Beyond hospital walls, nurses are helping the population to keep well, get well and age well.

By Lediati Tan, Singapore Health

Ten days after 86-year-old Mdm Mariam was discharged from Changi General Hospital (CGH), Senior Staff Nurse Imma Harliny Abdul Rahim visited her to ensure that she was recovering well at home.

Mdm Mariam, who has multiple complex conditions such as dementia and Parkinson’s di sease, was hospitalised for fluid overload and aspiration pneumonia.

After her discharge, she was placed under CGH’s Hospital-to-Home service – a service where a multidisciplinary team comprising community nurses, doctors and allied health professionals work together to provide post-discharge care to patients in the comfort of their homes.

During the visit, Imma, 36, noticed that Mdm Mariam had swallowing issues and difficulty coughing out phlegm, which resulted in her airways being blocked.   She immediately referred Mdm Mariam to a speech therapist for her swallowing problems.   She also ordered a suction machine for her to use at home.

“With Nurse Imma’s help, our whole family learnt the right suctioning technique very quickly. She is very caring towards our mother, and is patient in guiding us,” said Mdm Zainab, Mdm Mariam’s daughter-in-law and main carer.



With health care in Singapore shifting from hospital-centric care to community-based care, nurses like Imma play an increasingly vital role in keeping individuals well-supported in the community.

Every morning, after meeting with the multidisciplinary care team in the hospital to discuss cases, Imma sets out from CGH with a trolley bag containing medical equipment and supplies to visit patients who live in Tampines, Punggol, Pasir Ris and Sengkang.   Her patients range from 40 to 100 years old, and suffer from complex conditions such as stroke, heart failure and dementia.

During these home visits, she checks their vital signs and provides nursing care such as wound management.   She also finds out how their carers and families are coping, and sets goals for the patients’ recovery.

Depending on the patients’ needs, she refers them to a dietitian or speech therapist for follow-up care.   She also checks the home environment for clutter, and recommends changes to make the space safer.

Even though Imma has 10 years’ experience as a geriatric care nurse at CGH, she described the past year as one with a steep learning curve because she had to take on many other aspects of care when dealing with patients in the community.

“During home visits, you have to handle complex conditions independently and ask the right questions.   It is usually only after a detailed assessment and examination that we are able to identify what the problems are, and work in partnership with patients and their families, and support them in the community.”

It is not just in health care that Imma needs to be familiar with.   She also needs to know and understand the various financial assistance schemes available for patients.

Despite the challenges, she feels an immense sense of satisfaction when her patients greet her with a smile and thank her for the support.   “I always tell them not to treat me as an outsider or a nurse, but as somebody they can count on.”




Another care programme that is fast taking shape is the Community Nurse Post, where nurses are stationed at neighbourhood Senior Activity Centres or Family Service Centres to keep an eye on elderly residents who have little family support.

In the south-east of Singapore, a pioneer batch of community nurses from Singapore General Hospital (SGH ) has been stationed at community nurse posts in mature estates like Redhill and Bukit Merah since February 2018. They offer elderly residents health and geriatric assessment, health education and care coordination with social care agencies for social support.

One such community nurse is Senior Staff Nurse Low Shi Chia, 26, who specialises in gerontology. A nurse for the past six years, she previously worked in SGH ’s medical ward.

“The work we do in the community focuses on optimising the health of the elderly so that they are able to receive care closer to their homes,” said Shi Chia, who took on her new role as a community nurse in February 2018. She spends Wednesday mornings at NTUC Health’s SilverACE Senior Activity Centre in Redhill and the rest of the week at Montfort Care’s @27 Family Service Centre in Telok Blangah.

One of the patients she sees is 71-year-old Mdm See Tho, who suffers from diabetes, hypertension and other chronic problems. During her health assessment at the community nurse post, Shi Chia discovered that Mdm See Tho was not taking her medication correctly.

“In the hour that I spent with her, I went through her medication and taught her how to pack them correctly and when to take them. I also monitored her blood pressure and asked her to come to the post once a day to have her blood pressure monitored,” said Shi Chia.

Under her watchful care, Mdm See Tho’s blood pressure is well under control. Mdm See Tho is also able to correctly take her different sets of medication by herself.

In addition to attending to elderly residents at the community nurse post, Shi Chia conducts home visits for those who are home-bound. She sees around six residents every day, and currently has about 30 residents under her care.

Shi Chia said: “They come from diverse backgrounds and have different care needs. They open up more when they are in a familiar environment, and that helps me better understand what matters most to them, and find ways to help them take charge of their health. It has been very fulfilling.”