Projects

Project COMFORT – Supporting the Frail in the Community

Project Categories

Care Continuum

Care Process & Redesign

Platform

National Healthcare Innovation and Productivity Medals

Cluster

National University Health System

31 December 2024

Support patients with advanced frailty and their caregivers in their homes, reducing unnecessary hospital admissions and. The program successfully reduced hospital stays and supported frail patients at home.

Year Submitted: 2024
Published Date: 31 December 2024

Tags: Care Process ＆ Redesign, Care Continuum, Value Based Care, Patient Satisfaction, End-Of-Life Care, Palliative Care

About this Content

Aims

Support patients with advanced frailty and their caregivers in their homes, reducing unnecessary hospital admissions and clinic visits.

Background

Many frail patients prefer home care but lack confidence due to insufficient community support. Frequent hospitalizations increase their burden.

Methods

Nurse-led intervention involving home visits, telephonic reviews, care planning, and advance care planning (ACP).

Results

Reduced hospital admissions (median dropped from 2 to 0 annually). 40.3% of patients completed ACP, with 90% having their preferences honored.

Conclusion

The program successfully reduced hospital stays and supported frail patients at home. Future plans include expanding home-based support models.

Lessons Learnt

Engaging patients and caregivers improves confidence in home care. Consolidating teleconsultations reduces hospital dependency.

Keywords

Nurse-Led, Frailty, Healthy Ageing Programme, Hospital Admissions, Advance Care Planning

Innovators' Details

Healthcare Cluster(s)	National University Health System
Organization(s) Involved	Alexandra Hospital
Platform(s)	National Healthcare Innovation and Productivity Medals
Healthcare Professional Group(s)	Nursing, Medical
Applicable Specialty or Discipline	Geriatric Medicine, Palliative Medicine
Project Lead(s)	Hong Liyue
Project Member(s)	Tan Li Feng Jeremy Teng Tan Poh Hoon Myint Myint Than Radin Nur Faridah Binte Ali Nur Sa'idah Binti Jalani Siti Raihana Binte Mohamed Sharriff Heng Lee Ling Tan Li Ping Kelly Lai Santhosh Kumar Seetharaman

Connect with this contributor!

Hong Liyue - liyue_hong@nuhs.edu.sg

Project Attachment

427_AH_NHIP_2024_Project_COMFORT_supporting_the_frail_in_the_community.pdf