Hospital-to-Home programme paves smoother road to recovery for 8,000 patients

SINGAPORE — About 8,000 patients with a high risk of repeated hospital admissions have been returning home smoothly post-discharge since April last year, under the Hospital-to-Home (H2H) programme.

This was shared by Health Minister Gan Kim Yong at the inaugural Global Conference on Integrated Care on Friday (Feb 2). Mr Gan had highlighted that Singapore needs to “urgently transform” the way it delivers care in order to provide “appropriate and effective” care for an rapidly ageing population.

One way, said the minister, is to achieve a “seamless integration” of care services for the patient across different settings, such as between acute, intermediate and long-term care; between acute and primary care; and between primary and community care.

One example he cited was the H2H programme, where regional health systems coordinate medical, nursing and social care services — among other things — at the patient’s home after they are discharged.

These requires the combined effort of hospitals and community care providers — comprising doctors, nurses, allied health professionals, and case managers alike — to work together to manage the care of patients at their own homes, through phone calls and home visits.

Eventually, once caregivers and patients gain more confidence to manage at home, they can get further support by community care organisations.

This programme is currently implemented in public hospitals under all three Regional Health Systems in Singapore and administered by the Agency for Integrated Care.

Among those who has benefited from the initiative is Mr Choo Kim Sua, 67, who has multiple medical conditions such as diabetes, kidney failure and is a double amputee.

He was enrolled into the SingHealth H2H programme in April last year.

His wife, 61-year-old Sim Poh Cheng, recalled how she had initially been plunged into a state of “constant worry and helplessness” and sleepless nights as she did not know if she could manage with his condition after his discharge from Singapore General Hospital.

On top of visiting Mr Choo at his home, the SingHealth H2H care team also provided home nursing services and caregiver support. Madam Sim said she now knows basic caregiving skills, such as how to transfer him safely from bed to wheelchair, how to monitor his medicine, check his blood pressure and sugar levels, and how to aid him with his shower.

She also learnt how to better prepare food for his meals, such as chopping up vegetables to small pieces and cooking porridge to minimise his coughing fits, as compared to his previous diet of oily and rich hawker fare.

When his condition had stabilised, the team worked with Jamiyah Singapore in July last year to refer Mr Choo to community care services such as home and day care near his home in Jurong. Thus, Mr Choo was able to recover at home, instead of having to return to hospital.

Pointing out that she now has the security of knowing who to turn to when she needs help and can rely on them for emotional support, Madam Sim said she now has a “greater peace of mind”.

“At first, I didn’t know what to do, felt a lot of pressure and couldn’t accept this (situation)… But (with their help), I have a more positive outlook,” she said.