Walking Care Journeys Together – Re-envisioning Joint Case Discussions in the Community

Caring for our population means that care providers from different organisations and care sectors and with different capabilities will need to work closely together to deliver joined-up care to residents who have numerous healthcare providers, and are cared for by multiple care settings. While care transitions are a natural occurrence in our healthcare delivery system, one major challenge encountered in ensuring the continuity of care was that there was no common information sharing system between the hospital and its community partners.

However, partners across Central Health can now conduct regular joint case discussions with care teams in Tan Tock Seng Hospital (TTSH) – a regular communication platform where healthcare providers look at health-related problems from multiple perspectives and the care teams can co-create and co-manage patients ‘care plan.

Since the last quarter of 2020, the TTSH Community Health Team (CHT) has engaged several home care partners across Central Health, including the Home Nursing Foundation (HNF), to come on board on the journey to improve patients’ care delivery through joint case discussions. Some of these discussions involve NHG Polyclinics, who are a key partner in ensuring the localisation and accessibility of care to our residents.

The recent COVID-19 turn of events forced limitations on the direct care provision by the hospital. The existing care collaboration between home care providers and TTSH had to rapidly evolve to promptly facilitate patients’ discharges back to their community during this cluster outbreak, and manage their care in the comfort and safety closer to home. Both teams conducted early needs reviews and, if necessary, scheduled for assessment or procedures to be conducted via home visits by partners.

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In one memorable case, HNF Senior Staff Nurse Vanessa Lim recalled that she was preparing to conduct a home care visit for a patient Mr L, who needed his stoma bag changed. During the preliminary case discussion, however, Mr L was legislated to serve a Quarantine Order at a Stay Home Notice-dedicated facility. Heightened protocols at the facility meant that the care teams had to ensure that the care plan for Mr L was tailored accordingly, and Vanessa’s visit had to be planned down to the specific items that she could bring into the room that Mr L was serving his Quarantine Order in, when normally she would be able to bring all her equipment.

We were worried that Mr L would have a hard time while under quarantine, but despite the strict measures, he was in high spirits when I visited him, and he actually made my visit quite pleasant. I’m glad I was able to be there to care for him.”

Another example is home care partner NTUC Health who was also engaged to be part of this collaboration with the CHT. NTUC Health said: “Before the Community Health Team referred Mdm H to NTUC Health for further home medical follow-up, both care teams conducted a case discussion to coordinate Mdm H’s care plan. The care teams collaborated closely to manage Mdm H’s medical condition especially after she was discharged from the acute hospital after a minor stroke and urinary tract infection. The close working relationship between NTUC Health and TTSH has ensured that Mdm H is well taken care of and has sufficient medication before her next clinic appointment at the hospital.”

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The outbreak served to highlight the importance of integrated care across Central Health, where a network of collaboration between hospital, primary care, and community partners join up care to co-manage patients. As the Central Health teams constantly seek to improve last mile care delivery, we hope to establish closer working relationships and tighter communications channels with our partners.