The Integrated Primary Care for At-Risk Elderly (iPCARE) programme aims to keep patients discharged from community hospitals well by connecting them with the GPs in their neighbourhood, for post-discharge care. SingHealth Community Hospital shares more.
The Integrated Primary Care for At-Risk Elderly (iPCARE) programme aims to keep patients discharged from community hospitals well by connecting them with the GPs in their neighbourhood, for post-discharge care. The community hospital will continue to support these patients and their GPs with case management and essential backend support.
INTRODUCTION
Many of the patients admitted to SingHealth Community Hospitals (SCH) are elderly and have multiple comorbidities, spanning biopsychosocial domains. Though clinically stable upon discharge, they have ongoing complex care needs and are at a high risk of deterioration, especially during the initial weeks after discharge.
Some of the challenges these patients face include functional decline, worsening disease trajectory, falls and lack of caregiver support. This puts them at risk of trips to the emergency department and even hospital readmissions.
OUR SUCCESS STORY
Through our iPCARE pilot at Bright Vision Hospital (BVH) in 2017, the SCH team realised that many of these events could be averted if these patients are supported by a good primary care network, including general practitioners (GPs), post-discharge. The programme has successfully transited 110 patients to primary care physicians, complemented by support from community hospitals in the form of case management, allied health, nursing and peer support from family physicians working in community hospitals.
Following the successful pilot at BVH, iPCARE will be expanded to the other hospitals under the SCH umbrella, Sengkang Community Hospital (Northeast Singapore) and Outram Community Hospital (Southern Singapore).
We invite like-minded GPs to join iPCARE as partners to keep these patients well in the community. If you are a GP in the north-eastern or southern part of Singapore and are keen to co-manage patients with complex needs with SCH, we warmly welcome you to join us. As an iPCARE GP Partner, you will be supported by case managers from SCH, who are registered nurses, to co-manage elderly patients with complex medical and social care needs. Case management services will be provided by iPCARE case managers, to ensure a personalised care plan for patients. Patients will be reviewed every three to six months, through a multidisciplinary team discussion with you, to co-manage care. An online CME event, 'Complex Care with Family Physicians', was conducted on 8 May 2021 with GP partners, where we shared iPCARE case studies of co-managing elderly patients with multiple comorbidities. Click here to view the recording of the session. To sign up as a GP Partner or for enquiries, please contact iPCARE at:
Email: iPCARESengkang@singhealthch.com.sg or iPCAREOutram@singhealthch.com.sg
Tel: 6930 7196 (Weekdays, 8.30am - 1pm and 2pm - 5pm) SERVICES PROVIDED TO PATIENTS ENROLLED IN iPCARE- Case management
- Medicine reconciliation and delivery
- Allied health support (Physiotherapists / Occupational Therapists / Speech Therapists / Dietitians / Social Workers)
- Home safety assessment
- Caregiver training
- Wound management
- Referral to other community-based services
- After-hours hotline
ENROLMENT CRITERIA- Aged 60 years and above
- Singapore Citizens and Permanent Residents (PRs)
- Staying within 8 km of either Sengkang Community Hospital or Outram Community Hospital
- Keen to follow up with a GP for primary care
- Have at least 3 complex conditions that can be:
- Medical in nature (e.g., uncontrolled or complicated medical conditions, wounds, physical disability), or
- Psychosocial in nature (e.g., psychological, caregiver or financial issues)
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HELPING BOTH GPs AND PATIENTS
Caregivers such as adult children have expressed appreciation to the team for being a ‘one-stop service’ right after hospital discharge, which has helped them to efficiently cope with work and caregiving duties during this transition period.
"Having just to see one doctor for my father has been a seamless experience for me, as he has multiple chronic conditions. Before we knew about this programme, we had to go to various doctors for follow-up appointments, and it was tough for me to balance work at the same time, and also tiring for my father.
Seeing the same doctor who is familiar with my father’s condition has also been very useful as he truly understands what my father is going through from a holistic point of view."
- Mr Jeffrey, son of a patient who benefited from iPCARE
Under iPCARE, the doctors in SCH work together with GPs as part of the overall support for the programme. This is in addition to case managers and allied health professionals from the community hospital.
"I took care of a couple of patients who live near my clinic, after they were discharged from Bright Vision Hospital. The detailed and frequent communication from BVH facilitated the effective co-management of the patients’ complex chronic medical conditions.
I am grateful whenever different parts of the health system collaborate and communicate because when that happens, patients and their families can enjoy holistic care. Working with SCH allows for enhanced motivation of patients to comply with treatment, a support system to relieve caregivers, and early detection of deterioration."
- Dr Tan PK, PJ Clinic
ABOUT SINGHEALTH COMMUNITY HOSPITALS
SCH comprises Bright Vision Hospital, Sengkang Community Hospital and Outram Community Hospital. Being Singapore’s only cluster of community hospitals allows us to shape the way we deliver person-centred care to patients. Our community hospitals are poised to set standards in care, exchange best practices and strengthen collaborations with our healthcare and community partners.
