Eastern Health Alliance members announce programmes providing seamless and targeted follow-up care for patients after hospital discharge The Salvation Army Peacehaven Nursing Home launches new transitional convalescent facility – the 32-bed ‘Grace Corner’ aims to facilitate transition of patients from hospital to home through rehabilitation and supportive care so as to optimise function, delay the onset of frailty and help elderly patients avoid long-term institutionalisation; Changi General Hospital announces Transitional Care teams that bridge hospital-to-home care Friday, 18 November 2011 – At the launch of the Eastern Health Alliance today, founding members The Salvation Army Peacehaven Nursing Home and Changi General Hospital (CGH) each unveiled programmes that are focused on helping selected patients with complex long-term health conditions improve their recovery outcomes and support them to stay healthier for a longer period in the community, after their discharge from hospital. Transitional convalescent facility in Peacehaven (Grace Corner): Rehabilitate, recover, and return home Grace Corner is an innovative facility in Peacehaven Nursing Home which aims to help patients with debilitating hip fractures regain physical mobility and the independence they need to return to their homes. From December 2011, it will receive patients from CGH who require low-intensity rehabilitation – of more than a month – with medical, therapy and nursing support. Peacehaven’s Executive Director Madam Low Mui Lang said: “Our experience working with severe hip fracture patients has clearly shown that given the right, targeted support and a strong, nurturing environment, these patients have a high chance of being able to walk and lead normal lives again. At the Grace Corner, our clients – not patients – will learn to live independently and do everyday activities. We want to create the independence they need to return home and live in the community.” The 32-bed facility models a comfortable home environment with home-style furnishings and a common dining area. Clients will attend regular therapy sessions on muscle-strengthening to allow them to perform everyday tasks like sitting up, getting out of bed, feeding themselves and getting to the toilet. This helps build up independence in preparation for their return home. They will also be exposed to lifestyle and social activities like gardening, karaoke and Nintendo Wii games, to make them feel at home as much as possible. Meanwhile, they will continue to be cared for by Peacehaven nurses, therapists, healthcare assistants and social worker, and CGH doctors as needed. Madam Low added: “Clients are given a lot of autonomy and are free to participate in the programmes they want. They must take personal responsibility to go for a programme. If they can’t, they will have to learn to ask a nurse for help.” Clients will be chosen based on their medical profile and an assessment of care needs by doctors, nurses, therapists and social workers from both CGH and Peacehaven. Grace Corner targets to have at least 80% of its clients ready to return home in six to 12 weeks, depending on their rehabilitation potential. Training for their caregivers will also be provided by Peacehaven to support the client when the client is fit for discharge. While the Grace Corner provides transitional care for patients who would benefit from slow rehabilitation, St. Andrew's Community Hospital has a rehabilitation programme for patients who would benefit from more intensive rehabilitation after a stroke or a fracture of the leg or hip. Transitional Care: Bridging the gap between hospital and home Transitional Care (TC) teams help patients with complex or multiple care needs, and help their caregivers cope with care at home for up to three months after discharge from hospital. These include patients with unstable medical problems like heart failure, recurrent lung disease, frail elderly who require close medical or nursing monitoring, elderly who need help with managing multiple medication and those with a history of multiple admissions or a significant risk of re- admission. Helmed by a team of doctors, nurses, physiotherapists, dietitians and pharmacists from CGH, TC teams help stabilise conditions that may still be relatively vulnerable, rehabilitate patients through exercises to maintain a level of functional capacity after acute hospitalisation, reduce the risk of discharge failure and unscheduled re-admissions to hospital, and provide social support to patients and caregivers. Dr Chris Lien, Director of Community Geriatrics at CGH said: “Caregivers for such complex, frail patients would typically become overwhelmed by the care needed and the coordination of care, and often the patient would be sent back to the A&E. We saw a real need for continued support to help post-discharge patients and their caregivers manage their condition holistically, so as to sustain and improve their outcomes over time.” TC was piloted in April 2010 for CGH’s geriatric patients, and became a full-fledged service for geriatric patients in February 2011. It has received very positive feedback. “Some patients have told us, for instance, that they are very happy and grateful that the patient can be managed at home with the TC team’s support while avoiding A&E and doctor visits. The benefits are undeniable,” said Programme Manager Ms Yvonne Ho. TC teams are planned to extend their coverage to orthopaedic patients in early 2012, and to all other CGH patients eventually. Patients who require continuing care in the community after the TC team has stabilised their condition and caregiving arrangements at home will be linked to appropriate community service providers, such as home medical care, home nursing care and day rehabilitation centres. Right care at the right time Mr T.K. Udairam, CEO of Eastern Health Alliance and CGH said: “Grace Corner and the Transitional Care teams aim to bridge current care gaps between the hospital and community. They support the Eastern Health Alliance’s goal of helping patients achieve the best recovery outcomes by providing the right, targeted quality care at the right time, so that they can recover better, stay healthier and be well cared for in their own community as much as possible.” About the Eastern Health Alliance The Eastern Health Alliance is the regional health system for eastern Singapore. It is a partnership of health service providers dedicated to delivering, through their combined expertise, the right quality care at the right time for each patient. The Eastern Health Alliance coordinates an integrated range of healthcare services, from disease prevention, treatment, through to ongoing care. For more information, please visit www.easternhealth.sg. About The Salvation Army Peacehaven Nursing Home The Salvation Army Peacehaven Nursing Home is a 401-bed facility with a full range of services aimed at providing professional care in a Christian environment for the ailing poor. Opened in 2000, it is the nursing home with the largest number of beds in Singapore, and is run by The Salvation Army, a global Christian charity. Its residents have varying degrees of mental or physical disability, and the majority are either destitute or from low-income families. Peacehaven, located at Upper Changi Road North, has 13 separate Resident Living Areas, each designed as an individual home-like environment with its own bathroom, pantry, television and nurse’s station. The needs of the residents are met in a holistic manner, with services ranging from clinical care like medication management, wound-dressing and colostomy care; therapy from occupational and recreational therapists; and advice from allied health professionals such as dietitians, geriatricians and pharmacists. Peacehaven seeks to make patients as comfortable as possible by creating a homely ambience. It was the first nursing home in Singapore to set up a specially designed facility in 2006 called the Hope Centre, to allow people with early to moderate dementia to live in a home-like environment with their own rooms. The facility has since become a role model and showcase for the care of relatively independent dementia residents. About Changi General Hospital Changi General Hospital (CGH) is a 790-bed hospital in the east recognised for its excellence and compassion in service and patient care. CGH offers a comprehensive range of medical specialties and services, helmed by a highly experienced and skilled team of healthcare professionals who consistently deliver excellent health outcomes and care for patients. CGH has established itself as a centre of medical excellence with services such as the Integrated Sleep Service, Breast Centre @ Changi, Hepatobiliary Service, Vascular Surgery, Gastroenterology, Endocrinology and the Changi Sports Medicine Centre. CGH believes in the power of compassion in caring for patients, showing concern and empathy for them throughout their health journey. To improve care for patients, CGH has adopted a proactive integrated care approach. Partnering healthcare providers in the east through the Eastern Health Alliance and innovating by adopting new medical technologies and systems, CGH aims to deliver better, seamless and integrated medical services. CGH has been JCI (Joint Commission International) accredited since 2005. .