Hospital to Home (H2H) is a nationwide programme that supports patients’ safe and timely transit back home, so that they can stay well and age gracefully in the community. It is targeted at patients with complex health and social needs, and a high risk of readmissions.
During the patient’s hospital stay, a multi-disciplinary care team comprising doctors, nurses, therapists and medical social workers assesses the patient’s post-discharge needs and puts together a personalised care plan. Depending on each individual’s needs, the plan would cover medical and social support services such as home and day care, psychosocial support, medication reconciliation, financial assistance, interim caregiving, and meals-on-wheels.
Once the patient is discharged from hospital, the H2H care team conducts home visits for those with higher care needs and calls them regularly to ensure they are recovering well. We also work closely with community health service providers such as NTUC Health, Thye Hua Kwan Moral Charities, and the Tsao Foundation to ensure that patients receive the support services that they require to get well and keep well.
At SingHealth, Hospital to Home is complemented by the
Neighbours for Active Living programme run by Changi General Hospital (CGH) and the South East Community Development Council.
The Community Care team at CGH trains volunteers to care for vulnerable elderly living near them, equipping them with skills such as how to build enduring relationships with the elderly, how to identify red flags and assess if the elderly need medical attention. They also accompany volunteers on their initial home visits, and regularly review the clients’ cases.
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