Hospitals’ follow-up cuts rate of re-admittance for chronically ill patients

THE hospital bed crunch that Singapore is facing has forced hospitals to take a hard look at their operations. In the process, a silver lining has emerged: better care for elderly patients.

Forced to find creative ways to free up beds for patients waiting for treatment, public hospitals have embarked on studies of hospitalisation trends.

They have found that a significant group of patients being admitted comprises elderly and frail patients suffering from chronic ailments such as hypertension, diabetes or heart problems. This group usually stays longer – two weeks on average, against a week for younger patients.

They are also often re-admitted. At the National University Hospital (NUH), for instance, one in five elderly patients with chronic ailments is re-admitted within weeks.

The irony is that many of these patients could have avoided being hospitalised if they had received better care for their chronic illnesses from their regular doctors, at home, or in nursing homes.

After studying the issue, hospitals decided to take steps to reduce “unnecessary” hospitalisation.

Measures that some hospitals have taken include working with nursing homes, general practitioners (GPs) in the community and family members and patients, to help them provide better care for the chronically ill so they do not get so sick that they need hospitalisation.

Some hospitals, like Changi General Hospital (CGH) and NUH, have teams to visit chronically ill older patients at their homes to ensure that they get proper post-hospital care.
 
Nurses telephone patients to check if they are taking their medicine regularly. If a patient says he is not feeling well, a nurse will find out why and, if necessary, fix an early appointment with the doctor.

Hospital staff say some older patients seem more comfortable telling a nurse over the phone that they are feeling worse, and leaving it to her to decide if they need to see a doctor, than taking the initiative to fix an appointment themselves.

Mr T.K. Udairam, head of CGH, said many older people take their illness as part of growing old, and try not to make a fuss. But this means they do not admit that they are in a bad way until they are
severely so. But when a nurse asks pointed questions, they do mention their additional aches and pains or breathlessness.

At Tan Tock Seng Hospital (TTSH), 40 to 60 of the beds are occupied at any one time by patients from nursing homes. This is the hospital most hard-pressed for space, and it has resorted to leaving patients in beds along its corridors.
 
TTSH works with several nursing homes in the vicinity to treat their patients there rather than in the hospital, saving the patients from the risk of catching bugs that infest all hospitals.

A team of doctors and nurses makes the rounds of these homes every day. They tell the nursing homes if they know patients are on their last legs.

Dr Ian Leong, head of the hospital’s Elderly Pain Service, said doctors can tell when a person is dying. Signs include breaths that are more drawn out, for example. Or he might gasp, followed by a long interval before the next breath. His blood pressure might taper down and his fingers and toes might start to get cold.

The family is told, so they know what to expect. Few would want the patient rushed to hospital at that time, Dr Leong said, preferring to spend the last hours quietly with the patient.

The hospital also has a team that would rush down to the nursing home in an emergency. The patient would get the same care as at the hospital, but without all the to-ing and fro-ing which could make his illness worse.

Mr Udairam said a third of the very sick patients who are admitted through CGH’s Accident and Emergency wards are over 80 years old. CGH continues to monitor them after they are discharged.

The hospital has a list of more than 50 GPs it works with, and pairs each patient with a GP of his choice.
 
Nurses continue calling up the patients to remind them to go for regular checks. GPs who don’t have the resources to do this are appreciative, and the hospital doesn’t end up with a patient again because he missed his scheduled check- up, said Mr Udairam.

All these are small but important steps to reduce the strain on hospital beds, given Singapore’s ageing population. The United Nations projects that Singapore will have the fourth-oldest population in the world by 2050.

Such measures also improve the quality of care for the elderly sick. Hospitals can share success stories and best practices to learn from one another. The model pioneered by TTSH and CGH of having nurses continue to monitor discharged patients, and working with GPs, could be replicated nationwide.

They can also work with home nursing providers, and occupational therapists or physiotherapists and dietitians.

If more support is needed, there may be scope for active retirees living in housing estates to take on the role of paid caregivers, visiting the elderly sick in their homes to check on their compliance with medication or treatment, and monitor their meals.

This would be in line with the Health Ministry’s objective of providing more health care to patients in their homes, rather than in hospitals or in institutionalised settings.

In reaching out to patients after discharge, public hospitals have taken a good first step in bringing post-hospitalisation care into the community.

In two to four years, pressure on beds will likely ease, with the opening of two more public hospitals. But this should not stop hospitals from continuing with their programmes to reduce unnecessary hospitalisation.

The key is for acute care hospitals to work with step-down care and primary care providers and with patients and their families to provide a seamless web of care to patients and to prevent their illnesses
from getting worse.