚期痴呆症，30%有深部压疮，43%在一年内反复发生败血症；每位患者每月接受3.7次护理探访和0.4次医疗探访。每1000患者日（PD）的180天急诊科就诊率从15.3降至3.2（p<0.001）。住院天数率从每1000 PD的266.4天降至29.7天（p<0.001）。3个月时，相对压力量表中位数从24.5降至16（p = 0.001）。
ICAH项目能够为极度虚弱的老年人提供社区护理，显著减少他们的急诊科就诊次数、住院时间和照顾者压力。
