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Friday, 21 June 2013

KTPH project cuts hospital readmissions

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A team of nurses conducted regular home visits to check on Mr Teh C E’s (picture) general health. Photo: Khoo Teck Puat Hospital

Nurses visit homes, develop personalised care plans as part of Ageing-in-Place programme mailprintView all commentsTweet Pin It

Share on Tumblr By Eveline Gan - 19 June

SINGAPORE — Diagnosed with severe hypertension, Mr Teh C E was hospitalised at Khoo Teck Puat Hospital (KTPH) for almost three months following surgery and a stay in the intensive care unit. Instead of sending her husband to a nursing home after he was discharged, Mrs Teh chose to care for him at home, even though he was bedridden and on a feeding tube.

By all accounts, Mr Teh, who is in his 50s, is a classic example of a patient who is likely to be repeatedly admitted to hospital. Yet, support from the hospital has made it possible for Mr Teh to continue living at home. He has also managed to avoid another hospital stay in the past two years.

Mr Teh is among the patients who have benefited from KTPH’s Ageing-in-Place (AIP) programme, an initiative which identifies and offers assistance to patients with a history of frequent readmissions.

Under the programme, the hospital’s community nurses visit each patient’s home, develop a personalised care plan and coordinate necessary follow-ups, said Chief Transformation Officer of Alexandra Health Lau Wing Chew.

The care plan covers a range of medical, social, environmental and behavioural issues. For instance, if the patient’s home is found to be unsafe and has a high potential for falls, the nurse will apply to have grab bars and ramps installed. A pharmacist may also be called in if the patient has issues with his prescription.

Some 400 patients who were hospitalised at least three times over a six-month period have been identified since the programme started in 2011.

According to Dr Wong Sweet Fun, Senior Consultant at KTPH’s Department of Geriatric Medicine, the majority of these patients belong to the older age group and/or have multiple chronic illnesses such as hypertension, chronic obstructive pulmonary disease or diabetes. “However, prudent management of these illnesses at home minimises unnecessary readmissions,” she said.

Overseas studies have shown that a majority of hospital readmissions are directly influenced by a patient’s environment and behavioural patterns. For example, a patient who is not taking his medication correctly, faces financial difficulties or lives in an unsafe home environment is at higher risk of repeated hospital admissions, Mr Lau said.

To further reduce unnecessary readmissions, KTPH recently identified a group of 800 patients with two hospital admissions in a six-month period. Using an analytics technology, doctors were able to target specific patients who were most likely to be readmitted for a third time in the following month.

“This allowed our nurses to prioritise their home visits for more vulnerable patients,” said Mr Lau. He added that the pilot project achieved results of over 90 per cent accuracy.

There are currently 800 patients in KTPH’s AIP programme, which does not require additional payment by patients. Mr Lau said that, with timely intervention, the hospital can potentially free up to 58 beds in a six-month period.

In Mr Teh’s case, patient care has extended beyond the hospital setting. A team of community nurses offered support by collecting donations for a hospital bed to be placed at his home, installing ramps in the home as well as coordinating visits from various therapists. They also conducted regular home visits to check on his general health.

“Today’s healthcare is not merely about prescribing drugs or recommending surgery to deal with surface symptoms. It is about taking a holistic approach by looking at the various environmental and lifestyle factors that affect a patient and how they affect his chance of recovery,” said Dr Wong.

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