Mak Nenek comes a-calling at home...

This story was first published in The Straits Times on Nov 28, 2013

MR K. MUNISAMY, 61, was warded at Tan Tock Seng Hospital (TTSH) 12 times between Jan 18 and Aug 17 last year.

He is what the medical profession calls a "frequent flier" - a patient who is warded three or more times a year for the same medical conditions. His various ailments, including heart failure and high cholesterol, mean he often suffers from breathlessness, which lands him in hospital.

In August last year, TTSH's "virtual hospital" took over his case. Ms Di Teng, a senior nurse acting as his health manager, visited him twice a week in the first few months to find out why his condition deteriorated so badly that he needed such frequent hospitalisation.

She found that he tried hard to take his medication. But he struggled to keep up, because he had so many pills to take, and at different times of the day.

She raised this with the geriatric doctor who is part of this "virtual" team. The doctor paid Mr Munisamy a house visit and changed some of his medicine, reducing the total number and times he needed to take them.

Ms Di then packed his medicine into daily doses, some before breakfast, others after.

Since then, Mr Munisamy has been warded only twice. She now drops by his home every few months, but a voluntary welfare organisation (VWO) has nurses visiting him twice a week.

Home visits

MS DI explains that visiting patients at home helps her uncover their real problems. If they have financial problems, she links them with community help services.

Others have difficulty going for their medical appointments. Elderly patients living alone might also need help cleaning their homes. VWOs can help with these tasks.

The days when a hospital's interest and responsibility started when a patient entered its doors and ended when he was discharged are long gone.

Instead, the focus of public hospitals has shifted from merely treating patients who are ill to keeping them healthy and out of hospital.

Three regional health-care systems have been set up that do this: National Healthcare Group (NHG) helmed by TTSH, Eastern Health Alliance (EHA) with Changi General Hospital, and Alexandra Health with Khoo Teck Puat Hospital.

Each regional health-care system is in charge of more than a million residents in the vicinity it is responsible for. When the Ng Teng Fong Hospital in Jurong and the Sengkang hospital open, they too will form the nuclei of new regional systems.

These regional groups have hospitals which work with a group of health-care providers that include nursing homes, rehabilitation centres, polyclinics, general practice clinics and VWOs.

The partners work in close collaboration to keep "their" people in the pink of health and, preferably, out of hospital.

Ironically, this system started piecemeal some five years ago as a desperate bid to cope with a severe bed crunch that had patients sleeping in beds placed along the corridor of one hospital. But the attempt to keep patients out of hospital is turning out to be a formula for a healthier nation.

Said Professor Chee Yam Cheng, head of NHG: "The aim is for them to use less and less of the hospital, and to make sure that when they do use it, it's appropriate."

In a nutshell, the three groups now provide both pre- and post-illness care - on top of treating patients who are sick.

Pre-illness care has health-care staff going out into the community to screen residents for chronic ailments. Health Promotion Board staff are also involved in this.

At the EHA, residents in Simei and Tampines who are 40 years and older with no known chronic ailments are screened annually. This screening will be rolled out to other estates within the cluster's care.

Mr T.K. Udairam, who heads the alliance, said the screening managed to pick up about 1,000 people who were unaware that they were suffering from a chronic condition such as diabetes, hypertension or high cholesterol levels.

These patients are referred to a GP or polyclinic for treatment.

Said Mr Udairam: "After referring them for treatment, we become the "Mak Nenek" (grandmother in Malay) and will call them two to three times over the next few weeks to check if they are receiving treatment."

Those who have financial difficulties are referred to community help systems.

Over at NHG, Prof Chee wants his staff to get to know all 1.4 million people living in the central part of Singapore, and to identify those who are frail or might need help keeping illness at bay. So teams from TTSH have been going out with grassroots leaders on their community visits to get to know residents who might benefit from medical intervention.

Finding frequent fliers

AS THE population ages, the incidence of "frequent fliers" like Mr Munisamy increases, making it a challenge for hospitals to keep patient numbers down.

EHA started a Health Management Unit where nurses act as the contact person for patients with complex chronic conditions like diabetes and heart failure. They call patients a day or two after their discharge to discuss their problems and what they need to do.

EHA's Mr Udairam explained that older patients find it difficult to comprehend a whole list of instructions on the day of discharge. "Hospitals are busy places. Everything moves fast. Some doctors talk like they're rushing to catch a train. That doesn't work for older people."

So after the patient returns home, a nurse will call to see if the patient understands his condition and what he needs to do. This also gives the patient the chance to ask questions.

The patient is given a phone number to call if his condition changes before the next appointment with the doctor, or if there is anything he is unsure about. Some confused patients call up to check which pills they are supposed to take at night.

Alexandra Health also does home visits for frequent flier patients. Its spokesman said such visits to a group of 400 patients have reduced admissions from an average of 3.6 times to 1.2 times within a six-month period.

Home visits also help staff identify problems such as unsafe home environments that lead to falls, or patients' financial difficulties in affording the proper diet. They can then get the necessary help for the patients.

The three health-care groups learn from one another.

NHG is admired for its virtual hospital where a team monitors patients at home.

It also organises palliative care talks with patients and their families in nursing homes, so that they understand the role of palliative care for dying patients. This has significantly reduced the number of ambulance trips by patients to the hospital - sometimes only for the patient to die on arrival.

TTSH has extended such discussions on palliative care to terminal patients who live at home. This way, the patient and family can decide in advance whether they prefer to let nature take its course, with palliative care to reduce suffering, or to continue with maximum treatment.

One worry families have when a patient dies at home is getting a death certificate, without which the death becomes a coroner's case. The hospital has promised its long-term patients that it will issue a death certificate, even if the patient dies at home and not in hospital.

The way of the future

ASSIGNING a dedicated health manager to frequent flier patients. Knocking on doors to get residents screened to pick out chronic diseases. Sending nurses and doctors into homes to reduce the need for sick people to go to hospital.

All that may sound like a lot of visits and health-care resources devoted to a patient at home. But these visits help keep patients like Mr Munisamy out of hospital and mean the health-care system as a whole saves on resources.

It is a win-win-win situation: good for doctors and hospitals as they are freed to attend to the truly sick in hospital; good for patients who are cared for at home so well, they do not need hospitalisation; and good for the health-care system and country since this system uses less resources than one that has too many people lying in hospital beds.

It is the changing face of health care in Singapore, some adapted from practices round the world, which has seen a similar shift towards more preventive care, away from high-cost acute hospital care. The move to out-of-hospital health care is still in its infancy but it already promises a better experience, especially for seniors.

This story was first published in The Straits Times on Nov 28, 2013

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