To Increase Confidence Level of

“ESTHER” during Transition

from Hospital to Home

Presenter : Zunaitha

Community Partnership Council Meeting 16 February 2017

Esther Network Project Presentation

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S/No Name Designation

1 Ms Zunaitha Begum Patient Navigator, SGH (Team

Leader)

2 Ms Seng Gek Siang Patient Navigator, SGH

3 Ms Audrey Leo Care Manager of Cluster Support

@ Bukit Merah, NTUC Health

4 Ms Xu Yi Patient Navigator, SGH

5 Ms Magdalene Ng Assistant Nursing Director, SGH

Team Members

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S/No Name Designation Organisation

1 Dr Tracy Carol Ayre Chief Nurse SingHealth

2 Ms Jess Ho Principal Social Worker/

Centre manager

NTUC Health,

Cluster Support

Project Sponsors

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Background Information of Mdm Tan

Madam Tan

75 years old

• Visited Emergency Dept 11 times

Admitted 8 times (Mar to July 16)

• Medical:

• Co-morbidities:

Diabetes,Hypertension

• Functional status:

• Ambulant with walking stick

• Psycho-social:

• Widowed, living with flat mate in

rental flat

• Wants to go home

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Mdm Tan’s Concerns:

• No confidence in living independently

• Confused by the multiple care providers

• Not sure who to approach when she needs help

• Discharged home alone

• Being in reasonably good health as her top priority

• Prefers to go back home instead of going to senior group home

• Desires to be able to cope with her own care in the community

and to get help in the community

Mdm Tan’s Wishes:

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gap

gap

Entry to hospital

Discharge to community Community

Hospital

Transition of Care

Esther: “After I am

discharged, I don’t

know who to call

when I need help”

Unable to find out

how Esther has

coped in community

prior to admission

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Problem Identification

• No immediate ‘handshake’ between

acute and community partners upon

discharge

• No point of contact

• Issues can arise

• Medications error

• Medical documents misplaced

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Project Aim:

• To increase confidence level of ‘ESTHER’

• Keep ‘ESTHER’ in the community as long as

possible

• Early handover to community service provider

• Avoid unnecessary visits to Emergency Dept

and readmissions

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To remain at home independently

To make her own decisions

Have a contact person she can turn to for help

Intervention Refer to cluster support, prearrange discharge handover

Patient Navigator (PN) to escort patient home & handover to Case manager (CM)

PN to continue to collaborate with CM

PN and CM to remain as resource/ point of contact

PN educate patient on care management

CM provide ongoing psychosocial support

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PN Assessment/ Observation

• Medication Issues:

• Over-stock of medication

• Knowledge deficit

• Unable to retain information on

planned endoscopy and preparation

• Unsure of how to tap on existing

services

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Interventions by PN Post Discharge

Home visit on the

same day post

discharge

Home visit

3rd day post

discharge

Follow-up call 6th day

post discharge

Follow-up call 9th

days post discharge

Follow-up call 12th

days post discharge

Illustrates that Mdm Tan’s needs may be high in the beginning but there are long term gains in terms of her successful re-

integration back at home and in the community

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Interventions by Community CM

• Weekly home visits, build client’s social support network

• Arrange CAN Carer (volunteers) to visit patient regularly for psychosocial support

• Arranged counselling support

• Review safety of home environment

• Help client navigate community resources

• Update PN regularly, liaise with PN if patient has any medical issues

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Results

(Score 0-10) Pre-I

19.7.16

Post-I

9.9.16

Post -II

6.1.17

1 Moving around at home 2-3 4-5 8 to 9

2 Showering 2 3 8 to 9

3 Toileting 7-8 7-8 8 to 9

4 Dressing 7-8 9-10 8 to 9

5 Eating 5 5 8 to 9

9 Medication-taking knowledge 1-2 4-5 8 to 9

7 Shopping 0 4-5 8 to 9

8 Moving around in my community 1 4 8 to 9

9 Sleeping 1-2 4 5

• Increase in ESTHER’S confidence

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Pre-intervention (1/3/2016 to 18/7/2016)

4.5 months

Visited DEM 11 times

Admitted 8 times

Post-intervention (19/7/2016 to 15/2/2017)

7 months

Zero DEM visits

Zero re-admissions

No need for senior group home

Results

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Early and effective

collaboration with

community partner is a key success

Patient Navigator Cluster Support

Success Factor:

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Recommendations

• Early “ handshake” in the ward, before

discharge, between PN and CM

• Close communication loop upon discharge

• Extending Cluster Support Services

• Escalation plan: Align with new model of care

(H2H)

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Community

Hospital

Transition of Care

Linked by

• Early Handover

of Care

• Team-based

care planning

discussion,

including

community

partners

Linked by

• Point of

contact in

hospital for

community

partner

• Regular

networking

platform

Similar to Sweden’s “Safety Receipt” and “Welcome Home Package”

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