Characteristics of elderly patients receiving care coordination: the role of telephonic review and home visit

Introduction: Care coordination is an important aspect of nursing care especially for elderly patients admitted to an acute care setting. In Singapore care coordination and transitional care nursing is a new concept of care nevertheless important but unexplored. Aim/objectives: The objective of this paper is to explore the characteristics of elderly patients receiving care coordination, determine care gaps and intervention during home visit and telephonic review. Research design and sampling: A designed questionnaire was used to collect information on the patient’s demography, social and clinical profile and determine post discharge activities using Eric Coleman’s four pillars tool. A pilot study of ten questionnaires was conducted. The retrospective data from the patient’s index admission from the last six months (Nov ’08–April ’09) was analyzed using SPSS version 16. Result: Total of 517 patients were recruited from October 2008 to March 2009. Majority, 69% were above 70 years old of which 57% female and 76% lives with their children. Clinical information demonstrates that 53% had 3–6 co-morbidities and 58% were taking more than five medications. The abbreviated mental test score were 6.2, 6% were depressed and delirium was present in 14% of patients. Only 65 patients (0.1%) had home visits and telephonic review done whilst 97% of the remaining had only telephonic review done. Those who had both telephonic and home visit review, medications advice and compliance were checked only in 0.8% (at one week) and 1.6% (at one month) whilst during home visit this was done in 12.2% of patients as medication discrepancy were apparent at home. As for appointment compliance and compilation were done in 0.8% at one week and 51% at four weeks of telephonic review compared to during home visit only 4.8%. Caregivers education was emphasized in 14% of patients at home visit, 2% at one week and 4% at one month of telephonic review. Discussion: The result showed that home visit is effective in exploring medication compliance, advice and emphasizing caregiver education, managing appointments can be effectively done through telephone review. Conclusion: This study demonstrates the vital role of home visit for elderly patient to safely transit between hospitals to home.