Year 2021
September 2021


Abstract Title
Beyond the Walls - Promoting Safe Transitions Home



Yishun Community Hospital1, Khoo Teck Puat Hospital2

Background & Hypothesis

Transitions from hospital to home are vulnerable exchange points where miscommunication, errors, discontinuity of care and safety risks abound.

The Yishun Community Hospital (YCH) Aged Care Transition (ACTION) team comprises Medical Social Workers (MSW) and Social Work Assistants (SWA) who facilitate safe transitions of patients beyond our hospital walls.


Previously, post-discharge support was reactive. The YCH team formulated the CH ACTION care model and workflow using Plan-Do-Study-Act (PDSA), emphasizing early identification of vulnerable patients and good handover from inpatient to CH ACTION team.



Comparative studies of 572 CH ACTION patients with separate control groups showed 7% decrease in 3-day and 30-day Emergency Department readmission rates, and a significant reduction of 0.9 non-elective acute hospital bed day per patient.

Transitional support has reduced non-elective readmissions and acute hospital stay. These decreased risk of hospital-acquired infections and improved patient and caregiver well-being.

CH ACTION capitalised on MSWs’ training and sharpened MSWs’ community work skills. It promoted health-social integration through facilitating stronger linkages with community partners and care continuity.

Discussion & Conclusion

Sustainability can be built through setting standards and ensuring consistency. To-be, the programme can be scaled across our campus to support patients at Khoo Teck Puat Hospital.

MSWs, experts in social care, play a key role in transitional care. Feasible discharge care goals set by the inpatient team, early identification of patients requiring transitional support, good handover and follow-through ensure continuity of care beyond our hospital walls, and promote positive outcomes for our patients and caregivers, health campus, and community partners.