As part of an effort to help seniors age well in place, the Community Care sector is always looking for better integration between organisations and partners. This includes strong local care coordination to develop a seamless care journey for our seniors. This need prompted the launch of the Community Hospital Aged Care Transition (CH ACTION) Programme, an initiative currently run by six community hospitals: Ang Mo Kio - Thye Hua Kwan Hospital, Jurong Community Hospital, Ren Ci Hospital, St. Andrew’s Community Hospital, St Luke’s Hospital and Yishun Community Hospital. CH ACTION is supported by the Ministry of Health (MOH) Singapore.
Want to learn about transitional care to help your clients transition well from the hospital to the community? We spoke to St Luke’s Hospital and Yishun Community Hospital to find out more about the CH ACTION Programme has and how it has benefitted their patients.
Post-discharge Support For Senior Patients
To further facilitate safe transitions of patients beyond their hospital walls, the CH ACTION teams at both YCH and SLH include care coordinators with nursing or social work background who provide post-discharge support for patients with complex needs. These care coordinators provide care coordination and case management services to support these patients, helping them with smooth reintegration into their community. Post-discharge support is important to reduce emergency department attendances and non-elective hospital admissions.
As the CH ACTION Programme seeks to provide a coordinated system for post-discharge processes, the two Community Care organisations also found similar processes in integrating operations with their partners. To provide post-discharge support, a care coordinator will conduct patient assessments prior to the patient's discharge. During the patient's stay, the doctor, care coordinator, nurse and allied health professionals such as therapists, social workers will finalise the discharge care plans.
After the patient has been discharged, the care coordinator would arrange for a phone call or home visit to patients and their caregivers within a week of discharge to check-in on how they have been coping. The CH ACTION team would then review the care plan to ensure that it meets their patients’ needs as they transition back to the community. Apart from providing supportive counselling, the CH ACTION team also assists with referrals by linking them up to relevant services for care continuity.
Since the implementation of the CH ACTION Programme in both organisations, it has strengthened the social-health integration as the respective CH ACTION teams were able to build strong bonds from their collaborations with community partners. Here is how YCH and SLH have benefited from it.
How CH ACTION Programme Helps SLH Patients Transition Back to Community
Upon a patient’s discharge from SLH, care coordinators will be assigned to them to provide care coordination and case management services. With the implementation of the CH ACTION Programme in SLH, it allows senior patients to age comfortably, at home and within a community they are familiar with.
How SLH’s patients and their caregivers benefited from the CH ACTION Programme:
- Helps the patients and caregivers cope better and be able to remain well at home for as long as possible
- Reduces utilisation of non-elective admission visits by responding quickly to emerging medical issues which avoids potential trauma and brings financial savings to patients and their families
- Enhances the knowledge of seniors and their caregivers, which increases their confidence and ability to cope well on their own
- Provides guidance to the patients and caregivers by identifying problems they face at home and implementing solutions to address the causes
- Cutting down the risks of hospital-acquired infections, deconditioning from readmissions and prolonged hospital stay, has also led to the decrease in burden of care for families.
How SLH’s staff benefited from the programme:
- Helps staff further understand how patients and caregivers are coping at home
- Allows staff to identify hidden factors that were previously not detectable within the hospital and address the risk factors
- Achieve higher patient satisfaction with better quality of care that leads to higher job satisfaction
- Helps healthcare professionals adapt to provide better care to more patients at a time
How the Programme Helps YCH Deliver Patient-centric Care
Since 2017, YCH has supported more than 1500 patients under the CH ACTION Programme. Patients and caregivers are supported in the transition between the hospital and their home, such as being connected to relevant services and financial schemes to support their care in the community. YCH also found that it is instrumental for elderly patients who require additional post-discharge support to be identified early, so that the CH ACTION Programme team can determine the care needed for their various medical and nursing needs, functional decline and psychosocial circumstances.
In YCH’s CH ACTION Programme, medical social workers (MSWs) work closely with community partners in implementing personalised intervention plan to address both psychosocial and health issues. Being familiar with both healthcare and social care systems, MSWs help patients to navigate between the two systems that brings about social and health integration.
Here is how YCH patients have benefitted from the CH ACTION Programme:
- Linking up patients and caregivers with critical support services after discharge
- Providing supportive counselling to patients and/or caregivers whom might be stressed out with the new care arrangements
- Reviewing of care options with patients/ caregivers when there are changes to the circumstances at home (e.g. a premature termination of contract for foreign domestic help, caregiver falling ill)
- Coordinating with multiple stakeholders for patients who require multiple services (e.g. Ministry of Health’s intermediate and long-term care services, family service centre, volunteer groups)
- Reduction of non-elective readmission, which helps to reduce distress to patients and caregivers, and the chance of putting patients at risk for hospital-acquired infection and general deconditioning
How YCH’s staff benefited from the programme:
- Foster a stronger working partnership with Community Care organisations
- Development of community social work capabilities
- Appreciate patients’ resilience through seeing how they overcome challenges in the community
- Gain inputs through patient reviews to better understand the care suggestions and interventions rendered for patients
Improving From The Challenges Faced With The CH ACTION Programme
Under the COVID-19 safe management measures, the CH ACTION teams had difficulties entering the wards to perform the pre-discharge introduction to the patients or their family members. Without the pre-discharge introduction, some patients might be doubtful and hesitant about the post-discharge contact. To overcome this, the inpatient team would highlight high-risk cases to the CH ACTION teams before a patient’s discharge for case discussion. The team would then provide the assigned care coordinator contact to the patient and their caregivers through an inpatient colleague so that the patient is aware of who to look for after their discharge.
Another learning point the community hospitals picked up was that having processes in-place and following through is important in ensuring adequate support for senior patients post-discharge.
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