In a recent article in The Straits Times ‘Bring back house calls’, Dr Sandeep Jauhar called for the return of house calls in the United States, owing to lack of continuity of care for patients post-discharge and resulting in costly unplanned hospital readmissions.
However, according to Associate Professor Gerald Koh from the NUS Saw Swee Hock School of Public Health, in Singapore, hospitals and intermediate and long-term care providers have been working closely to tackle on care for patients after discharge.
Aged Care Transition (Action) teams of care coordinators, set up by the Agency for Integrated Care (AIC), are stationed at public general hospitals to arrange appropriate community care services for patients and caregivers prior to discharge, helping patients transition smoothly from a hospital to home setting.
These transitional care services also help minimise the occurrance of “frequent fliers”, patients who are unnecessarily readmitted to hospitals multiple times.
There are also numerous initiatives in place, such as Khoo Teck Puat Hospital’s Community Nurse Home Visit Programme, the Tsao Foundation’s Hua Mei Mobile Clinic, and Care for the Elderly Foundation’s CODE 4 Home Care, geared towards developing individualised care plans for patients and caregivers, as well as multidisciplinary long-term home care for medically stable, housebound elderly people.
A/Prof Koh also highlighted the importance of communication systems, such as the new National Electronic Health Records system, which improves communication between hospital teams and primary care physicians.
Media Coverage:
- Patients gain from new focus on home care, The Straits Times, 2 November 2015