[AVBC 2025] Accountable Discharge Care Model: A Nurse-led, Team-based Approach
Care Process & Redesign
Appropriate & Value-based Care Conference
National University Health System
6 November 2025
To align discharge planning in an inpatient ward through a nurse-led, team-based approach. Early, structured and collaborative discharge planning is the key to safe transition from hospital to home.
Year Submitted: 2025
Published Date: 06 November 2025
Tags: Care Process ＆ Redesign, Discharge Planning, Value Based Care, Workflow Redesign, Quality Improvement
About this Content
Aims
To align discharge planning in an inpatient ward through a nurse-led, team-based approach
Background
The initiative is a pilot project conducted at the National University Heart Centre, Singapore, and the National University Hospital.
Methods
The approach involves a nurse-led, team-based model for discharge care.
Results
Refer to project attachment.
Conclusion
Early, structured and collaborative discharge planning is the key to safe transition from hospital to home.
Lessons Learnt
Refer to project attachment.
Keywords
Nurse-Led, Team Based, PDCA
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | National University Health System |
Organization(s) Involved | National University Hospital, National University Heart Centre of Singapore |
Platform(s) | Appropriate & Value-based Care Conference |
Healthcare Professional Group(s) | Medical, Nursing, Allied Health, Pharmacy |
Applicable Specialty or Discipline | Cardiology, Medical Social Workers |
Project Lead(s) | Angeline D/O David Raja |
Project Member(s) | Lee Xin Yu Jasmine |
Connect with this contributor!
Lee Xin Yu Jasmine - jasmine_xy_lee@nuhs.edu.sg
Project Attachment
476_NUHS_NUHCS_AVBC_2025_Accountable_Discharge_Care_Model_A_Nurse_led_Team_based_Approach.pdf