Bringing Health Back to the Community - Transitional Care

Started in 2016, the Transitional Care programme aims to provide patients with complex care needs the support required to transit them from the hospital back to their homes. In line with the Healthcare 2020 Masterplan, the programme aims to move health and healthcare beyond the hospital to the community. GP Buzz spoke with Dr Tan Kok Leong, Senior Consultant and Head, Department of Continuing and Community Care, and Clinical Lead, Transitional Care.

Transitional Care (TC) service, according to Dr Tan, empowers both the patient and caregiver by imparting to them the knowledge and skills to better manage and cope with their medical conditions, and assisting them in coordinating care with community healthcare and social partners, and hospital service providers.

The typical patient who benefits the most from TC falls into a few broad categories:

  • patients with chronic medical conditions and the associated complications, such as heart failure, chronic kidney disease, etc
  • patients with issues related to medication handling and compliance
  • patients with functional impairments who are at risk for falls and malnutrition
  • patients with poor social support whose main focus is more on basic needs and making ends meet, instead of disease management and medication compliance
Team effort is key to managing patient with complex care needs, with patients and/or the caregiver, and primary care doctors being the key members in the team."

TC Specialists work closely with the primary care doctors in both the private settings and polyclinics to better care for the patients in the community. They follow up with patients to ensure that they understand when and how to take their medications, how to self-monitor their medical conditions, and where to seek assistance when needed. He mentioned that TC Specialists also provide feedback to the primary care doctors with regards to patients’ clinical needs. Dr Tan cited the example of a TC Specialist who attended to a visually impaired patient who lived alone. The patient was on insulin therapy for the management of diabetes mellitus. This vital piece of information was relayed back to the primary care doctor and alternative options for pharmacological therapy were explored to ensure safe and effective care.

Dr Tan pointed out that for TC to achieve its care goals, patients and their caregivers need to be actively involved and play their parts, in addition to the involvement of doctors and community partners.

Be part of the Transitional Care! 

If you are a GP in the central region of Singapore, email Ms Lisa Chan, to find out more on how you can be a part of the TC programme.

  • Ang Mo Kio
  • Toa Payoh
  • Bishan
  • Geylang
  • Hougang
  • Serangoon