Year 2021
September 2021


Abstract Title
Descriptive Study of A Therapist-led Transitional Care Service in Community Health Team (CHT)



Tan Tock Seng Hospital1

Background & Hypothesis

In response to the COVID-19 pandemic in 2020, Physiotherapists and Occupational Therapists from Tan Tock Seng Hospital’s Community Health Team (CHT) piloted a therapist-led transitional care service. This service sought to minimise prolonged hospital stay and transit patients back into the community safely. The aim of this study is to review the effectiveness of this service model.


A descriptive analysis was done for patients referred to the CHT therapist-led transitional care service from April 2020 to March 2021.


102 patients (45 females, 57 males; mean age 72.4 years) were referred. 72% patients were enrolled for home-based intervention and 26% were enrolled for telephonic follow-up. 25% of the patients enrolled were lone elderly, while others either stayed with family members or a helper. A total of 147 home visit sessions were conducted with an average of 1.8 telephonic reviews made for all enrolled patients. Common interventions included education and case co-ordination (98%), home exercise prescription (73%), and home safety assessment/modifications (57%). The average length of service provided was 41.7 days, and more than 50% of enrolled patients were eventually discharged to intermediate and long-term care services.

Discussion & Conclusion

Our findings demonstrated that CHT therapist-led transitional care interventions play a major role in supporting patients at home post-acute care. Our findings also suggested the potential of tele-consults as an alternative to home visits when appropriate. To determine the effectiveness of this service model, further evaluation of patient outcomes and comparison with other transitional care models locally or internationally are needed.