Hospital-to-Home: A Model for Transition of Care

Abstract

Singapore is among the fastest-aging countries in the world. By 2030, about one in every five residents would be 65 years or older and many of them may need long-term home care. Local studies have predicted a rise in disability rates as the population ages. To meet this need, our government has ramped up home care services to enable the elderly to “age in place” at home. In line with the Singapore Ministry of Health's vision of building sustainable healthcare and the initiative of "Beyond Hospital to Home", transitional care programmes in hospitals were renamed Hospital-to-Home in April 2017. Under the programme, a comprehensive care plan is constructed to ensure safe and seamless transition from hospital to community settings. This requires the expertise of a multidisciplinary team to establish care needs as well as implement appropriate and cost-effective interventions to achieve positive outcomes. An enhanced nursing role, "Patient Navigator", was established to help navigate the transition of care beyond the usual nursing care needs that oversees coordination of care and social services.