Heart Failure is a serious condition that tends to worsen overtime, with many patients having to visit the emergency department and being readmitted due to deteriorating symptoms. Observing a rise in heart failure patients seen at NHCS, and in line with the nation’s call for Healthier SG to build a healthy nation, MSS put together a team, the Heart Connectors, to tackle the issues.

Ms Tan Boon Cheng, Master Medical Social Worker (MSW), Medical Social Services (MSS) explained, “Previously, care for patients with heart failure could sometimes be fragmented and episodic, with reliance on the healthcare providers, and that care provision is often problem focused rather than holistic.” 

 

The Heart Connectors led by Boon Cheng, comprises heart failure doctors, nurses, and community care partners, introduced a new care model which involves more involvement from patients and different partners in the care of patients, with the aim to help delay the progression of heart disease.

The project uses an empowerment model which helps patients with significant health and psychosocial risk factors, to establish connections and regular huddles between hospital and community providers to enhance care coordination. This coordinated care pathway for heart failure patients helped achieve a holistic, integrated and seamless care for these patients discharged from hospital to the community. 

Prior to their discharge, MSWs would first engage the patients in the ward to help them understand the importance of continuity of care and life goals through simple questions. “Though the questions asked were simple such as what their goals are, some patients were uncertain and struggled to answer. We use the Goal Attainment Scale (GAS) worksheet to start the goal setting conversations with the patients, and help reframe their thinking so that they can better visualise and articulate their personal goals that were close to their hearts,” shared Boon Cheng.

A session would typically take an hour, and depending on the progress of the patient, it may take two or three sessions for each patient. The team would also follow up regularly with patients on their progress in achieving their goals. 

The Heart Connectors shared the philosophy that guided the team, “While we can't change the medical diagnosis of a patient, we can empower the patient to change his/her experience of living with it.”

The project which started in December 2019, was not without challenges especially when Covid-19 struck. During the pandemic, the team had to work closely with community partners to reach out to uncontactable patients, and also changed physical meetings with external partners to virtual sessions. 

 

MSS also introduced the Local Area Coordination (LAC) principles, a person-centric care model, into hospital and community work. To smoothen the shift from provider- to person-centric care, the team met with several community partners such as SATA CommHealth, a charitable organisation which provides medical services for the elderly and vulnerable in the community, to explore opportunities for collaboration such as using LAC principles to train their group of volunteers.

While caring for the patients, the team had to also be equipped with relevant skills and knowledge in the new expanded role in caring for patients in the community. MSW Jasmine Ku shared, “We actively sourced for relevant trainings such as design thinking, to broaden our perspectives and approach in our work with patients.”

The project has seen good outcomes. An example was 60 year-old Mr Chan, who was critically ill and on life support machine when he was introduced to MSS. Mr Chan was then depressed over the loss of his family members, and had poor social support. 

Following the good life conversations with MSW Sim Yu Xuan, Mr Chan discovered his strengths and purpose in life. He is now a transformed person with a sense of purpose and aspiration to give back to his community day. For instance, he volunteers to accompany NHCS patients for their appointments and shares his experiences, cooks for the elderly in his community, and even formed a walking exercise interest group in Sengkang!

The team shared that almost 94% of 182 patients* recruited in the project experienced an improvement in attaining their goals, as well as a significant enhancement in quality of life such as improved mobility and self-care. With the project’s success, the team intends to roll out similar pathways to other patient groups, such as those who have had health shocks, and pre-frail or frail patients. 

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