Table 3 Components of ED PLUS
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) |
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. |