Mr Ang (not his real name), 60, lives alone in a rental flat, suffers from end stage renal failure and is blind in one eye. Two years ago, his big toe was amputated due to a diabetes-related complication. He often ignored the doctor’s advice to restrict fluid consumption and did not take his medication regularly.

An SGH study found that patients like Mr Ang are at risk of multiple hospital re-admissions due to complex health problems and lack of proper support at home. The Transitional Care (TC) service set up by SGH’s Department of Family Medicine and Continuing Care (FMCC) looks into providing “Hospital at Home” services for this group of patients.

Comprising doctors, nurses, medical social workers, pharmacists and therapists, the multidisciplinary TC team meets weekly to discuss cases and arrange follow-up care that best meets each patient’s needs. Before a patient is discharged, the team assesses their health and social care needs and draws up a support plan for the patient and his caregiver.

"Transitional care and home visits enable us to support patients after they leave our hospital."

– Assoc Prof Lee Kheng Hock, Director, Office of Integrated Care and Senior Consultant, Department of Family Medicine and Continuing Care, SGH

They also reconcile the patient’s medication and advise on self-care. Patients are closely monitored for three months via phone calls and home visits to address any complications early and prevent hospital readmissions.

“Because of the complexity of their health and psychosocial conditions, high-risk patients require well-coordinated care between different care providers to help them cope. Transitional care and home visits enable us to support patients after they leave our hospital. By keeping an eye on them, we can intervene and help them before their conditions worsen,” said Associate Professor Lee Kheng Hock, Director, Office of Integrated Care and Senior Consultant, Department of Family Medicine and Continuing Care, SGH.

Prof Lee’s department has been conducting randomised-controlled trials to assess the effectiveness of this service. In comparison with patients who received standard hospital care, patients under the programme had an average reduction of 30 per cent in hospital re-admissions, A&E attendances and length of hospital stay.

“The encouraging results gave us the confidence to roll out the service on a larger scale. From October 2016, we will enhance the service by including social care providers in the community as part our team. We will also reach out to vulnerable elderly persons living in rental flats in the communities around our hospital,” said Prof Lee.

The Patient Navigator (PN) programme has also kept at-risk patients well-supported in the community. PNs are trained nurses who support patients with complex health and social issues from the point of admission to discharge or end-of-life. They collaborate with different care providers to assess patients’ needs and plan post-discharge care.

They also connect patients with community partners and VWOs who can provide resources such as financial assistance, meals on wheels, home and day care. To ensure patients comply with their care plan, PNs also actively engage caregivers to support patients after discharge.

“Most patients want to go home as soon as they can and recuperate in familiar surroundings, close to their loved ones. It gives me great satisfaction to prepare them to return home and ensuring that their post-discharge care meets their needs,” said Nurse Clinician Manisah binte Somadi, Patient Navigator at SGH.

Intervention by PNs reduced A&E attendances by 43 per cent within a year, for 3,754 SGH patients enrolled on the programme between June 2014 to April 2015.