Heart Failure Transitional Care Programme

The team from NUHCS gives support to heart failure patients and their caregivers.

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Heart failure is the leading cause of rehospitalisation in the United States1. In Asia, a study of 11 Asian regions, including Singapore, revealed that Asians are likely to suffer from heart failure 10 years earlier than Westerners.

Transitional Care in Singapore

In 2011, there were some 6,000 hospitalisation episodes for Singapore residents due to heart failure, which can be a deadly condition with dismal survival rates comparable to most cancers. To improve this situation, the heart failure service under the National University Hospital (NUH) Transitional Care Programme aims to maintain the best quality of life for both patients and their caregivers by providing a transitional care facility for patients in Singapore during this difficult period of recovery from heart failure.

Heart failure patients are often faced with frequent rehospitalisation due to multiple reasons, such as lack of confidence, knowledge and support regarding how to perform self-care and identify worsening symptoms.

The National University Heart Centre, Singapore (NUHCS) heart failure team works in partnership with its patients and their caregivers to provide continuous clinical and education support in the comfort of their homes.

The healthcare team comprises cardiologists, nurses, medical social workers, physiotherapists and occupational therapists.

 

Objectives of Transitional Care Programme 

To improve heart failure patients’ confidence and quality of life by providing self-care through education and counselling
To help family members and caregivers be more confident in caring for the patient through education and counselling
To provide patients with clinical support in the comfort and privacy of their home

Transitional Care Programme Outline 

A team of healthcare professionals will visit the patient's home for up to three months (maximum of 24 home visits)
Patients are provided with health assessment, an individualised care plan, and advice 

Transitional Care Programme Benefits and Advantages 
Provides continued care for post-discharge heart failure patients
Empowers heart failure patients and caregivers on management of well-being in the comfort of their home and community
Ensures a smooth transition from NUH to home

Duration of Transitional Care Programme

Each home visit lasts between 30 and 45 minutes

Transitional Care Programme Contacts and Links 
Charles Wu, Care Coordinator, Transitional Care
Tel: +65 65 6772 5271 

Hours: Mondays–Fridays, 8am–5pm
(Closed on Saturdays, Sundays and public holidays)

Reference 

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Heart Failure Transitional Care Programme

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