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Bridging care into the community

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The rehabilitation team journeys with the community, working hand-in-hand with individuals to maintain independence and quality of life on home ground.

One day, Mrs J* fell and fractured her hip – she had been feeling giddy, and has diabetes and high blood pressure. She underwent surgery to fix the fracture but had difficulty walking after the operation, and was later found to have fallen a second time when her blood sugar dropped too low.


For many patients like Mrs J, chronic diseases often take a toll on their health, with complications setting in as the diseases progress.


Even though more people live longer today, they may not necessarily be living better. Some may be frail to begin with, and have a serious illness requiring hospitalisation. Others are prone to falls and fractures, or have undergone major operations that place stress on their already weakened bodies.


As such, it is not uncommon for these patients to start declining in all areas of health, physically and mentally. They will require a longer period of recovery and will often benefit from a period of rehabilitation in a hospital.


Rehabilitation is not just for the frail or those who had surgery – it benefits anyone suffering a loss of function due to disease, injury or disability.


Helping patients achieve meaningful health goals
Teamwork is the key factor in rehabilitation where a multi-disciplinary team works together to provide the best care for each patient, which includes understanding their functional, psychological and social needs. Rehabilitation does not single out a problem area. Instead, we treat the whole person to get patients home and back into the community.


The team comprises family physicians, nurses, physiotherapists, occupational therapists, speech therapists, dietitians, medical social workers and pharmacists, each performing their own roles to provide holistic care.


Although the care focuses on rehabilitation, family physicians in the hospital continue to provide medical attention to stabilise medical conditions, treat chronic diseases, along with carrying out vaccinations and preventive screening for osteoporosis.


We involve patients in many healthcare decisions and respect their choices, so that they can continue to live meaningfully in spite of their existing medical conditions. In scenarios where patients depend greatly on their caregivers, the rehabilitation team can provide training for caregivers to look after them at home.


Bridging care, building communities
Patient care management does not stop with discharge from the hospitals. Family physicians and the team of nurses and allied health professionals anticipate the evolving conditions of their patients post-discharge, and coordinate care as a patient moves out of the hospital.


Post-discharge care preparations include planning which primary care doctors (general practitioners) the patient should see, and which day-care or rehabilitation centres they should go to receive ongoing therapy.


Home visits are also arranged to ensure that a patient will be safe at home after discharge. These visits may include instructions to modify existing home environments so that patients are able to move around independently and safely.


To prevent falls, occupational therapists may recommend home modifications such as grab bars and anti-slip tiles. For HDB flats requiring home modifications, these can be subsidised under the Enhancement for Active SEniors (EASE) programme.


The healing journey may begin in hospitals, but by connecting patients with the wider health care teams within their own communities, they can continue receiving the medical, nursing and therapy care when they return home – all in a day’s work for us in bridging care and building communities.


*This article appeared in Skoop issue #2 (Dec 2017) published by Sengkang General Hospital.