Many patients face challenges keeping themselves well after leaving the hospital. With lack of physical ability, tools or social support, they can be readmitted to hospital multiple times.

Even with the best nurses, surgeons, social workers and primary care physicians, "The vast majority of patients are their own care coordinator," said Professor Eric Coleman (photo, bottom left), Director of Care Transitions Program at the University of Colorado.

Prof Coleman was delivering his keynote address to some 400 people from various healthcare institutions, social service agencies and grassroots organisations at the SingHealth Integrated Care Symposium, held 10-12 January 2018 at Academia, SGH Campus.

Over three days, the various care providers will be learning from each other, exchanging ideas and coming up with solutions to improve care delivery in the community.

Dr Amy Khor, Senior Minister of State for Health & the Environment and Water Resources attended the event as guest-of-honour. She said, "The aim is for these partners to work more closely together to deliver person-centred care, so that patients can move across care settings with ease and be assured of receiving timely and appropriate care."

"The ultimate goal [for integrated care] is to create a match between an individual's care needs and their care settings."
- Prof Eric Coleman, Director, Care Transitions Program, University of Colorado

"The ultimate goal [for integrated care] is to create a match between an individual's care needs and their care settings," said Prof Coleman. To do this, feedback loops need to be created to give healthcare professionals and care institutions a sense of whether the patient is indeed recovering well in their new care setting.

One of the ways his team did this was to "test-drive" the patients' home care instructions before they were sent home from the hospital. The instruction could be as simple as weighing oneself at home. But when the team asked one patient to do it, they discovered she wasn't able to – due to poor eyesight, she couldn't read the numbers on the scale.

From this experience, it is clear that successful care has to involve the patient and their caregivers.

SingHealth Group CEO Professor Ivy Ng shared in her welcome address that on the ground, SingHealth care teams have been working closely with community partners to drive person-centred improvement work.

One of the projects had a Patient Navigator from SGH conduct a home visit with an NTUC Health case manager on the day of a patient's discharge, and both keep each other informed of issues the patient faces.

The improved workflow has helped patients such as 75-year-old Madam Tan who had been admitted through the SGH emergency department 11 times over five months in 2016. With the team's help, she is now coping well at home and has had zero readmissions.

Prof Ng said, "I believe this is the outcome that we are all striving for, not just for Madam Tan but for all patients who entrust their care to us. We may come from different organisations but we share a common goal to keep our patients well-supported so that they can age-in-place with confidence and grace."