Project CARE

When Associate Consultant Dr Cindy Yeo and Senior Staff Nurse Eng Sock Luan walk through the serene corridors of St Theresa’s Home (STH), they greet the nursing home’s staff like old friends. As part of TTSH’s Project CARE (Care At the end of life for Residents in the homes for Elderly) team, Dr Yeo and Sock Luan have been working alongside STH’s team for over a decade to help residents live out their final days in dignity and comfort within the Home.

Since September 2009, the Project CARE team has been working with nursing home partners to enhance end-of-life care for residents. The team’s 3 doctors, 7 nurses, and medical social worker assess residents based on the severity of their conditions and risk of mortality, and deliver treatment accordingly. Their work has also paved the way for smoother care continuity for residents; for example, should a resident need hospital admission, processes are in place for them to be admitted directly to the ward, with a clear care plan handed over to the hospital team.

The Project CARE team also guides residents and their families in Advance Care Planning and Preferred Plan of Care conversations about future care preferences, to ensure that residents’ wishes are heard and honoured.

A music teacher by training and passion, Jeannette met her husband John when they were teenagers; she played the organ for the church choir he sang in. They married in 1964, and had been retired for more than ten years when John noticed Jeanette wandering aimlessly off during a family trip. In 2010, she was diagnosed with dementia, and in 2015 was admitted to STH as her condition worsened.

John has been visiting his wife every day at the nursing home to spend time with her and help with mealtimes. In 2018, as Jeannette began eating and communicating less, the Project CARE team was activated to care for her. They also reached out to John about future care plans for Jeannette.

“It was not an easy conversation,” John said, “but I now have a better understanding of her illness and was able to make better decisions about her care, moving forward.”

Project CARE also drives learning initiatives with nursing home partners through joint case discussions as well as structured training frameworks. For example, nursing home nurses learn to identify residents who require early end-of-life interventions, such as better symptomatic care; they also train in specialised skillsets to better care for patients at the end of life.