For Mr Ng, discharge from the hospital was just the beginning of his road to recovery. The Regional Health System ensures that vulnerable patients like Mr Ng do not fall through the cracks. By appointing a Patient Navigator to coordinate his care, different healthcare professionals, welfare organisations and other sectors of the community are mobilised to provide a continuum of services to Mr Ng. This way, he can ease back into normalcy.

Mr Ng's story is published in our latest annual report.

A walking frame stands in a corner of Mr Ng’s rental flat, with clothes draped on it to dry. Mr Ng underwent an operation in early 2017 for spondylodiscitis, inflammation in his spine, which gave him severe lower back pain. “It was unbearable. I couldn’t walk and had to be hospitalised,” he explains in Mandarin.

Mr Ng was warded for a month after the operation. With the help of a Patient Navigator, Assistant Nurse Clinician Ong Li Jiao, and various community services, Mr Ng has made a smooth transition home and progressed from using a walking frame to a simple walking stick, or his handy tongkat.

Mr Ng is the face of many seniors in Singapore, with multiple health conditions such as hypertension and diabetes on top of spondylodiscitis. The role of Patient Navigators like Nurse Ong is to support such patients’ recovery, as well as synchronise care from different parties. Besides coordinating and explaining Mr Ng’s medication to him, she checks on him and ensures that he gets the equipment he needs. For example, she noticed that he was having difficulty moving around his flat, so she arranged to have grab bars installed.

“I made my first visit about two days after Uncle Ng’s discharge, as I was quite worried about him,” Nurse Ong said. “My colleagues saw to Uncle Ng’s needs in the wards, and I’d follow up at his home.

Today, Mr Ng is happy with his painfree simple life, enjoying the occasional phone call from his siblings. “I’m more confident, with the home visits and assistance. My favourite times are walking to the market for a breakfast of chee cheong fun, and watching TV serials in the late afternoon,” Mr Ng beams.

A BEACON OF LIGHT

When Nurse Ong first called Mr Ng to tell him that she would be dropping by for a home visit, he was apprehensive. He took a long time just using the walking frame to open the door for her. “I was quite shocked,” admits Nurse Ong. “The house was untidy and the floor was dirty. During my one-hour visit, he was lying down most of the time. I could see that he needed a lot of help.”

It took a while but Mr Ng has now completely opened up to Nurse Ong, who affectionately calls him “Uncle”. During her home visits, she performs a general check-up and makes sure his recovery, such as the healing of his wounds, is on track. When he complains of discomfort in his abdomen, she examines him to determine if the cause is a side effect from the medication.

THE COMMUNITY ANSWERS THE CALL

Nurse Ong also checks on the community services arranged by her colleagues. For Mr Ng, assistance is provided by Thye Hua Kwan Moral Charities. They send meals to his doorstep and provided personal hygiene services when he was first discharged. “I knew he would not be able to prepare his own food or take a shower by himself so I requested for those services,” explains Nurse Ong.

Now that his condition has improved, Mr Ng has stopped the personal hygiene services and requested for housekeeping services once a week. Thye Hua Kwan also provides Mr Ng with medical escort facilities.
For a typical follow-up orthopaedic consultation, a representative from Thye Hua Kwan picks Mr Ng up from home, accompanies him to SGH and stays with him during appointments, before seeing him home.

FROM HOSPITAL TO HOME SWEET HOME

Thanks to combined efforts under the Regional Health System, Mr Ng is able to lead a normal life, within his own home and community, establishing a routine for himself. Every day without fail at 3pm, he makes his way to the Senior Activity Centre at his void deck where he enjoys watching his favourite TV programme and having a drink with friends.

“I live a simple life, keeping to myself,” he says. “I was worried I wouldn’t be able to look after myself after my operation but now, I’m happy to come home, with Nurse Ong and community services helping me . I’m back to watching Taiwanese TV serials and drinking kopi with my kakis!”

Mr Ng Lye Huat’s recovery is possible with the support of the Hospital to Home programme under the SingHealth Regional Health System (RHS). Read about the journeys of Mr Ng and other patients like him in our latest annual report.