Some patients with complex co-morbidities and psychosocial needs may need post-discharge care support. Under the Integrated Primary Care for At-Risk Elderly (iPCARE) programme, BVH works closely with key health and social care community providers, and General Practitioners (GPs) who are located near BVH. By ensuring patients get follow-up care, the programme helps to prevent unnecessary emergency department visits and re-admissions to acute hospitals.
With patients' consent, BVH's doctors update the GPs on patients' health status, medical condition and medications. Patients also get assigned to a nurse case manager who can guide and coach them on how to take care of themselves after their hospital discharge.
BVH also supports GPs by providing key resources and manpower, including a multi-disciplinary team specially trained to coordinate care for multiple conditions. The team, consisting of doctors, nurses, physiotherapists, occupational therapists and social workers, review and develop a personalised care plan, and follow up with patients. The team also teach patients how to monitor their condition at home, maximise their capabilities to perform daily activities, make their environment safer by identifying barriers, and recommend devices that will aid their mobility or in respiratory care.The programme team helps to:
BVH doctors visit Henderson Nursing Home three times a week, spending four hours each session to provide medical coverage to the residents. The team plays an intermediate role between the nursing home team and healthcare professionals in the acute and community hospitals, to enable patients to receive the continuous care that they need across the various healthcare settings. The initiative also allows the care team to help residents with Advance Care Planning, and reduce their readmissions to acute hospitals
The collaboration also helps to strengthen partnerships among regional care providers, improving patient flow and coordination through a complex healthcare system, creating seamless care for an ageing population.
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