Heart Failure Transitional Care Programme

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

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

Transitional Care for Heart Failure Patients 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.

Transitional care, amongst other things, promotes a patient’s confidence.

Objectives of Transitional Care Programme for Heart Failure Patients

  • 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 the 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 
Email: charles_wu@nuhs.edu.sg

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

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  1. Special report: Rehospitalization for Heart Failure by Akshay S. Desai and Lynne W. Stevenson, 2012.
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