Scientific Programme
Abstract
Register
Abstract
Year 2021
October 2021

SHBC1412

Abstract Title
The effectiveness of Community Health Team (CHT)-Inpatient ward-Agency of Integrated Care (AIC) / tripartite case discussion in developing care plans to aid transition from hospital to home.
Authors

L.L.LAU1, J.M.P. CHEE1, W.T. CHEN1, Z.R. TAN1, J.Y. YEO1, B. BANGAR1

Institutions

Tan Tock Seng Hospital1

Background & Hypothesis

Poor discharge planning and communication amongst care team affects patient’s care transition. A biopsychosocial approach was adopted to explore on patient’s care needs and co-develop a holistic discharge care plan. This study aims to evaluate the effectiveness of a tripartite case discussion in formulating discharge care plans for smooth transition from hospital to home.

Methods

Data was collected from July 2020 to March 2021 on the case discussions conducted by Ward Resource Nurse (WRN), CHT Nurse and AIC staff for patients who were admitted for seven days or longer in four acute care wards. Readmission rates pre- and post- 90days of weekly case discussion on 275 patients were measured.

Results

A total of 356 discussions was conducted for 275 patients. Fourteen patients (5.1%) had discussion done but nil established care plans, 43 (15.6%) were successfully discharged to community service provider(s), 99 (36%) were enrolled into CHT, 119 (43.3%) were followed up by WRN. A positive reduction in utilisation of hospital facilities was seen from 365 admissions pre-90 days to 146 admissions post-90 days. A survey questionnaire has shown that the discussions promoted closer communications amongst the team and raised awareness on the importance of discharge planning with available community support services.

Discussion & Conclusion

Tripartite case discussion is effective in helping to formulate better discharge care plan for patients and aiding smoother transition of care from hospital to home, as shown in the reduction of readmissions. This was achieved by the closer collaboration and communication between hospital and community teams.

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