Under the Community of Care programme, elderly with complex medical and social needs find comfort in being able to recuperate at home.

IN spite of suffering chronic knee pain, anaemia and several other ailments, Mr Low Teck Guan, 70, often forgot to take his pills – all 11 of them – in the morning.

This went unnoticed until Ms Lisa Ang, a Patient Navigator and staff nurse from Singapore General Hospital, visited him at his two-room rental flat in Lengkok Bahru, five days after he was discharged from hospital. It had been his third hospital admission in the past year.

“I counted his medication and noticed he had not been taking them every day as prescribed,” said Lisa.

She packed his medication into pill boxes and labelled them according to days of the week to help give Mr Low a visual reminder to take his pills.

Lisa is part of an SGH care team that conducts home visits under the Community of Care programme. Launched in April 2017 by the SingHealth Regional Health System (RHS), the programme aims to enhance health and social care for elderly patients after they are discharged from hospital.

The care team, comprising doctors, nurses, medical social workers and therapists, identify patients who are at-risk before they are discharged. Together with community partners, they monitor patients at home until their condition is stabilised.

Lisa assessed Mr Low during his hospital stay and found that he might have difficulty coping at home.

“He is single and has no close family members to depend on. His legs were weak and he needed rehabilitation at a community hospital but he declined and preferred to return home,” explained Lisa.

During the home visit, she found that Mr Low was not only skipping his medication but also his meals. As he had to use a quad stick to move around, he found it challenging to buy meals and would wait for his flatmate, who works full-time, to do so. If his flatmate was busy, Mr Low would miss a meal.

It takes a village

Working together with Mr Alan Yong, a care executive from NTUC Health Cluster Support, Lisa helped to make arrangements for Thye Hwa Kuan Moral Society to deliver lunch and dinner to Mr Low every day.

They arranged for nurses from Home Nursing Foundation to change his wound dressing and applied for grab bars to be installed in his flat to improve safety. Lisa also taught him simple strengthening exercises which he could do at home.

Mr Low’s flatmate was also enlisted to help monitor his medication routine and accompany him for appointments. In addition, Alan helped to secure financial assistance for him.

Adjunct Professor Lee Chien Earn, Deputy Group CEO (RHS), SingHealth, said the strong partnership and coordination between care agencies that can provide different types of services, is critical in keeping the vulnerable elderly healthy and happy in the community.

“Many have emotional and social needs, beyond the medical issues that we help to address. By working closely with the community, we can strengthen the post-discharge care support system, spot complications early and intervene before their condition worsens.” 

Adjunct Professor Lee Chien Earn, Deputy Group CEO (RHS), SingHealth.

Working as one
Regular meetings are held between the SGH care team and anchor care provider in each district to review the residents’ well-being, and flag out social and medical issues that require attention.

“By linking together the many helping hands, we find that this vulnerable group receives better care and is less likely to be readmitted to hospital as frequently,” explained Associate Professor Lee Kheng Hock, Director of SGH Office of Integrated Care.

The programme now covers about 3,000 patients in the five Communities of Care: Chinatown, Tiong Bahru, Bukit Merah, Katong and Telok Blangah, with plans to extend it to a total of 5,000 patients by end 2018.