A scheme launched last April to help patients manage their conditions after being discharged from hospital has benefited about 8,000 people.
The Hospital-to-Home (H2H) programme aims to help patients with multiple medical conditions reduce their risk of re-admission by offering services such as home nursing.
The programme pools manpower resources by consolidating existing transitional care schemes run individually by hospitals. It zooms in on those who may need help in a more systematic way, to cut the risk of people falling through the cracks.
The scheme is part of a wider plan spelt out by the Government last year to shift healthcare from one centred on the hospital to one that caters to Singaporeans' needs closer to their homes.
"Our healthcare system was initially designed for a much younger population," said Health Minister Gan Kim Yong yesterday, noting that one in four Singaporeans will be aged 65 and above by 2030.
There is a need for a "seamless integration of care services organised around the patient", he added.
Mr Gan was speaking at the inaugural three-day Global Conference on Integrated Care 2018 at Resorts World Convention Centre.
A way to better integrate care is to make funding more flexible, he said, by moving away from per-day or per-visit funding towards funding the bundles of services needed for an event of care.
Workflows in identifying patients for the programme are more structured... Patients are more systematically identified and referred, based on their number of hospital admissions, medical history and age.
MR CHERN SIANG JYE, group chief of AIC's Regional Engagement and Integration Division, on how the Hospital-to-Home (H2H) scheme has a more foolproof way of identifying patients who need help.
For example, the H2H programme is funded on a per-episode rate to give flexibility for care providers to tailor services to each patient's specific needs.
The programme, which is run by the Agency for Integrated Care (AIC), has a more foolproof way of identifying patients who need help with managing their conditions at home, said Mr Chern Siang Jye, group chief of AIC's Regional Engagement and Integration Division.
"Workflows in identifying patients for the programme are more structured... Patients are more systematically identified and referred, based on their number of hospital admissions, medical history and age," he added.
Patients were previously identified for transitional care programmes mainly based on medical workers' interactions with them.
Pilots by individual hospitals have had good results. A study of 800 patients by Singapore General Hospital in 2012 found the transitional care pilot helped to reduce re-admission rates by up to 30 per cent.
One patient who has benefited from the H2H programme is retired sub-contractor Choo Kim Sua, 67, whose diabetes has led to kidney failure and a double leg amputation.
A nurse and medical social worker provided home nursing and caregiver support and referred him to community care services.
"It is still stressful, but they taught us how to take take care of him and ourselves as well," said his wife, Madam Sim Poh Cheng, 61, a part-time worker in a seafood restaurant who looks after her husband with support from a domestic helper.
In his speech, Mr Gan also noted that progress has been made in connecting social-and health-related services. The Care Close to Home programme, for seniors in ageing rental precincts, has benefited more than 2,500 seniors, he noted.