Chronic diseases
Conditions
Interventions
Two groups:the community nurse will conduct patient pre-discharge comprehensive assessments within 48 hours after admission versus community nursing service as usual with 8 times home visits and witho
Sponsors
Princess Margaret Hospital
Eligibility
Sex/Gender
All
Age
65 Years to No maximum
Inclusion criteria
Inclusion criteria: 1) Aged 65 or older; 2) with current hospitalization through A&E or at risk of frequent hospital readmissions as indicated by Hospital Admission Risk Reduction Program for the Elderly score equal or greater that 0.2 3) have been diagnosis with one or more chronic Obstruction Pulmonary Disease, Diabetes Mellitus, Hypertension, Congestive Heart Failure 4) Chinese and able to communicate with Cantonese 5) cognitively intact as indicated by Abbreviated Mental Test score ( Hong Kong version) of 6 or more out of 10 6) living within the hospital service area and discharge to home 7) willing to accept community nursing service
Exclusion criteria
Exclusion criteria: Paticipants who are discharged to institutionalized care or followed by a designated disease -specific management program being under care by Hospital Authority Integrated Care Model Program, Virtual Ward Program or non-governmental organization enhanced home care program, will be excluded
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| the number of hospitalization, emergency room visits and length of hospital stay; | — |
Secondary
| Measure | Time frame |
|---|---|
| psychological status by using the Hospital Anxiety and Depression Scale, quality of life; | — |
Countries
China
Contacts
Public ContactWong Yuk Fong
Princess Margaret Hospital
Outcome results
None listed