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5 ACTION Care Coordination Service

Alexandra Health started the Ageing-In-Place (AIP) Programme to address the issue of consistently high demand for subsidised beds in KTPH. A team initially identified a group of patients with three or more admissions to KTPH over a six-month period, and visited them in their homes to find out the causes for their frequent readmissions.
Following the visits, we discovered that other factors besides the patients’ medical conditions were causing their repeated admissions. These include:
Social e.g. financial difficulties, untrained caregiver
Behavioural e.g. patient’s non-compliance to medication
Environmental e.g. unsafe home
The findings are consistent with studies that indicated 70 per cent of these health determinants are modifiable and can be addressed via holistic post-discharge care.
The focus on post-discharge care is to ensure that patients who are discharged from the hospital receive help and support in recovering well and rehabilitating at home.  This can range from ensuring the right medication is taken at the right time and having regular meals, to regular physiotherapy, simple wound care to prevent further deterioration, and prevention of falls. 
By cutting down their readmissions, patients can better manage their healthcare costs.

KTPH’s Aged Care Transition (ACTION) Team streamlines and coordinates care services to support patients’ recovery in their transition from hospital to home or community. The ACTION Care Coordination Service is a free service targeted at elderly patients. The service may be extended to younger patients and those suffering from trauma, on a case by case basis.

A care coordinator will support the patient and his family for about two to three months with regular follow-up phone calls and home visits. Should the patient require a longer period of follow-up, the ACTION care coordinator will facilitate a referral to KTPH community nurses or another service provider.

The ACTION care coordinator will assess the patient on his medical, functional, cognitive and psycho-social aspects, and initiate an appropriate referral when needed.

Some of the services include:

  • Assessment of the patient’s home environment
  • Assessment of caregiver’s ability to cope in caring for patient
  • Patient education and caregiver training
  • Medical reconciliation during home visits
  • Phone reminders to patients for follow-up appointments

The ACTION Team has also set up a one-stop service hub at the Patient Service Centre at Level 1 of KTPH to provide information on community services and financial schemes, as well as facilitate applications for patients and their family members.



The focus of the ACTION Team is on the well-being of the patient recovering in his home or the community. Towards this end, the Team works closely with the clinical and allied health services in KTPH as well as community partners such as community hospitals, day rehabilitation centres, home medical and home nursing services. 

For enquiries on the ACTION Team, please call 6602 4654.

Interested to become a Care Coordinator? Please e-mail