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SPECIALTIES & SERVICES

2 Community Nurse Home Visit Programme


Alexandra Health started the Community Nurse Home Visit Programme to address the issue of persistently 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:

  • Medical
  • Social e.g. financial difficulties, untrained caregivers
  • Behavioural e.g. patient’s non-compliance to medications
  • Environmental e.g. unsafe homes

The findings are consistent with studies that indicated 70% of 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. By cutting down their readmissions, patients can also better manage their healthcare costs.

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.

AIP community nurses are geographically organised according to the 10 divisions in Nee Soon and Sembawang GRCs in the North. The care model is “high touch” in that the community nurses first build trusting relationships with patients and their caregivers in their homes, holistically assess their clinical, social and environmental needs, and co-develop individualised care plans for patients to keep them well at home. In line with high touch care, the AIP community nurses become the patients’ single point of contact for care access and navigation of available assistance schemes and services. Dietitians, pharmacists and physiotherapists may also conduct home visits jointly with the community nurses.

Patients on this programme are identified by KTPH and must meet specific criteria.

 

                                  Top Award

The Community Nurse Home Visit Programme was one of the three Gold Award winners at the Public Service 21 ExCEL Awards 2013 in the category for“Most Innovative Project/Policy”. The PS21 ExCEL Awards celebrate innovative ideas and projects by public service organisations that have made significant impact within and beyond their organisations.

The Community Nurse Home Visit Programme, as part of the Ageing-In-Place Programme, won the first prize in the 2014 United Nations Public Service Award in the category of “Improving the Delivery of Public Services”. The Award was conferred at the UN Public Service Forum, Day & Awards Ceremony on 26 June 2014. Alexandra Health is the first public healthcare institution from Singapore to win this prestigious international award that celebrates the creative achievements and contributions of public service institutions that have resulted in a more effective and responsive public administration in countries worldwide.

Alexandra Health’s Ageing-In-Place Programme Team with the 2014 UN Public Service Award
Alexandra Health’s Ageing-In-Place Programme Team with the 2014 UN Public Service Award: (from left) Senior Staff Community Nurse Ang Man Yun, Dr Wong Sweet Fun (Alexandra Health System's Chief Transformation Officer, Senior Consultant, KTPH’s Department of Geriatric Medicine), Cynthia Lee (Executive, AIP Programme), Mr Lau Wing Chew (then Chief Transformation Officer) and Senior Nurse Manager Jesbindar Kaur.


Read on to find out how AIP community nurses have helped two patients to achieve a better quality of life.

 

Mdm Goh's Story                                                      Mdm Santarleha's story

                      

Click here to read more                                               Click here to read more

 

 

 

The community nurses also work with community partners such as grassroots organisations and voluntary welfare groups to address the patients’ needs holistically to facilitate ageing in place. The nurses act as a single point of contact maintaining overall ownership of the patient while facilitating assistance from multiple community resources.
Some of the partners we work with:

The community nurses also work with community partners such as grassroots organisations and voluntary welfare groups to address the patients’ needs holistically to facilitate ageing in place. The nurses act as a single point of contact maintaining overall ownership of the patient while facilitating assistance from multiple community resources.

Some of the partners we work with:

                                     

                                           Click on the “leaves” to access our partners’ websites. 


Click to read more about the AIP Programme in the news:

Patients gain from new focus on home care — The Straits Times, 2 November 2015

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Tri-Generational Home Care at North West Programme - Students' home visits bring warmth and joy to elderly patients — Shin Min, 6 July 2015

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Student visits bring cheers to the elderly — Berita, 3 July 2015
Suasana yang sunyi dimeriahkan dengan kehadiran lapan pelajar yang melawat pasangan warga emas itu sekurang-kurangnya sekali sebulan.

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Home care programme commences. North West seniors receive medical care without having to leave home — Zao bao, 29 June 2015

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Tri-Generational Home Care at North West Programme — Wan Bao, 27 June 2015
Students volunteer to conduct home visits and do health checks for elderly patients

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What's needed for home care to work — The Sunday Times, 1 March 2015
Khoo Teck Puat Hospital found that giving 800 patients home care saved about 60 beds, or close to two wards of space, over six months.

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More return to hospital within a month — The Straits Times, 3 January 2015
More people are landing back in hospital within a month of being discharged, prompting hospitals here to ramp up care for patients in their homes and the community, so they can avoid such re-admissions.

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Khoo Teck Puat Hospital's new programme wins UN Public Service Award — Shin Min Daily News, 27 June 2014
A new community programme by Khoo Teck Puat Hospital that has successfully helped to bring about "bed savings" beat 700 nominations from 80 other countries to win the United Nations Public Service Award.

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Khoo Teck Puat Hospital's Ageing-In-Place programme wins the United Nations Public Service Award — Lianhe Zaobao, 27 June 2014
The Ageing-In-Place Programme by Alexandra Health System's Khoo Teck Puat Hospital beat 704 nominations from 80 other countries to win the United Nations Public Service Award.

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Alexandra Health wins UN Public Service Award — The Straits Times, 26 June 2014
The Alexandra Health System on Thursday became Singapore's first healthcare system to win a United Nations Public Service Award - for a scheme to keep people out of its hospital.

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Alexandra Health wins UN Public Service Award — CNA Online, 26 June 2014
Alexandra Health System (AHS) has become the first public healthcare system to win a United Nations Public Service Award for its Ageing-in-Place (AIP) Programme.

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KTPH project cuts hospital readmissions — Today, 19 June 2013
Nurses visit homes, develop personalised care plans as part of Ageing-in-Place programme.

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Disco classic’s dance moves help pupils improve Chinese (Article on AIP’s PS21 Award win) — Straits Times, 15 Nov 2013
Khoo Teck Puat Hospital and national water agency PUB also got gold for the Ageing-in-Place programme and Kallang River @ Bishan-Ang Mo Kio Park project respectively.

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Home checks cut hospital stay — The Sunday Times, 15 Dec 2013
KTPH's "Ageing-in-Place" scheme reduces readmission rates and may be adopted by other centres.

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Hospital admissions cut as patients encouraged to recover at home — Lianhe Zaobao, 14 Dec 2012
A new initiative by Khoo Teck Puat Hospital introduced last year - where community nurses visit the homes of frequently-admitted patients - has helped to reduce hospital admissions and brought about savings for such patients.

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Keeping ‘frequent flyers’ at home — The Straits Times, 14 Dec 2012
Singapore's newest public hospital is expanding a scheme which has seen it slash numbers of patients being admitted repeatedly - and often unnecessarily.

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For enquiries on the community nurse home visit and community nurse posts, please call 6602 2202 or e-mail ktph.community.nurse@alexandrahealth.com.sg.