Daniel C. N. Yau, Miranda C. C. Lam, May K. W. Lung, Ada Y. H. Chow, Neva
S. Y. Yung, T. Y. Chui , Antony C. T. Leung
(Modified Plenary Session Speech presented in the 14th Annual Nursing Conference:
"Advanced Nursing Practice")
Abstract
A recent in-house study conducted on a group of elderly patients who were discharged from a geriatric day hospital indicated that the patients and their caregivers could neither tell their rehabilitation goals nor remember their rehabilitation regimes which they should comply in order to improve or maintain their functional performance at home. On the other hand, previous literature revealed that the provision of written information that was tailored to individual needs of patients and their caregivers will benefit treatment outcome. Thus, a pre-discharge planning program was developed to enable discharged elderly patients to carry out their post-discharge rehabilitative treatment plan effectively and to achieve their treatment goals in their home environment. A key component of the program was a practice protocol developed to guide the rehabilitation team members in formulating and providing verbal and written information on individualized treatment goals and post-discharged training regimes i.e. the "Home-based Rehabilitation Instruction Sheet" (HRI). By performance-based evaluation and the 'Goal Attainment Scale (GAS)', outcomes were measured 3-4 weeks after discharge. Twelve patients were recruited to participate in the program. Six of them were female. Mean age of the program participants was 70.1 (SD=4.8). Participants were followed for an average of 30.2 days after discharged from the hospital. The mean number of goals per participant was 1.75 (range 1-3). The results showed that 83.3% of participants were able to achieve or exceed the standards of their individualized therapeutic goals (mean GAS score=57.7 SD=11.3). The findings suggest that nurses, as members of the rehabilitation team, could play an important facilitative role in helping elderly patients to achieve their therapeutic goals by developing and providing the HRI for them.
Key words: Elderly patients, home-based rehabilitation, pre-discharge planning, therapeutic goal