Beyond the Walls – Promoting Safe Transitions Home
Care Continuum
Care Process & Redesign
AIC Community Care Excellence Awards
National Healthcare Group
31 December 2022
Facilitate safe discharge and post-acute care for complex elderly patients to reduce ED visits and non-elective admissions. The program was successful in reducing hospital readmissions and improving patient and caregiver satisfaction.
Year Submitted: 2022
Published Date: 31 December 2022
Tags: Care Process ＆ Redesign, Care Continuum, Quality Improvement, Lean Methodology, Workflow Redesign, Value Based Care, Safe Care, Productivity, Home Care, Outpatient Care
About this Content
Aims
Facilitate safe discharge and post-acute care for complex elderly patients to reduce ED visits and non-elective admissions.
Background
Elderly patients faced challenges with continuity of care post-discharge, leading to frequent ED visits.
Methods
Developed a proactive transition care model involving early identification of patients, follow-up calls, and partnership with community providers.
Results
Reduced 3-day and 30-day readmissions by over 5%, with significant improvement in patient outcomes and satisfaction.
Conclusion
The program was successful in reducing hospital readmissions and improving patient and caregiver satisfaction. It is now being scaled to other wards.
Lessons Learnt
The importance of early intervention, clear communication, and collaboration with community partners was key to success.
Additional Information
Winner of AIC Community Care Excellence Awards (CCEA) 2022: Productivity Improvement Gold Award
Keywords
Aged Care, Hospital-to-Home, Care Transitions, Readmission Reduction, Patient Safety, Community Partnerships
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | National Healthcare Group |
Organization(s) Involved | Yishun Community Hospital |
Platform(s) | AIC Community Care Excellence Awards |
Healthcare Professional Group(s) | Allied Health, Healthcare Administration |
Applicable Specialty or Discipline | Medical Social Workers |
Project Lead(s) | Esther Koh Hwee Cheng |
Project Member(s) | Chua E.C. |
Connect with this contributor!
Esther Koh Hwee Cheng - koh.esther.hc@yishunhospital.com.sg
Project Attachment
C_447_YCH_CCEA_2022_Beyond_the_Walls_Promoting_Safe_Transitions_Home.pdf