The Accident and Emergency departments are among the busiest parts of a hospital, but Tan Tock Seng Hospital (TTSH) has managed to cut the A&E visits of frequent hospital-goers by a third.
This 32 per cent reduction was achieved through comprehensive post-discharge medical care from the hospital's Virtual Hospital team, which provides medical care and advice via phone or visits patients in their own homes.
A study by the team - from September 2015 to March this year - showed that inpatient admissions from those in the programme had fallen by 44 per cent.
Between them, patients spent a total of 2,427 fewer days in the hospital in the six months after they were enrolled in the Virtual Hospital programme, compared to the six months before.
Dr Tan Kok Leong, deputy head of the Virtual Hospital team said caring for patients in their own homes gave them more ownership of their own healthcare.
"When we bring in the necessary support elements to the community, to the patient's home, we can see the patients go from being passive to actively participating in their own care," said Dr Tan.
"This is our key objective, to empower them to manage their problems and be able to have independence, rather than keep coming back to the hospital."
The Virtual Hospital, set up in August 2012, targets TTSH patients who have had three or more admissions in a year. Many of these patients have two or more chronic diseases that require long-term medication and nursing care.
After a patient under the Virtual Hospital programme is discharged, a member of the six-person team checks in with them on the phone a few days later. Sometimes, they do home visits in a week or two.
Members of the Virtual Hospital team also work with community and social service providers to care for patients with physical or psychological handicaps.
Mr Mohamed Ibrahim Abdullah, 65, who was hospitalised in 2012 for chronic obstructive pulmonary disease, hypertension, diabetes and high cholesterol, is one such patient.
He used to go to the hospital almost weekly as he had difficulty breathing. But after being enrolled in the Virtual Hospital, he is attended to via phone and needs to go for a check-up only every month.
A spokesman for TTSH said there are plans to enhance the Virtual Hospital with technology such as video consultations and remote health monitoring.
The team received the National Healthcare Group (NHG) Team Recognition Award (Gold) at the NHG Awards Ceremony yesterday.