KTPH's "Ageing-in-Place" scheme reduces readmission rates

Senior staff nurse Serene Sng (left) and staff nurse Nursetiawati Abdul Rahman visiting Mr Lee Chee Keong, 73, at home to check on him. Mr Lee has breathing difficulties and often ends up in hospital. -- ST PHOTO: MUGILAN RAJASEGERAN
Senior staff nurse Serene Sng (left) and staff nurse Nursetiawati Abdul Rahman visiting Mr Lee Chee Keong, 73, at home to check on him. Mr Lee has breathing difficulties and often ends up in hospital. -- ST PHOTO: MUGILAN RAJASEGERAN

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.

During her first few visits to the former administrative officer's home in February, Ms A'zizah was puzzled that the patient's blood pressure remained high despite being put on medication.

After investigating, she realised that Madam Azizah had 21 types of medicine for her conditions and had not been taking them as claimed by her. The mother of six also indulged in fried chicken skin, mutton and beef fat, on top of treats like chocolate.

But things have now changed. A hospital pharmacist visited Madam Azizah and helped reduce her medication to just nine types. The team also trawled her kitchen to point out the unhealthy food that she should avoid.

"Last time, when my blood pressure was high, I didn't care. Now, I am scared because I know the health risks," said Madam Azizah, whose weight has since plummeted from 134kg to 103kg.

With success stories like Madam Azizah's, the scheme may be expanded. A comprehensive evaluation of the scheme is ongoing and details will be unveiled by KTPH next year.

Conducted by Duke-NUS Graduate Medical School, the evaluation seeks to assess the effectiveness of the scheme and whether it can be adopted by other health organisations, said Mr Lau Wing Chew, chief transformation officer at Alexandra Health, which runs KTPH.

The Ministry of Health also said it will "study the feasibility of implementing similar models across Singapore if the results of the full evaluation are positive". It added that several models similar to the KTPH scheme are undergoing trial.

Initial findings of the scheme provided by KTPH to The Sunday Times show that it has helped slash readmission rates by as much as 61 per cent.

This was based on the first 400 patients involved in the scheme, whose ages range from 19 to 109 and who are suffering from conditions like chronic obstructive pulmonary disease and diabetes.

The average six-month readmission rate among them has fallen from 3.47 to 1.34 times per patient. This translates to 29 beds being freed up at the hospital's inpatient wards.

Based on the 800 patients currently on the scheme, the hospital is possibly saving about 60 beds every six months.

Mr Lau, who is also the co-director of the scheme, cited a few factors for its initial success.

"We go to the homes and see things that we can intervene - stopping self-medication for wounds or getting patients to take their medicine as instructed."

Nurses also give home safety tips to patients, such as advising them to install grab-bars to prevent injuries from falls. Such actions will ensure that patients are less likely to suffer from injuries or ailments that necessitate a visit to the hospital, said Mr Lau.

Another patient who has benefited from such home visits is retired laboratory worker Lee Chee Keong, 73, who has been in and out of hospital for the past several years. He suffers from a restrictive lung disease caused by a severe curvature of his spine.

Last year, he regularly showed up at KTPH, complaining of breathlessness. This year, he has managed to avoid returning to the hospital, thanks to the regular checks by nurses at his four-room flat in Yishun.

Nurses have taught him how to use a machine that helps him breathe properly during sleep.

"They encourage me to exercise too. I feel less breathless these days," said Mr Lee.

Beyond home visits, nurses also operate out of 11 "community nurse posts" located in residential estates in Nee Soon and Sembawang GRCs. Anyone can drop in there for health checks and advice.

Staff nurse Yap Mei Kei, who is stationed at Nee Soon South's Wellness Centre, at the void deck of Block 839 Yishun Street 81, said she also carries out tests to assess if the residents are suffering from conditions like memory loss or poor mobility, and helps them to sort out their medication.

Dr Lee Bee Wah, MP for Nee Soon South, lauded the community posts as a "good concept". She hopes the collaboration will lead to a better understanding of the health needs of residents in her constituency.

One such resident is Madam Ng Leng Hua, 58, who said she visits the Wellness Centre every week for health checks as she is worried about high blood pressure.

"If I don't come here, I wouldn't know my health status," she said.

chpoon@sph.com.sg