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, Bright Vision Community Hospital (BVCH) works closely with key health and social care community providers, and General Practitioners (GPs) who are located near BVCH. 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, BVCH'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.
BVCH 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:
As part of the care integration plan under Regional Health Systems (RHS), BVCH has collaborated with Henderson Nursing Home to improve the quality of care for their residents and help them to meet the Enhanced Nursing Home Standards.
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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