Supporting Transplant Patients: Resources for Collaborative Care with GPs

18 Mar 2025 | Defining Med

By Ms Ng Zhen Ling, Senior Transplant Coordinator, SingHealth Liver Transplant Programme; Ms Toh Xin Yi, Senior Transplant Coordinator, SingHealth Duke-NUS Transplant Centre

The article is contributed/written by SingHealth Duke-NUS Transplant Centre

For general practitioners (GPs) managing post-transplant patients, collaborative care with tertiary partners enables the best possible outcomes and quality of life. Discover the full spectrum of support available at the SingHealth Duke-NUS Transplant Centre – in our partnership with GPs to manage the long-term health of transplant recipients in the community.

INTRODUCTION

The SingHealth Duke-NUS Transplant Centre (SDTC) has developed an integrated care model combining specialised clinical coordination with structured psychosocial support, to ensure comprehensive care for transplant recipients.

This dual approach encompasses both medical management and community support, where GPs can leverage on additional resources and support systems to refer their transplant patients, thus enhancing the continuity of care between primary and tertiary settings.

The Transplant Journey: What Patients Can Expect

Understanding the transplant journey helps you prepare your patients for the process ahead.

The critical role of transplant coordinators

The transplant programme is supported by specialised transplant coordinators who guide patients through five key phases. Our recipient transplant coordinators manage comprehensive care coordination at every stage while ensuring seamless communication between all healthcare teams.

Throughout all the phases, they serve as the central point of contact, ensuring optimal outcomes through coordinated, patient-centred care. They work closely with our multidisciplinary team to provide comprehensive support for both patients and their families throughout the entire transplant journey.

The Transplant Journey: What Patients Can Expect

Phase 1: Pre-transplant evaluation	During this initial phase, our transplant coordinators: Serve as the primary point of contact for all new case referrals Provide comprehensive education to patients and families about the transplant journey, including programme outcomes and potential risks Help patients make informed decisions through detailed counselling Coordinate and schedule all necessary evaluations required for the transplant selection committee Manage the overall evaluation process, including follow-ups and documentation
Phase 2: Waitlist management	Once approved for transplant, patients enter the waitlist phase where coordinators: Work continuously to optimise the patient’s medical condition, ensuring they are ready for transplant at any time Maintain up-to-date surveillance records Ensure timely updates in the national waitlist system Monitor patient status and medical compliance Coordinate regular follow-up care
Phase 3: Transplant activation	When a potential donor becomes available, coordinators spring into action to: Facilitate donor referrals and assess donor suitability with the transplant team Oversee recipient selection based on medical urgency and compatibility Coordinate all aspects of recipient admission Arrange pre-transplant investigations Activate surgical and support teams Ensure all necessary preparations are in place for a successful transplant
Phase 4: Transplant and hospitalisation	During the critical transplant and recovery period, coordinators: Manage postoperative care in collaboration with the medical team Monitor patient progress closely Provide detailed education to patients and families Address any complications that may arise Prepare for and ensure a smooth transition to recovery at home Support families through the recovery process
Phase 5: Long-term follow-up	After discharge, the coordinators’ commitment to patient care continues as they: Coordinate regular clinic visits and follow-up care Monitor and follow up on laboratory tests and diagnostic investigations Triage patient calls and concerns Watch for signs of complications Ensure timely intervention when abnormalities arise Take prompt action on any flagged results or issues Provide ongoing support to patients and families

THE GP’S ROLE

The success of solid organ transplantation often depends on early referral and intervention. As a GP, your role in identifying and referring potential transplant candidates is crucial. We encourage you to reach out to our transplant coordinators for any questions or concerns about your patients' health.

One Journey, Many Transplants: A Community of Support

The journey of a solid organ transplant patient is often marked by resilience and a lifelong commitment to achieving better health. Each patient faces unique challenges, from physical recovery to emotional adaptation.

Recognising these complexities, SDTC established its first Solid Organ Transplant Patient Support Group to create a nurturing community for solid organ transplant recipients to connect, share stories and inspire one another.

MISSION

The support group was founded given that solidarity among transplant recipients can foster hope, reduce feelings of isolation and promote holistic well-being. With a mission to empower patients and caregivers, the support group aims to:

Provide emotional support: Create opportunities for patients to process their experiences through open discussions, group activities and guided reflection.
Educate patients: Offer access to valuable insights from transplant specialists, peers and caregivers on managing life post-transplant, covering topics such as health maintenance and emotional resilience.
Build a community: Establish a safe, inclusive space where patients feel heard, validated and supported by one another who understands their unique experiences.

STRUCTURE

The biannual support group sessions are thoughtfully structured to ensure meaningful engagements and tailored learning opportunities.

Organ-specific groups: In the initial stages, participants are divided into smaller, organ-specific groups, such as liver, kidney and heart transplant recipients. This focused approach allows patients to discuss organ-specific challenges in a comfortable and relatable setting, benefiting from the collective wisdom of others who have undergone similar procedures.
Mixed group sessions: As participants grow more confident and comfortable, they transition into mixed group sessions, where patients from all organ groups come together. These sessions highlight the shared aspects of the transplant journey, fostering broader connections and a deeper sense of solidarity.

ACTIVITIES AND HIGHLIGHTS

The support group engages patients through various activities designed to educate, connect and inspire.

Specialist talks: The support group sessions often begin with talks led by transplant specialists, including doctors and allied health professionals.
- Past sessions covered key topics such as mental health and emotional resilience, post-transplant dietary management and post-transplant skin care.
- These expert-led sessions provide patients and caregivers with actionable advice and practical tools to manage their health with confidence.
Peer-to-peer sharing: At the heart of the support group lies the peer-sharing sessions, where patients openly discuss their experiences.
- These meetings are emotional and uplifting, as patients recount their transplant journeys and personal growth. Caregivers are also given a platform to share their challenges and triumphs, recognising their crucial role in the transplant process. The exchanges are filled with tears, laughter and an overwhelming sense of encouragement.
- By the end of each session, many patients realise that others have faced similar struggles, reducing their feelings of isolation. They draw strength from the triumphs of fellow patients and feel validated in moments of vulnerability.
Social activities: These serve to strengthen bonds and promote holistic well-being.
- The group organises creative workshops and mindfulness activities. These events encourage relaxation, fun and deeper connections within the community.

IMPACT ON PATIENTS

The Solid Organ Transplant Patient Support Group has proven to be a transformative experience for its members. Patients and caregivers have reported numerous positive outcomes, including:

Emotional growth: Participants develop greater self-awareness, emotional resilience and confidence in their ability to navigate post-transplant life.
Improved health literacy: Specialist talks equip members with the knowledge to make informed decisions about their health, improving long-term outcomes.
Social connections: Friendships and support networks are fostered, as patients bond over shared struggles and victories. The impact of the support group is best illustrated in the words of its participants:
- “Hearing others’ stories gave me hope and reminded me of my own strength.”
- “Thank you for this initiative, I learned so much from the specialist talks and enjoyed interacting with other patients.”

PLANS FOR FUTURE DEVELOPMENT

As the support group continues to evolve, SDTC plans to expand its offerings to reach even more individuals in need.

Inclusion of cell and tissue transplant patients: Broadening the support network to include those who have undergone cell or tissue transplants, addressing their unique challenges and experiences.
Living donor support group: Establishing a dedicated group for living donors to provide resources, peer support and a platform for sharing their journeys. This initiative aims to recognise the donors’ contributions and support their physical and emotional well-being. Through these expansions, SDTC aims to create an even more comprehensive and inclusive community.

The Solid Organ Transplant Patient Support Group exemplifies the power of community and shared experiences. By providing a safe space for connection, education and encouragement, it has become a beacon of hope for transplant recipients and caregivers.

Through its continued efforts and commitment to inclusivity, the group is set to grow, empowering more individuals to overcome their challenges and embrace life after transplantation.

CONCLUSION

For the practising GP, awareness of these comprehensive support systems at SingHealth enables superior coordination of care for transplant patients. Whilst GPs continue to play a pivotal role in the day-to-day medical management of transplant recipients, they may now confidently direct patients to specific resources – whether it be connecting them with transplant coordinators for specialised medical concerns, or referring them to the support group for psychosocial assistance.

This integrated approach ensures that transplant patients receive consistent support across all healthcare settings, from tertiary centres to primary care clinics.

As SDTC expands its services to include cell and tissue transplant patients, GPs can expect even more comprehensive support systems to assist in the long-term care of their transplant patients. The collaboration between primary care physicians and specialised transplant services remains crucial in achieving optimal outcomes for this unique patient population.

This article is contributed by the SingHealth Liver Transplant Programme

ABOUT THE PROGRAMME

The SingHealth Liver Transplant Programme, established in 2005, represents a comprehensive multidisciplinary approach to liver disease management and transplantation. The programme brings together a diverse team of specialists, including:

Hepato-pancreato-biliary/ transplant surgeons
Hepatologists
Infectious disease specialists
Allied health professionals

This integrated approach ensures holistic care delivery, with all services centralised for patient convenience.

TRANSPLANT SERVICES
The programme offers comprehensive transplantation services, including:

Living donor liver transplant

Blood group compatible and incompatible options
Solutions for small-for-size grafts
Pure laparoscopic donor hepatectomy

Additional services

Adult deceased donor liver transplant
Combined solid organ transplant
Pre-transplant recipient assessment
Comprehensive donor assessment
Lifetime post-transplant follow-up care
Specialised post-living-liver-donation care

GPs who would like more information about liver transplant, please contact our SingHealth Liver Transplant Coordinators at:

Tel: 8123 2934 | Email: liver.transplant@sgh.com.sg

Ms Ng Zhen Ling is a Liver Transplant Coordinator at Singapore General Hospital. She manages new case referrals, as well as pre-, peri- and post-transplant patients. She works with a dedicated multidisciplinary team in the liver transplant programme to provide holistic care for patients with liver disease who require liver transplant.

Ms Toh Xin Yi is a Transplant Coordinator at the SingHealth Duke-NUS Transplant Centre. She plays a pivotal role in managing and facilitating the organ donation process. Her responsibilities include identifying potential organ donors from both brain death and cardiac death pools, ensuring high standards of quality and safety in transplantation and collaborating with transplant stakeholders to raise awareness.

To find out more about our transplant programmes, GPs can contact the SingHealth Duke-NUS Transplant Centre or visit the website here.Tel: 6312 2720
Email: sd.transplant.centre@singhealth.com.sg