SINGAPORE: About 8,000 patients at high risk of repeated hospital admissions have taken part in a programme that aims to help them return home smoothly since its launch in April last year.
This was revealed by Minister for Health Gan Kim Yong on Friday (Feb 2) at the inaugural Global Conference on Integrated Care 2018.
The H2H programme coordinates medical, nursing and social care services at a patient's home after he or she is discharged from hospital.
The programme is currently implemented in all public hospitals and administered by the Agency for Integrated Care.
Aside from improving patients' emotional well-being, the programme has also produced clinical benefits, according to Singapore's largest public healthcare cluster SingHealth.
"We did a randomised controlled study to see the effect of our service on the patients," said Associate Professor Lee Kheng Hock from Singapore General Hospital's (SGH) Office of Integrated Care.
He added that those in the programme were less likely to come back to hospital, and there was "as much as over 30 per cent reduction in the likelihood of being readmitted to the hospital again".
"IT'S VERY BENEFICIAL TO US"
One beneficiary of the programme is diabetic patient Choo Kim Sua, who is a double amputee because of his condition and also has other conditions such as kidney failure.
On days when the 67-year-old wakes up in a foul mood, his wife will be at his side to calm him down.
But managing his outbursts and multiple medical conditions wasn't always so easy for her until she signed up for the H2H programme.
“It's very beneficial to us, because the healthcare workers taught me how to look after a sick patient. I can’t understand the pain he goes through sometimes, so they also teach me how to manage my emotions when he gets into a bad mood,” said Mrs Choo.
In Mr Choo’s case, healthcare workers from SGH and Jamiyah Singapore visit him at home for follow-ups sessions.
The nurses also teach Mrs Choo and her domestic helper basic caregiving skills such as how to transfer a patient safely from bed to chair and measuring his sugar levels.
SGH patient navigator Haslinda Barman, who was assigned to the family a year ago, said there have been vast improvements in Mr Choo’s condition since he joined the programme.
"He is a lot more co-operative with his family. He's able to manage his behaviour," she said.
"As for Mrs Choo, she's not as stressed and is much happier. Mr Choo also knows that we visit him in the hospital and at home. So when he recognises us, he can collaborate with us even better."
Mr Gan cited Mr Choo's case as one example of how the healthcare system can be anchored in the community to support an ageing population.
However he acknowledged that more needs to be done to support an ageing population.
“We need to build new capabilities to achieve better care integration," said Mr Gan. "Firstly, deepening our manpower capabilities to support care integration. Good integrated care requires a skilled workforce that is trained and competent in the delivery of good community care."
He gave the example of a recent initiative to develop community nursing so they can "bridge patient care needs" between hospitals and the community.
Currently, nursing graduates can deepen their skills in community care by signing up for two new specialist diplomas in gerontology in Nanyang Polytechnic and Ngee Ann Polytechnic.
Mr Gan added that technology should also enable a seamless flow of information across care settings, while funding arrangements must provide the flexibility to care for each patient’s unique circumstances.