Smoother recovery with integrated care

PHOTO: Smoother recovery with integrated care

SINGAPORE - Madam C, who is in her 80s, was putting on her trousers at home when she accidentally fell on her left hip. The pain was so severe that she was unable to get up from the floor.

She was taken to Tan Tock Seng Hospital's (TTSH) emergency department, where doctors found that she had a left hip fracture.

Once she was admitted to the orthopaedic ward, the integrated care manager initiated the hospital's integrated hip fracture care path.

This is a new protocol that addresses issues from hip fracture care options to the patient's final discharge from a community hospital after rehabilitation.

In the ward, Madam C was reviewed by the orthopaedic surgeon and geriatrician to determine the earliest date she could undergo surgery. Early surgery followed by early mobilisation has been shown to prevent many complications.

As it turned out, Madam C had her operation the following day.

She was then referred to Ren Ci Community Hospital (RCH) to continue post-surgery rehabilitation.

Various measures to pave the way for an early transfer to the community hospital were initiated.

They included financial counselling and sending details of her medical status and wound care plans to RCH.


While waiting for the transfer, Madam C began her rehabilitation early at TTSH, and could already walk for about 10m using a walking frame when the time came for her to move to RCH.

But TTSH medical staff continued to visit her during her stay in RCH.

This illustrates how collaborations with other hospitals and community partners result in integrated care for patients.

Detailed pathways chart out what patients would require across the different stages of health care - from prevention to end-of-life care.

For each condition, a workgroup of local clinical experts identifies and prioritises interventions based on a detailed scan of medical literature.

This determines how cost-effective each intervention would be and the type of patients who are most likely to benefit from it.

At TTSH, suitable patients aged 60 and over who are diagnosed with hip fractures are enrolled into the integrated hip fracture programme.

Last year, of the 565 patients admitted to TTSH for hip fractures, 214 (38 per cent) were discharged to RCH to continue their rehabilitation under this programme.

It has helped to reduce the average length of stay in TTSH for patients who have had surgery from 12.4 days to 10.9 days.

But the care does not end at the acute hospital.

Madam C, for instance, was thoroughly assessed by the management team at RCH to help set her rehabilitation targets.

The team evaluated her functional status, surgical wound, risk of falling, co-morbidities and home environment, among other factors.

A meeting, comprising doctors, nurses, as well as the physiotherapist, occupational therapist, medical social worker and care coordinator, was held within a week of her admission. Afterwards, the course of care, projected recovery and discharge plans were relayed to Madam C's caregiver.

The team at RCH constantly watched for complications in order to treat any reversible condition that might arise after her operation.

Aside from constipation, her route to recovery was smooth.

But if the need arose, specialists from TTSH would be able to see her at the community hospital.


After three weeks of rehabilitation, the doctors at RCH were able to arrange for Madam C to have an X-ray taken at TTSH. An orthopaedic surgeon could then assess online how well her fracture was healing.

This in-house orthopaedic review saved Madam C the hassle of having to consult the doctor at TTSH's outpatient orthopaedic clinic.

The RCH team identified the necessary community services that might be helpful to Madam C when she goes home. Her husband was also given caregiver training.

Next, an occupational therapist visited Madam C's home to assess the environment and safety issues.

He advised Madam C's family to install a few non-slip mats and grab bars in the toilet.

Such assessments help seniors to stay comfortable, independent and injury-free in their own homes. They can therefore continue to be active in their communities.

Before Madam C was discharged, the nurse, physiotherapist and occupational therapist assessed her caregiver's competency in taking care of her. They also coordinated the transition of her care to a primary care provider, such as a polyclinic or a general practice.

She was also advised to continue rehabilitation at a day rehabilitation centre near her home.

This integrated hip fracture programme helps patients like Madam C to get the right treatment at the right time in the right place.

It provides a smooth transition of care from one facility to the next, and allows patients and their families to anticipate and plan for discharge.

Likewise, TTSH also works with Ang Mo Kio - Thye Hua Kwan Hospital to care for patients who require complex respiratory support.

Such collaborations deliver better health outcomes by improving the quality of care and patient experience, with fewer fragmentations in the journey to recovery.

Dr Cheong Seng Kwing is a senior consultant family physician at the department of continuing and community care at Tan Tock Seng Hospital, the flagship of the National Healthcare Group, the Regional Health System for central Singapore. He has a special interest in community geriatrics.

This article was published on May 15 in Mind Your Body, The Straits Times.Get a copy of Mind Your Body, The Straits Times or go to for more stories.