[AVBC 2025] Integration of Community Nursing and Specialist Heart Failure Care Reduces Hospital Readmissions
Care Continuum
Care Process & Redesign
Technology
Appropriate & Value-based Care Conference
SingHealth
27 November 2025
The aim of the Homing-HF programme is to reduce HF-related emergency department visits and hospitalisations by integrating. The Homing-HF Programme demonstrated significant reduction in healthcare utilisation and is well received by patients and caregivers.
Year Submitted: 2025
Published Date: 27 November 2025
Tags: Care Process ＆ Redesign, Productivity, Cost Saving, Access To Care, Readmission Rate, Population Health, Community Health, Care Continuum, Intermediate and Long Term Care ＆ Community Care, Home Care, Technology, Telehealth, Tele-Consultation
About this Content
Aims
The aim of the Homing-HF programme is to reduce HF-related emergency department visits and hospitalisations by integrating community nursing with specialist heart failure care.
Background
Heart failure presents a growing challenge in Singapore's ageing population, with patients frequently having multiple comorbidities and substantial financial burdens due to hospital readmissions and emergency department visits.
Methods
The programme enrolled HF patients from cardiology wards and outpatient clinics, using a tiered follow-up system with CMN teleconsultations, home visits, and early HF clinic reviews based on symptom severity. ED visits and 30-day HF-related hospitalisations were compared pre- and post-intervention.
Results
Post-intervention, only 14% of patients had 2 ED visits, and 30-day readmissions fell to 28%. 72% of patients were managed successfully in the community without ED visits and hospitalisation.
Conclusion
The Homing-HF Programme demonstrated significant reduction in healthcare utilisation and is well received by patients and caregivers, representing a sustainable, cost-effective, and value-driven solution for HF care delivery in community settings.
Lessons Learnt
Structured community-based HF management reduces reliance on hospital-based services, enhances patient empowerment, and improves quality of care. Success factors include early nurse-led intervention, multidisciplinary care, and alignment with national healthcare goals.
Keywords
Heart Failure, Community Nursing, Hospital Readmissions, Value-based Care
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | SingHealth |
Organization(s) Involved | Sengkang General Hospital, National Heart Centre Singapore |
Platform(s) | Appropriate & Value-based Care Conference |
Healthcare Professional Group(s) | Nursing |
Applicable Specialty or Discipline | Cardiology |
Project Lead(s) | Evin Tay Geok Ling |
Project Member(s) | Zhang Jin |
Connect with this contributor!
Evin Tay Geok Ling - evin.tay.g.l@skh.com.sg