putting the social into healthcare · collaboration with lions befrienders on chp • pilot a model...
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Putting the Social into Healthcare17 Apr 2019
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NUHS envisions
A Healthy CommunityShaping Medicine . Transforming Care
To advance health by synergising care, education and research
in partnership with patients and the community
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Alexandra
Health Campus
NUHS Community
Campus
Kent Ridge
Health Campus
Jurong Health
Campus
NUHS Community Campus, together with the three Health Campuses, will
work to support residents in improving their health and remaining in the
community.
Adoption of a 4-Campus Model for NUHS – Integrate & Anchor Care in the Community
A Healthy CommunityShaping Medicine ∙ Transforming Care
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Promotes joint
ownership for
community care within
NUHS – collaborative
efforts among four
campuses (and NUP),
led by NUHS Community
Campus – in
collaboration with
community partners
Population in the West
Kent Ridge
Health Campus
JurongHealth
Campus
Alexandra Health
Campus
Primary Care
Intermediate &
Long-term Care
NUS, Grassroots,
social & private
organisations
NUHS
Community
Campus
Hospital (NUHS Health Campuses)
Community partners (working in
collaboration with NUHS
Community Campus)
RHS
NUHS Community Campus: Model of Care
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Community Health Post (CHP) - an extension of NUHS Community Campus services within Community
CommunityCampus
Hospitals / ILTC
Community Hospitals
NursingHomes
NUH NTFGH
AH
• Coordinate care• Co-manage patients• Tap on resources
CommunityHealth
Post
CommunityHealth
Post
CommunityHealth
Post
CommunityHealth
Post
CommunityHealth
Post
CommunityHealth
Post
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Building a healthy and engaged population
NUHS Community Health Post(In collaboration with Community Partner)
Local Community(Residents / NOK)
Polyclinics
Grassroots
GP/PCN/ FMC
Other Community Services and Partners e.g.
NUS
SocialOrganisations
• Aim to:• increase accessibility
to healthcare• empower residents to
take care of their health
• Community Care Team• Community Nurse
(v1.0)• Community Health
Manager (trained layman)
• Allied health
Community care team
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Aim to achieve community health goals
• Improve health literacy
• Empower patients/residents to take care of health
• Help residents to lead a healthy lifestyle
• Manage their chronic diseases better
• Tag every patient/resident to a primary care doctor
• Fulfil the elements of Prescriptive Plan (PP)
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Prescriptive PlanA population-based preventive and management plan for adults and seniors
• Plan to keep adults and seniors healthy and delay the onset of disease and
frailty
• Recommends suite of evidence-based preventive health services and
interventions
Chronic Disease
Screening
Obesity
Hypertension
Diabetes
Hyperlipidaemia
Cancer
Screening
Colorectal Cancer
Cervical Caner
Breast Cancer
Other
Screenings
Functional Screening
Frailty Screening
Vaccination
Influenza
Pneumococcal
Chronic Disease
Management
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NUHS started with community nursing services at CHP (v1.0)
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Medication Reconciliation & Upskilling resident to
pack her own medication
Nurse Counselling
Performing Frailty Assessment
• Support and educate the residents to understand and manage their own
health through formulating a personalised care plan
• Engage and provide training sessions for the population in the community to
increase their health literacy
Health Talks
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Collaboration with Lions Befrienders on CHP
• Pilot a model of managing a population with a Social Care partner
• Lions Befrienders’ vision: A nation where every senior is active, healthy
and happy
• Project site: Lions Befrienders’ Mei Ling Street Senior Activity Centre
(SAC) - 3 rental blocks (290 seniors)
• Started in July 2018. LB staff actively outreach to seniors. A total of 139
seniors.
1 N = 139; number of individuals seen in Queenstown SAC
Blk A(41.4%)
Blk B(18.5%)
Blk C(22.9%)
Others(17.1%)
Block A
• 58 seniors (41%) are
“enrolled” at our CHP.
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Together we inform, “reform” and transform
• Have the needs of residents at the heart of the project
• See healthcare as one of residents’ needs. Move away from
multiple programmers’ perspective. Operate as one team.
• Co-create the model with NUHS: Social - Health Integration
• LB’s other services co-locate near the SAC – home personal
care & cluster support
• Share data to provide more holistic care to residents
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Involvement of residents is most important
Outreach Reach out to the seniors e.g. door-knocking
and “breakfast programme”.
Trust
Buy-in of seniors through building
relationship and close follow-up. Winning
their trust that we are there to stay and care
for them.
Resource CHP as a healthcare resource to seniors.
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Key needs identified at CHP and follow up
Assessment of Health Needs
The common health needs identified include:
• Chronic Disease (DHL)
• Cognitive Impairment
• Frailty
• Unhealthy Lifestyle
• Medication Management
Follow-Up and Interventions
Interventions and referrals were done to address those needs, including:
• Patient education
• Arrangement of home visits
• Referrals to GP and Polyclinic
• Subsequent Review at CHP
141 N = 56
Profile of Blk A seniorsChronic Disease Prevalence
F/U for
DHL mgt
To check for status
of DHL Screening
67%with at least one
chronic condition1
17%with three
chronic conditions1
1 in 3 have
Diabetes
3 in 5 have
Hypertension
1 in 2 have
Hyperlipidaemia
High prevalence of chronic disease among residents - CHP provides health
education to the population on chronic disease management, and integrates with Primary Care for further interventions
0(32.8%)
1(17.2%)
2(32.8%)
3(17.2%)
Number of Chronic Disease1
(% of individuals)
15
0
20
40
60
80
Very Fit Well ManagingWell
Vulnerable Mildly Frail
Profile of Blk A seniorsClinical Frailty Score
Clinical Frailty Score1
12% (~1 in 8 residents)
requires additional
follow-up
1 N = 56
Residents generally coping well (88%) – CHP provides education on falls prevention
and regular reviews, with SAC supporting residents in daily activities and encouraging
them to remain active.
For frail residents, nurses will provide home visits.
% o
f se
nio
rs
CFS Status
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Profile of Blk A seniorsCognitive Status
1 N = 52. Those mini-cog with score 0 – 2 require further follow-up.
CHP has identified a significant proportion (50%) of residents with high likelihood
of cognitive impairment (followed up with Primary Care for further assessment
and intervention).
10.5%8.8%
21.1%
14.0% 14.0%
22.8%
0%
10%
20%
30%
0 1 2 3 4 5
Mini Cog Score1
50% (~1 in 2 residents)
requires additional follow-up
% o
f se
nio
rs
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Case Study 1
• 77-year-old, widowed, lives alone in rental flat
• Has hypertension and hyperlipidemia
Mdm C’s Profile
• Coordinate care between Primary Provider and Social Partner.
• Improve patient safety• Provide patient education
Issues Identified
Fall at home
s
Confused about medication Strained relationship with son and daughter-in-law
(
What did we do?
Education on medication
regime
Medication reconciliation, provided pillbox and
guided Mdm C inself-pill packing
Facilitated early review appt at QT polyclinic,reduce medication to
2 types
Encouraged her to attend functional
screening
Senior group home staff visit frequently and monitor BP
Result:
Mdm C is able to self pack her medication correctly for 3 visits
Mdm C is taking her medication correctly
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Case Study 2
• 87-year-old, single, lives alone in rental flat
• Community ambulant with walking stick• Diabetic, Hypertension, Hyperlipidemia,
IHD, BPH, Anaemia, H Pylori, Gallstone, PVD
• F/u @ Queenstown Polyclinic and SOC
Mr K’s Profile
• Coordinate care between Primary Provider & Social Partners
• Provide patient education• Improve compliance in medication
and medication safety
Result:
What did we do?
Educate on medication, reinforce compliance
Provided pillbox, CHP nurses guide him to self-pack weekly (unable to
do it independently due to poor vision)
Regular home visits by cluster support to check on
medication compliance
Facilitated early appointment at QT polyclinic for eye review
Motivated him to participate in SAC activities
Persuaded him to agree to Home Help services twice a
month
Issues Identified
15.1
163/83
Poor BP readings and blood sugar levels
Not compliant in medication -defaulted insulin, mistakes
dosage of medication.Refused medication packing due
to cost
Visualimpairment
Compromised personal
hygiene/home cleanliness
Improved personal hygiene/home cleanliness
Improved medication
compliance
Improved BP readings and
blood sugar levels
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Key learning from our journey together
• Take a leap of faith
• Leverage on partners’ strengths
• Build trust and rapport with residents
• Appreciate social realm is important to the overall health
• See the change in behavior of our seniors
Moving ahead
• Expand the role of SAC
• Expand model to other sites and enhanced model of CHP
v2.0
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Thank You
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