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Home > Central Health > Central Health Stories > Community Health Teams: Journeying with Patients from Hospital to Home

A bright and sweltering Thursday morning greeted Community Nurse Katherine Lai Kai Yun and Occupational Therapist Lee Hengky as they arrived at Mdm Z’s home for their pre-arranged appointment.

The team had plans to check up on Mdm Z’s condition after her discharge from hospital, as well as on her functional status within her home environment. However, her son informed the team at the door that Mdm Z had gone to the nearby market; he had no idea when she would be back, and she had no mobile phone.

There was no question of saving it for another day; Katherine and Hengky immediately headed back downstairs to look for Mdm Z. No sign of her at the wet market as Katherine and Hengky split up to search. “On the bright side, I met her during my assessment while she was still warded so I know what she looks like,” said Katherine. A few minutes later, she approached someone sitting at the hawker centre with a smile: Mdm Z had been found.

The journey back to Mdm Z’s home took much longer than the brisk walk there, as Mdm Z’s knees were not in the best condition. Katherine and Hengky took the opportunity to observe their client’s gait and balance, and the way she used her shopping trolley as a walking aid. When Mdm Z took a break at the void deck, they spoke to her about the pain in her knees and asked if she was having any breathing discomfort. Eventually they reached her home, and the assessments continued as planned.

Serving Residents Across Central Singapore

Singapore’s Central Zone has a population that is ageing more rapidly than the rest of the country’s: 17% of the residents in the zone are aged 65 and above, compared to a national average of 12%. This means that many of our residents have complex care needs, from medical and nursing care requirements to social support.

TTSH’s multidisciplinary Community Health Teams comprise nurses, allied health professionals like occupational therapists and physiotherapists, pharmacists, medical social workers, and doctors. Each CHT is stationed within one of seven subzones in TTSH’s care range, and by creating a single team and point of contact, we can deliver holistic community-based care to our patients.

The teams also work hand-in-hand with community partners, such as grassroots organisations, social services, and other healthcare providers. As experts in their own fields and having built ties within the community over the years, our partners are best placed to help us connect with residents, and collaboratively create a strong base of support for patients and residents.

Journeying With Patients From Hospital to Home

Despite the community focus of the CHTs, care actually begins within the four walls of the hospital. While the patient undergoes treatment with our inpatient teams, the CHT conducts an assessment to understand the patient’s post-discharge care needs. The CHT nurse in charge of the patient then begins to coordinate the services that the patient will need, such as home nursing services or social or financial assistance. In Mdm Z’s case, Katherine had arranged for Hengky to visit at the same time, so that he could provide suggestions on adapting her home environment such as grab bars in the bathrooms. Katherine also spoke with Mdm Z’s daughter about procuring a motorised scooter to help Mdm Z get around more safely.

Caring for Residents in the Central Zone

Not every resident requires admission to the hospital, and even if they do, some may not meet the requirements for the home visit plans. To ensure that residents are given the care they need, the team conducts weekly clinic sessions at locations frequented by residents, such as senior activity centres.

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