Objective: Integrated Care for the Elderly is a core strategy for addressing the needs of an aging society and the management of complex chronic diseases. The study clearly demonstrates how the introduction of a health information system in Post-Acute Care (PAC) for stroke becomes the key to achieving highly efficient integrated care.
Methods: Traditional care models are often fragmented and lack continuity, imposing a significant burden, particularly on elderly patients requiring long-term rehabilitation after a stroke. This study utilized electronic medical record integration, quantified rehabilitation progress data, and Dashboard visualization to successfully synchronize data and decisions in real-time across the interdisciplinary team, including physicians, nurses, and occupational therapists.
Results: This information-enabled integrated model not only transformed the elderly patient's "impaired physical mobility" into quantifiable data (such as improved muscle strength scores, and restored ability to walk and self-feed) but also incorporated caregivers into the system, thus enhancing rehabilitation compliance.
Conclusion: Ultimately, this data integration significantly shortened the recovery time and improved the function of elderly individuals returning to social roles and the workplace. This validates the high effectiveness of achieving "Person-Centered Integrated Care" through digital health capabilities, which contributes to optimizing the utilization of healthcare resources in rural areas and enhancing overall health quality.

Authors:
You-Xuan Lai, Qishan Hospital, Ministry of Health and Welfare, Taiwan
Jia-Yu Wei, Qishan Hospital, Ministry of Health and Welfare, Taiwan
Tai-Yi Chiang, Qishan Hospital, Ministry of Health and Welfare, Taiwan
Shu-Chun Hsueh, Meiho University, Taiwan

About the Presenter(s)
You-Xuan Lai, Master of Science in Health Care, Meiho University of Science and Technology. Clinical Nursing Faculty at Qishan Hospital, Ministry of Health and Welfare.

See this presentation on the full schedule – Tuesday Schedule

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