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Home > Central Health > Central Health Stories > R.I.S.E to the Challenge - A Holistic Care Model for Clients with Chronic Lung Disease to Reintegrate into the Community

 By Dover Park Hospice

Often, the quality of life for people with chronic lung disease is greatly diminished as their conditions progress over time with declining functional health status. The R.I.S.E. (Restitutive. Integrative. Supportive. Empowering) programme hopes to enable patients to continue living meaningful lives even as their conditions deteriorate with refractory and exertional breathlessness.

Piloted in January 2021, the R.I.S.E programme is a partnership between Dover Park Hospice, Tan Tock Seng Hospital and Ren Ci Hospital that aims to create a seamless ecosystem of care for patients with chronic non-cancer lung diseases such as Chronic Obstructive Pulmonary Disorder (COPD), Interstitial Lung Disease (ILD) and Bronchiectasis.

Through a multidisciplinary team comprising doctors, nurses, medical social workers, spiritual counsellor, occupational therapists and physiotherapists at Dover Park Hospice Day Care, the 12-week programme provides individualised rehabilitation, nursing, psychosocial and social support to empower clients in developing self-mastery skills, so that they can better manage their breathlessness and anxiety, and optimise physical functions through functional pulmonary rehabilitation.

In each session, the clients undergo an hour of exercise followed by educational sessions to equip them with the skills and knowledge for self-management. Through supported exploration and reinforcement of pacing of activity, medication use and expression of needs, the team encourages integrated practice of these skills and behaviour adaptations to enable clients to break the cycle of anxiety and breathlessness at home, which would have often resulted in recurring hospital admissions.

Breathlessness Crisis Management – An Individualised Plan for clients to better manage their symptoms at home

With referrals from both TTSH Respiratory Medicine and Palliative Care teams, the programme has a total of 17 clients thus far, with six successful reintegrations into the community and six more still in progress. These clients have shown improvements in self-awareness of exertion and activity pacing, which in turn optimises their functional performance and self-coping strategies at home. Through the group sessions, the clients have developed great camaraderie as they share tips, motivate and encourage one another throughout the programme.

As a palliative care provider, Dover Park Hospice Day Care is also well-poised to discuss advanced care and end-of-life care early in the trajectory of clients’ chronic terminal condition. With concerted efforts, the three partners continue to refine the programme to benefit more clients with chronic lung diseases in the Central Health region.

Client graduating from the R.I.S.E programme

R.I.S.E clients participating in group exercise

Dover Park Hospice Day Care Team

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