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Table 3 Components of ED PLUS

From: A physiotherapy-led transition to home intervention for older adults following emergency department discharge: protocol for a pilot feasibility randomised controlled trial

Administration timeline Personnel Description
Week 1 Physiotherapist visiting the patients home Physiotherapy assessment and action plan including individualized goal setting based on the CGA conducted in the ED and the physiotherapy assessment. The physiotherapist performs an assessment of gait, balance, upper and lower limb strength assessment, assesses the patients ability to function independently. An exercise programme is tailored to the patient (examples attached)
https://www.nhsinform.scot/healthy-living/preventing-falls/keeping-well/strength-and-balance-exercises
https://theros.org.uk/information-and-support/osteoporosis/living-with-osteoporosis/exercise-and-physical-activity-for-osteoporosis/
Week 2 Medication assessment and medication action plan
Via telephone
Physiotherapist via telephone call
The geriatrician will assess the medication the patient is taking as well as make recommendations for tapering of medication and cessation.
Physiotherapist will advise on progressions of exercise programme as appropriate.
Week 3 Nutritional assessment with a dietitian via telephone.
Physiotherapist via telephone call
Nutritional status will be determined using validated screening tools and a nutritional care plan will be implemented.
Physiotherapist will advise on progressions of exercise programme as appropriate.
Week 4 Physiotherapist visiting the patients home The physiotherapist reassess the patient and progresses as appropriate, discuss any concerns with the patient and action plan as appropriate
Week 5 Occupational Therapist via telephone
Physiotherapist via telephone call
The occupational therapist (OT) will discuss with the patient regarding self-management based on the individual goals set by the patient and physiotherapist. These strategies may include:
• Fatigue and energy management
• Managing stress and anxiety and maintaining mental health and well-being
Physiotherapist will advise on progressions of exercise programme as appropriate.
Week 6 Physiotherapist will visit patients home to conclude the sessions with a focus on review of patient goals and action plan to follow. Input from all HSCPs is collated for each patient to conclude their ED PLUS management.