KTPH's "Ageing-in-Place" scheme reduces readmission rates
Armed with a backpack of basic medical supplies and devices, Ms A'zizah Rais, a 24-year-old nurse from Khoo Teck Puat Hospital (KTPH), visits the homes of patients who have been discharged.
Making as many as 100 home visits monthly, Ms A'zizah's routine is part of a broader scheme to bring down the rate of hospital readmission, especially among elderly patients who have been hospitalised more than three times within a six-month period.
The "Ageing-in-Place" scheme was launched by the hospital in 2011 to lighten the workload of the staff at its emergency department, as well as to ease the perennial bed crunch. During such home visits, nurses try to find out why patients often end up in hospital and advise them how to avoid doing so.
One example is Madam Azizah Mohd Noor, who had been hospitalised up to four times a year. The 51-year-old diabetic also suffers from high blood pressure, and heart and kidney problems.
HOW SCHEME HELPS
Failure to take prescribed medication, lack of home safety measures and financial constraints are the top problems identified by the Ageing-in-Place scheme run by Khoo Teck Puat Hospital.
By tackling them, medical staff are able to help patients reduce the frequency of, or even avoid, hospital admissions.
For example, when patients self-treat serious wounds, they may end up getting an infection. This could escalate into a situation where emergency attention is required.
Under the scheme, community nurses visit patients at home to help them develop a comprehensive care plan. Therapists, pharmacists and dietitians could also be involved.
If a patient requires help in sorting his medication, a pharmacist may be assigned to assist him. A physiotherapist can help evaluate the home safety of patients who are vulnerable to falls.
Community nurses conduct basic health checks for patients at each visit, such as taking their temperature. They also give tips on financial assistance.