After 70-year-old Mr Tan (not his real name) was discharged from Singapore General Hospital (SGH), he continued to receive care from a medical team under SGH’s Transitional Home Care (THC) programme.
This story was reproduced from the Singapore health Special Edition on Nursing 2016
By Audrina Gan
After 70-year-old Mr Tan (not his real name) was discharged from Singapore General Hospital (SGH), he continued to receive care from a medical team under SGH’s Transitional Home Care (THC) programme. This was a great relief to his daughter, who had worried about not being able to look after her father properly at home.
“It is very reassuring to have the care team visit him at home, especially nurse Stephanie who taught me and my helper how to tube feed him and how to transfer him from the bed to the wheelchair safely. She also calls us regularly to find out how he is doing,” Ms Tan said.
Mr Tan is one of 40 patients whom Ms Stephanie Lam, Senior Staff Nurse, Office of Integrated Care, is caring for under the THC programme. Set up by the Department of Family Medicine and Continuing Care, the service helps patients with sub-acute medical conditions and limited mobility receive care at home.
The multi-disciplinary team comprising doctors, nurses, medical social workers, pharmacists and therapists meets weekly to discuss patients and their follow-up care. In addition to stroke patients, the programme also benefits those who suffer from Parkinson’s disease and end-stage organ failure.
“There are daily tasks that patients and caregivers need help with. For instance, inserting feeding tubes properly to ensure food reaches the stomach. If not done properly, this can affect a patient’s recovery. During home visits, I observe how well caregivers perform these tasks and train them if needed,” Ms Lam said.
“The programme usually lasts about three months post-discharge. When a patient’s condition is stable, we discuss the next care plan in detail. If necessary, we will arrange for the patient to continue receiving care from community partners such as the Home Nursing Foundation or NTUC Eldercare.”
Ms Lam (left) and Nurse Clinician Xu Yi, both from SGH, work together to care for patients post-discharge.
Ultimately, the aim of providing transitional home care is to empower both patients and caregivers to successfully manage their medical conditions at home, and avoid having to be admitted back into hospital.
Connecting the dots Working closely with nurses from the transitional care programme are Patient Navigators who help to assess, plan and coordinate care for patients from admission to discharge. They connect patients with the wider health care teams, community hospitals, hospices, and other external agencies in the community.
One Patient Navigator is Nurse Clinician Xu Yi, who works with cancer patients in Ward 48 in SGH. A key part of her daily work is to review the medical records and social backgrounds of patients due for discharge, and to understand their medical, functional and psychosocial needs. Together with a multi-disciplinary team, she then crafts a plan that ensures a patient’s care isn’t disrupted or changed too dramatically when he returns home.
She refers the more complex cases, including patients who are admitted repeatedly, to the THC team for additional support. Ms Xu recalled a patient with late stage cancer who had fractured her pelvis after a fall at home. “She came to us with severe pain and was unable to undergo surgery due to her pre-existing condition,” said Ms Xu.
As the patient, who is in her late-30s, wanted to be cared for at home, the health care team met with her family to discuss her needs af ter her discharge.
“To receive care at home, she needed a trained caregiver, pain-relieving devices, and community support,” said Ms Xu, who arranged for colleagues from SGH’s Pain Management Centre to train the hospice home care team and the patient’s caregiver.
For instance, they were taught to handle and monitor an intrathecal device, which delivers medication directly to the spinal cord.
“The patient navigator’s role benefits patients and the health care system. For me, the opportunity to better understand my patients has helped me to grow professionally and personally,” said Ms Xu.
What’s in her bag?
Ms Lam totes a small suitcase with medical supplies such as:
• stethoscope
• blood pressure monitor
• thermometer
• bladder scanner (when needed)
• medication
• wound dressings
• disposable gloves
• hand sanitiser
• disinfectant wipes
Click Here to read more inspiring stories about nurses from the Singapore Health Special Edition on Nursing 2016
