Alexandra Hospital’s purpose statement reads, “We walk with you and your loved ones through your health journey as we redesign healthcare with our people and our community.” This is manifested through our care model which starts from treatment to rehabilitation and beyond the hospital, where a discharge plan is already in place when the patient is warded.
Madam Shamala (not her real name), 76, is single and stays alone in a two-room flat. She suffers from chronic diabetes and movement disorder and recently had a fall. She was warded at Alexandra Hospital (AH), where she met Care Manager Bernice. From their first introduction, Bernice connected with Madam Shamala and started working on on her personalised discharge plan. Her aim was to ensure Madam Shamala safely transits back home and receives appropriate care in the community.
As part of her discharge planning process, the hospital made arrangements for a therapist to visit Madam Shamala’s house to assess her living conditions. The therapist pointed out that Madam Shamala’s house floorings were unsafe, that her floor tiles were uneven and corroded. Realising how this could be an issue for Madam Shamala who was prone to falls, Bernice quickly linked up with FaithActs, who offered to clean up Madam Shamala’s place and redid her floorings. Madam Shamala was also hoarding medications and have not been very compliant with taking them. She was later trained by the hospital on how to manage her oral medications as well as how to administer her subcutaneous injections. She was further empowered on how to prevent unnecessary injuries and falls at home. She continued to receive care during this time and got better and returned home. But the care she received, did not stop there. Bernice continued to follow up with Madam Shamala even after she was discharged. She continued to ensure that she was taking her medications correctly. With the help of community partners who visited her regularly, Bernice was also able to ensure that Madam Shamala was coping well at home. Madam Shamala has since been recuperating at home.
Madam Shamala is just one of the many patients AH Care Managers have helped since the role was introduced on 1 June 2018.
Traditionally, hospitals offer discharged patients hospital to home services to help patients with multiple medical conditions manage their conditions at home. This process, referred to as transitional care or under the Agency of Integrated Care’s (AIC) Hospital-to-Home (H2H) programme, can include home visits by patient navigators or community-based nurses and comprises a period of typically three to six months.
The AH Care Manager seeks to complement the patient navigator or H2H programme, and to help patients integrate back to their homes from the hospital, so that care in the home and community is strengthened and anchored.
These Care Managers are part of the CareHub@AH initiative which is a multi-disciplinary team approach to caring for patients. The team is made up of doctors, care managers, nurses, and administrators.
The initiative is specially designed to streamline and coordinate care across the various healthcare settings (e.g. inpatient, outpatient, urgent care centre, nursing home, homecare) for existing AH patients and caregivers.
Working with the hospital and the primary care and social service partners in the Community, CareHub@AH aims to ensure patients receive appropriate person-centred care in a coordinated and seamless manner.
As of April 2019, there are seven care managers with CareHub@AH. Most of who are nurses with one with a background in psychology.
As Care Managers, they strive to be the single point of contact to patients with a host of complex social and medical issues and to ensure patients’ needs are met and that their caregivers are well supported. This is especially important for the Queenstown district, which is one of the oldest housing estates, with about 20% of the residents being 65 years and above, and many facing with not only medical but complex social issues which are interlinked to their admission episodes. Some of these issues include lack of carer support, family background of abuse, neglect and violence, ‘hoarder syndrome’ – with not only medication, compounded living conditions such as bed bugs, medication non-compliance and poor finances.
The aim is to tackle the problem at the source, and this will involve the Care Managers working with members of the care team or with Voluntary Welfare Organisations and Social Service Offices for assistance and resources to help the patient at home.
Like Madam Shamala, the follow up care process for AH patients starts once a patient is admitted. The Care Manager screens the patient to find out if there are any recurring, underlying social and medical complexities and what the support network and family background of the inpatient could be. It is only with fully understanding the whole patient’s needs that Care Managers can begin to work with the rest of the care team to decide what the patient needs for a smooth and efficient transition to the home and the community.
Madam Shamala, like so many elderly Singaporeans with multiple chronic conditions, needs help to navigate through our health care system. Like her, many of these elderly need regular care across various medical specialties but they also need empathetic advocates who know their names, their stories and their social barriers. As they continue to journey with patients, Care Managers will be trained in activation assessment, motivational interviewing, health coaching, resource allocation and community care to provide patients with better care from an inpatient setting to the community.
CareHub@AH will assist in areas such as:
- Assessing patients' care needs and providing timely interventions and follow-ups and prevent re-admissions. Work with patients, families and community partners to initiate clinical and social interventions early.
- Helping patients navigate healthcare options, including hospital care and community care
- Providing support to caregivers with resource navigation with primary care and social services providers in the community.
- Providing support to community partners
CareHub@AH hotline provides support for existing patients, caregivers, and community partners. Our Care Managers can be contacted at 8181 3288, Monday to Friday, 9am -6pm. for advice, information, or an assessment of care needs.