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178Facilitating Discharge Wishes and Easing Discharge Concerns for Patients and Their Families in Ren Ci Community Hospital

Facilitating Discharge Wishes and Easing Discharge Concerns for Patients and Their Families in Ren Ci Community Hospital

TAN HUI HAN

Abstract

Community hospitals play a crucial role in the smooth transit of patients from an inpatient setting to the comforts of their homes. Working alongside the ‘Go Home, Stay Home’ work group in Ren Ci Community Hospital, I aimed to better understand the discharge concerns of patients and of their caregivers, and explored ways of easing their transitions from hospital to home. Primary data were collected through observations, interviews, and discussions with patients, caregivers, and staff in Ren Ci. Existing resources were also evaluated to identify the unmet discharge needs of patients and their caregivers. Data collected revealed a spectrum of discharge concerns and uncovered the limited effectiveness of collateral materials provided for patients and caregivers during discharge due to comprehension difficulties and perceived redundancy. A preliminary discharge resource file was developed in collaboration with the ‘Go Home, Stay Home’ work group, and feedback on its usefulness and comprehensibility was also gathered. This paper outlined two recommendations that Ren Ci could implement in the future: introducing a more coordinated discharge process, and increasing the emphasis placed on patients’ post-discharge social wellbeing.

Introduction

The healthcare landscape in Singapore is in a state of transformation. As Singapore is faced with a rapidly ageing population, the need for the healthcare sector to step up and meet the needs of older persons becomes all the more pertinent. In response, the Agency for Integrated Care (AIC) was established by the Ministry of Health (MOH) in 2009 to further integrate Singapore’s healthcare system (Ho, 2009). Ren Ci Community Hospital (henceforth ‘Ren Ci’) plays an important role in this integrated healthcare system. As one of Singapore’s community hospitals, Ren Ci provides step-down care for its patients who are ready to return home after having undergone prior care and rehabilitation.

179 Heartbeats Volume 4

One of Ren Ci’s goals is to care for its patients even after discharge, so that they can make the transition from hospital to home seamlessly. In fact, Ren Ci’s vision for 2016 can be succinctly summarised by the tagline, ‘Go Home, Stay Home’ (GHSH; Ren Ci Hospital, 2014), which explicates its desire to help patients and residents stay safe and healthy at home so as to lower readmission rates. This goal is intertwined with the focus of this paper, which aims to better understand the concerns that patients and their families faced post discharge. This paper also evaluates existing measures that Ren Ci has introduced to alleviate the patients’ concerns, and proposes both short- and long-term recommendations to achieve the ultimate aim of lowering readmission rates. Additionally, this paper documents and evaluates the initial stages of implementation of the recommended short-term solutions.

In line with its vision, Ren Ci established a GHSH work group in 2013. The work group is cross-departmental in nature, and comprises staff from the social work, rehabilitation, nursing, and corporate development departments. Along with other initiatives, it had plans to develop a customised GHSH resource file for each patient. This paper was written as part of an attachment with Ren Ci Community Hospital, which involved working alongside the GHSH work group to develop a preliminary discharge resource file.

Methodology

My research project took on both internal (within Ren Ci) and external (in the wider community) perspectives. Figure 1 provides an overview of the research methodology that the project adopted.


Figure 1. Overview of research methodology

To understand Ren Ci’s internal situation, I looked into discharge procedures, the concerns patients had, and the resources that were available to patients post discharge. I shadowed medical social workers and care coordinators on their rounds in the wards, and went for follow-up home visits to individuals who had been recently discharged from Ren Ci.

I also sat in on a weekly case management meeting that provided me with a clearer perspective of how the hospital prepared patients for discharge, as well as how they followed up with the patients and their caregivers. Doctors, nurses, and allied health professionals came together during these case management meetings to discuss the progress and next steps for each of the patients.

To uncover discharge concerns that the patients and their families had, I conducted interviews with patients or caregivers of patients who were about to be discharged within the week, as they would be the most aware of the intricacies and issues associated with their impending discharge. Of the fifteen interviews conducted, eleven were conducted with patients, and four were conducted with family members or caregivers. The interviews were conducted in English, Mandarin, or Hokkien, and were semi-structured: a list of questions was prepared for the interview but questions


were also adapted according to each patient’s unique situation. The list of questions asked in the interview can be found in Appendix A.

In addition, I made post-discharge calls to two patients whom I had interviewed prior to their discharge, with the consent of the medical social worker or case coordinator who had previously handled the case. During the calls, I asked the patients how they were coping at home and if they had faced any problems with the transition from hospital to home. Questions asked during these post-discharge calls can be found in Appendix B.

I spoke to staff members across several departments to find out more about existing discharge procedures, and to seek their advice on important considerations when developing the customised discharge file. I also evaluated the usefulness and effectiveness of existing materials prepared by AIC and Ren Ci for discharged patients.

Lastly, I looked into resources that were available outside of the hospital to evaluate the adequacy of community provisions for discharged patients. I also identified potential gaps in community services through observations and interviews with patients and their family members, before taking a closer look at the community resources available to determine if these gaps were real or imagined.

Results

Summary of Observations

I observed a case management meeting, a home visit, and the interactions between a social worker and a care coordinator with patients in the ward. During these observations, I paid special attention to three areas: the potential or existing needs of patients post discharge, community resources available or currently utilised, and existing problems with or gaps in community resources. The findings are summarised in Table 1 below.


Post-Discharge NeedsCommunity Resources

AvailableGaps in Community

Resources

Social • Befriending services• Cleaning services• Striking a balance

between freedom/ independence and safety

• Weekly visits and befriending services (e.g., Lion Befrienders, Brahm Centre, TOUCH Community Services)

• Community support (e.g., neighbours, volunteers from the community centre, seniors activity centre)

• Lift doors closed too quickly

• Routes to nearby food places were not elder-friendly

Medical • Refilling of pill box • Weekly refill of pill box (e.g., Brahm Centre, TOUCH Community Services)

Rehabilitative • Commuting to the day rehabilitation centre

• Rehabilitation exercises at home by physiotherapy-trained volunteers (e.g., Brahm Centre)

• Escort services were not provided by day rehabilitation centre

Table 1. Social, medical, and rehabilitation needs identified through observations

As seen from Table 1, community resources were able to meet most post-discharge needs or community gaps that patients might have had. For instance, while the absence of escort services might have been a significant barrier for older persons who required rehabilitation services and who lived alone, alternatives were available (e.g., carrying out rehabilitation exercises at home with volunteers from the Brahm Centre).

Voluntary welfare organisations (VWOs) like Lion Befrienders, TOUCH Community Services, and Brahm Centre played crucial roles in facilitating the recovery and rehabilitation process in an outpatient setting. These organisations had volunteers who were trained and equipped with the skills needed to effectively address patients’ rehabilitation needs. Ren Ci worked very closely with Brahm Centre—a centre that promoted happier and healthier living to counter both mental and physical health challenges. A volunteer from Brahm Centre was also present during the case management meeting observed, and offered inputs about befriending services and support for older persons provided by the centre.


The only noticeable gap was observed at the neighbourhood level. Neighbourhoods had yet to become fully barrier-free and senior-friendly, which prevented post-discharge patients from moving around their neighbourhoods safely and with ease.

Analysing Data Obtained from Interviews

Profile of interviewees. In total, eleven patients and four family members or caregivers were interviewed in the hospital’s wards. A summary of interview results can be found in Appendix C.

Male Patients

Female Patients

Family Members

Caregivers (who were not family members)

Total

Ward 11 4 5 2 1 12

Ward 12 2 0 1 0 3

Total 6 5 3 1 15

Table 2. Breakdown of interviewee profiles

There were two wards in Ren Ci: Ward 11 and Ward 12. As depicted in Table 2, twelve interviewees (80 percent) were from Ward 11 and three (20 percent) were from Ward 12. Fewer interviews were conducted with patients from Ward 12 as the turnover rate of patients in that ward tended to be much lower than that of Ward 11. Therefore, Ward 12 had fewer patients who were preparing for discharge.

Of the eleven patients interviewed, six (54.5 percent) were male while five (45.5 percent) were female. Of the primary caregivers, three were family members (two sons, one daughter-in-law), while one was an unrelated caregiver (domestic helper).

Type of Concern RaisedNumber of

PatientsNumber of Family

Members / Caregivers

Financial 2 0Caregiving / Daily activities / Nursing 3 1Health 1 1Services 1 0Personal (e.g. family) 1 0No concerns 5 1Not applicable 1 1Total interviewed: 11 4

Table 3. Nature of concerns raised by patients, family members, and caregivers


Categorising patient profiles. From the interviews, four patient profiles could be identified. They are described in Figure 2.

Figure 2. Types of patient profiles

As illustrated above, the diversity of patient profiles implied that it was unlikely that there would be a one-size-fits-all solution that could benefit all patients and families equally.

Discharge concerns. As shown in Table 3, the majority of the patients—five out of the eleven interviewed—did not express any concerns or worries about post-discharge life. The lack of any discharge concerns could be the result of extensive preparations their families made to ease their transition from hospital to home. However, an alternative explanation was that it was difficult for patients to anticipate the difficulties they might face after discharge.

To overcome this limitation, patients were asked to think about how they would conduct daily activities (e.g., cooking, showering); the process of recovery and rehabilitation (e.g., precautions, exercises); and their medical needs after leaving the community hospital (e.g., wounds, prescribed medication). Among the patients who expressed one or two concerns, most did so only after the prompts.

Around 27.3 percent of post-discharge concerns revolved around nursing or the conduct of daily activities, including but not limited to household chores and wound dressing. Other concerns that surfaced were financial concerns and the lack of housing and employment opportunities. Some patients were also worried about the


services they would require post discharge, as well as more personal issues related to their health and family members.

Family members and caregivers interviewed did not express any pertinent concerns. Of the three family members interviewed, only one expressed concern that the newly-hired domestic helper did not have experience in working with and caring for older persons, and hence might not be able to attend to the patient’s needs. Another family member was concerned about the patient’s highly independent personality, which she felt might pose problems for the patient’s safety. Otherwise, all three family members were confident about the caregiving capabilities of their domestic helpers.

Gaps in community resources. Patients and caregivers did not highlight many community gaps when interviewed, likely because many of them had yet to start using these resources, or were not aware that the resources existed. Hence, only three out of fifteen interviewees highlighted existing gaps in these resources. During an interview with a patient from Ward 11, he shared that he was unsure of how to travel from his home to the dialysis centre for his sessions. In another interview, a patient from Ward 12 mentioned that he really wanted to visit his former temple and meet up with his friends there. However, he would be unable to do so after discharge, due to his immobility. This highlighted the lack of barrier-free features in his neighbourhood. Lastly, another patient from Ward 11 shared his concerns about his possible unemployment after discharge.

In response to the sentiments gathered during the interviews, I conducted research on the community resources available. Two prominent problems that could be addressed by community resources were uncovered. Firstly, post-discharge patients faced difficulties in getting from their homes to recovery and rehabilitation services, as well as to other places for leisure. Secondly, post-discharge patients faced uncertainties in employment, and might find it hard to rejoin the workforce. Research conducted looked into the community resources relevant to these two problems.

A list of VWOs that provide transportation and employment services for post-discharge patients can be found in Appendix E. The list shows the availability of services that seem to fill these community gaps. However, further primary and secondary research would be necessary to find out if the listed VWOs are effective


in reaching out to post-discharge patients, and if there remains a significant need for more community support.

Effectiveness of existing AIC booklets. Two AIC booklets, titled Activities of Daily Living and Body Mechanics: Positioning, Moving and Transfers, were shown to family members and domestic helpers during interviews. Of the four interviewees, two found the booklets useful. One interviewee shared that the booklets would be “very useful for the domestic helper”, and the daughter-in-law of another patient also responded positively when asked if her domestic helper would be able to understand all the content in the booklets.

On the other hand, the two domestic helpers interviewed, who had a rather poor command of English, found the booklets to be less useful. They were unable to understand the content of the booklets despite the accompanying pictures.

Usefulness of proposed discharge materials. Patients were asked if having a list of important numbers they could call would be helpful in the event that they encountered difficulties after discharge. The ward telephone number was given to them as an example, and the purpose of having the ward telephone number was also explained to the patients. For instance, they could make a call if they experienced a change in their conditions or if they forgot how often or when they had to take their medications. Seven out of eleven patients interviewed (63.6 percent) found such information very useful.

Whenever possible, the examples given were tailored to the specific situations of the patients. For example, a female patient in Ward 11 was asked if it would be useful to have someone to talk to anonymously about her personal problems. This was in response to her sharing about her anxiety and insomnia, and how she was unable to share her personal problems with her neighbours, as they might not respect her desire for confidentiality. I eventually provided her with the numbers for the Samaritans of Singapore and the Singapore Action Group of Elders.

I also asked the eleven interviewees for their opinions on the draft copies of the revamped discharge materials developed by Ren Ci. For example, handouts of rehabilitation exercises for patients who underwent hip replacement surgery were shown to the interviewees. These handouts provided a step-by-step guide of various rehabilitation exercises, along with pictorial representations of each step.


Yes NoNot engaged during

conversationTotal

Pictures could be understood 6 3 2 11

Information was useful 3 6 2 11

Table 4. Patients’ opinions of the usefulness of proposed discharge materials

As shown in Table 4, six of the eleven patients interviewed could understand the pictures without the step-by-step descriptions. This was especially important as many of the patients interviewed were illiterate or could not understand English. However, six out of eleven of the interviewees did not find the handouts useful. Some of them did not see the need to carry out rehabilitation exercises on their own when they were scheduled to do so every week at a day rehabilitation centre. Others could remember the exercises taught, so the handouts were redundant.

Data from Post-Discharge Calls

Two types of post-discharge calls were made to patients who had been interviewed before they were discharged. The first type aimed to determine if key concerns that had been expressed in the previous interview were resolved post discharge. The second type targeted a patient with no concerns expressed previously, aimed to determine whether the patient was coping well at home and experiencing a smooth recovery.

Unfortunately, only a very small sample size of two patients was obtained. The limited sample size was due to confidentiality issues, limited availability of patients’ details, and reluctance of social work staff to reveal patients’ details. Despite the small sample size, there were two useful insights gleaned from the post-discharge calls made.

Firstly, when asked how he had been caring for his wound, one interviewee expressed concern over the slow healing of his wound. Therefore, patients could benefit from personalised information on their expected post-discharge recovery progress, so that patients would be aware of the normal pace of recovery progress and know when to seek further medical attention, should the recovery process take longer than expected.

Secondly, both interviewees expressed gratitude for the concern shown to them even though they had already been discharged from Ren Ci. One interviewee


in particular was very touched by the phone call, and was glad to share about her recovery progress and her regained ability to perform household chores. Carrying out post-discharge calls to all patients is an initiative that the GHSH is working on and intending to roll out in the future.

Findings from Discussions with Ren Ci Staff

Through discussions with staff from various departments in Ren Ci, I was able to obtain more comprehensive insights into the current discharge processes and concerns faced.

There are four departments involved in the discharge process: Rehabilitation, Social Care & Counselling (SCC), Pharmacy, and the Clinical Quality Management Unit (CQMU). I spoke to a staff member from each department to understand the department’s role in the discharge processes. I also shared about plans by the GHSH work group to develop a customised discharge resource file for each patient, and to distribute more materials to patients upon their discharge. I then asked staff members to highlight some concerns and suggestions pertaining to the two proposed initiatives. The concerns and suggestions surfaced are compiled in Table 5.

Department Current Situation Concerns / Suggestions

Rehabilitation

• Handouts existed but were often not given out, as the distribution depended on the individual judgment of the staff

• One of the physiotherapists had a personal set of handouts on precautions and exercises

• Handouts could be useless if the staff did not explain them to the patient and/or the caregiver

• Language barriers could have been an issue

Social Care & Counselling (SCC)

• No existing handouts • Care coordinators or medical social workers

applied for most social assistance and services through AIC, except for selected services (e.g., Lions Befrienders)

• Discharge materials should be part of a discussion process, and not simply handed to the patient and/or caregiver

Pharmacy

• Bilingual handouts existed but only for more critical medications

• Current handouts were useful, with pictures that communicated clearly

• Pharmacy handouts had to be personalised for each patient

Clinical Quality Management Unit (CQMU)

• Handouts on pressure ulcer and methicillin-resistant Staphylococcus aureus (MRSA) existed and were given to identified patients and/or caregivers at admission

• Giving similar handouts at discharge might be repetitive

Table 5. Findings from discussions with staff from Ren Ci


Apart from the SCC department, all departments involved in the discharge process had developed handouts for patients. However, the handouts from the Rehabilitation department had not been very effective as they were often not given out, despite existing demand. One of the physiotherapists I spoke to developed her personal set of handouts for patients, who found them useful. The Rehabilitation department could consider developing handouts that are user-friendly and easy to comprehend. The inclusion of multiple languages would be an added bonus.

For the Pharmacy department and the CQMU, staff members mentioned that current handouts were sufficient and effective for post-discharge patients. The Pharmacy department disseminated handouts to all patients as part of the discharge process. As for the CQMU, handouts were distributed and explained during the patients’ admission to the hospital.

Lastly, even though the SCC department had not developed any handouts, the staff had frequent discussions with patients and family members to help them with their needs. Therefore, new materials developed ought to complement and enhance staff’s existing efforts in engaging patients and family members.

Evaluating Publicly Available Materials

Publicly available materials developed by the AIC, Health Promotion Board, Housing Development Board (HDB), and ABLE Studio on coping with life after discharge and transitioning from hospital to home were collated and reviewed. Some of these materials are tailored to caregivers, while others provide general information that could be useful for both caregivers and patients. I evaluated each material on several aspects that would affect its effectiveness, such as the intended target audience, number of pages, proportion of illustrated to non-illustrated pages, whether the illustrations were self-explanatory, and font size. Some of the findings are summarised in Table 6 below, and more details can be found in Appendix D.


Title of Publicly Available MaterialPages with

Illustrations (%)Were the illustrations

self-explanatory?Font Size

Body Mechanics: Positioning, Moving and Transfers

63.2 Yes Medium

Activities of Daily Living 24.2 No Medium

Caregiver Basics 101 (A Resource Guide for New Caregivers)

25.0 Yes Large

A Caregiver’s Guide to Avoid Burnout 0 - Medium

Eldercare Service Directory 0 - Small

Understanding Dementia 0 - Small

Table 6. Evaluation of materials tailored specifically to caregivers

As depicted in Table 6, only two sets of materials seem to be suitable for caregivers. They are Body Mechanics: Positioning, Moving and Transfers and Caregiver Basics 101. The first set details the steps that have to be taken to position, move, and transfer patients of different profiles (e.g., patients with strong and weak sides, or patients who are unconscious) and in different situations (e.g., transporting a patient alone, or getting a patient into and out of bed). Caregiver Basics 101 is a more general guide for caregivers, with emphasis on the wellbeing of caregivers and tips on financial and home modification matters.

Title of Publicly Available Material

No. of Pages

Pages with Illustrations (%)

Were the illustrations self-explanatory?

Font Size

Enhancement for Active Seniors (EASE)

17 23.5 Yes Medium

Non-slip Tips for a Safer Home 2 50.0 Yes Large

Dressing Made Easy 5 40.0 No Large

Lighting Tips for a Safer Home and Easier Living

6 100 No Large

Basic Guide for Choosing Wheelchairs

6 66.7 No Large

Table 7. Evaluation of materials for patients and/or caregivers

As shown in Table 7, of the five materials for patients and/or caregivers that were evaluated, only Non-slip Tips for a Safer Home—which lists tips to prevent falls at home—seems suitable. Enhancement for Active Seniors (EASE) could also


be a useful resource, but only for those who actively seek information on the topic and would not be deterred by the length of the material.

Proposed Solutions

Proposed Short-Term Solutions

After uncovering patients’ discharge concerns and existing discharge procedures and resources, a customised discharge file for each patient was proposed as an immediate, short-term solution.

The discharge concerns experienced by patients—which emerged in observations, interviews, and post-discharge calls—cover a wide spectrum: from concerns over daily activities and nursing, to the lack of transportation or escort services. However, many of these concerns could be resolved via effective communication or via referrals to relevant information or services. Therefore, developing collateral materials that effectively communicate the availability of help and possible solutions could potentially alleviate many of these patients’ concerns.

In addition, there is room for improvement in the existing discharge procedures and resources, in terms of the information provided to patients upon their discharge. The SCC and Rehabilitation departments could benefit from developing and disseminating collaterals to patients and their family members when the patients are discharged. While some of these collaterals might have to be created from scratch, staff members can use existing handouts as a reference point and improve on those, or tap on publicly available materials, such as the brochures produced by AIC.

Contents of the discharge file. Interviews conducted with patients uncovered many different patient profiles and a variety of discharge concerns. Hence, developing a personalised discharge file would be most appropriate and effective. This personalised file should consist of both standardised and personalised pages, with personalised content produced according to each patient’s needs. However, as 54.5 percent of the patients and caregivers interviewed did not find some of the sample information (e.g., rehabilitation exercises) presented to be useful, it would be important to explain the importance and usefulness of the file when presenting it to the patient and family members.


Contact numbers. Contact numbers for the patient’s ward should be provided upon discharge, as 63.6 percent of the patients interviewed found it useful to be able to contact Ren Ci should they require assistance post discharge. There should also be a message that describes the purpose of the discharge file, as well as the different points of contact in different situations. This information would constitute the standardised pages of the discharge file.

Collaterals. Both domestic helpers who were shown the AIC booklets were unable to understand the content or the accompanying pictures. Hence, the language of the collaterals would need to be simple and easy to understand. The pictures would also have to be easily understood, preferably without the accompanying verbal descriptions, so that illiterate older persons or those who cannot understand English would still be able to comprehend them.

This would not be an impossible goal. When shown Ren Ci’s rehabilitation collateral, 54.5 percent of the patients responded that they could understand the illustrations in the collateral. With some effort, it would definitely be possible to create more materials that most patients can easily understand.

Implementing short-term solutions: Developing the contents of the discharge file. The needs and preferences of different patient profile types were identified from interviews with staff members involved in the discharge process. All of them provided useful insights into the contents that should be included in the customised discharge file.

Social Care & Counselling. For the SCC department, the contents of the discharge file should focus on social services or assistance that patients and families could benefit from. These include various types of financial assistance, as well as home and centre services for patients and caregivers. Most of these services were usually explored with families by medical social workers and care coordinators before discharge. However, as mentioned by a medical social worker, the discharge file could help to spark the patients’ and their families’ interest and facilitate further conversations.

Rehabilitation. The contents for the Rehabilitation department could include improved versions of their existing handouts. There is also a need to coordinate with the Nursing department to prevent duplication of efforts, as the latter was developing a similar booklet on precautions for patients who underwent post hip replacement surgery.


Pharmacy. No changes need to be made for the existing handouts given out by the Pharmacy department. The current handouts were found to be useful, with pictures that communicated clearly.

CQMU. Brochures on MRSA and pressure ulcers were already distributed upon admission to patients and family members who could comprehend them. As such, the staff member interviewed felt that it might be slightly repetitive to include the same information again at discharge. Hence, there might not be a need to include materials from the CQMU in the discharge file.

Others. The Nursing department highlighted useful information and suggestions for the development of the customised discharge file. However, due to the technical nature of the information provided, not much was done to explore this aspect during the research project. In addition, an existing AIC booklet on various daily activities that might be taught by nurses during caregiver training already existed. Though it might not be very appealing to caregivers due to the lack of self-explanatory pictures, it was still a very useful resource for caregivers who were keen to read extensively. This booklet could hence be an optional add-on to the discharge file whenever appropriate.

One piece of information that the Nursing department could include in the discharge file is the patient’s expected recovery duration. This suggestion was inspired by a post-discharge call to a patient who expressed concerns over the long recovery process.

Collecting feedback and making changes. Feedback was sought from some of the patients and caregivers after developing a preliminary version of some of the proposed discharge materials.

Determining the optimal amount of information to provide. A poll was conducted with seven caregivers to determine the optimal amount of information that should be presented in each handout in the discharge file. A handout on eldercare services was used as a reference for the poll. Two different versions of the handouts were shown to the respondents (see Appendix F). Version 1 was a simplified version that identified only the name of eldercare service centres. The medical social worker or care coordinator then had to explain the details personally to the caregiver. By contrast, Version 2 also listed some basic activities and services offered by these centres. While Version 2 conveyed more information, it also appeared wordier.


Participant Language SpokenPreferred Version

Reason

Family member Chinese 2 -

Family member English (eloquent) 2

Would not have known what SCC was without explanation, might have thought it was for entertainment activities

Family member Chinese 1 -

Family member English (eloquent) 1 -

Family memberChinese (eloquent), English (intermediate)

1Version 2 had too much information

Domestic helper (Burmese)

English (basic) 1Could not understand any of the material

Domestic helper (Indonesian)

English (basic) 1Could understand the information in Version 1, but was overwhelmed by Version 2

Table 8. Results of a poll conducted with seven caregivers

As shown in Table 8, five out of seven respondents (71.4 percent) preferred Version 1, primarily because the amount of information on Version 2 was too overwhelming for them.

It was possible that four of the participants preferred the simpler Version 1 largely due to their limited grasp of English. As the handouts were in English, the wordiness of Version 2 might have been overwhelming for those with a limited grasp of the language, even though the content and context of the poll were explained to them in another language. It was possible that four of the five participants who chose Version 1 might have chosen version 2 had the handouts been presented to them in another more familiar language.

Therefore, the version that was eventually decided on was a middle ground between Versions 1 and 2. The final version of the handout provided descriptions of the basic services offered by each type of eldercare centre, though more simplified than in Version 2.

Proposed Long-Term Solutions

A more coordinated discharge process. The conveyance of important


information to patients and their family members during the discharge process lacked clear structure. Firstly, the use of handouts lacked standardisation. In the Rehabilitation department, handouts were disseminated only when it was subjectively deemed that the patient or caregiver could understand it. Individual therapists also resorted to developing their own versions of the handouts. Secondly, discharge advice was given at multiple time points: medical information provided by the CQMU stopped after admission; advice was given by the SCC department in a continuous discursive process; and pharmaceutical advice was only given by the Pharmacy department right before discharge. This might have been confusing for patients and family members.

Component of Discharge Preparation

Upon Discharge Confirmation

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Discharge Date

Social Care & Counselling

Introduction to discharge file # #

Explanation of applicable services/assistance

# # #

Explanation of other available post-discharge resources

# # #

Updates on service/assistance application status

X X

Nursing

Caregiver training # # #

Updates on patient condition X X

Rehabilitation

Caregiver training # # #

Updates on patient condition X X

Pharmacy

Patient/caregiver familiarisation with medication

X X X

Prescription and explanation of medication

#

Closing of discharge file #

# Information sheet to be included in discharge fileX No action needed for discharge file

Table 9. Possible discharge preparation timeline


In the future, a more structured and coordinated framework or timeline should be put in place to prepare the patient and family members for discharge. One possible discharge preparation timeline is illustrated in Table 9. The timeline should be clearly explained to the patient and caregiver upon confirmation of the discharge date, and followed through until the date of discharge. The framework should aim to facilitate cross-departmental communication, to ensure that the whole process of preparing patients for discharge and transition back to their homes is comprehensive and efficient.

Community discharge programme. Future initiatives could look into improving follow-up interventions post discharge by replicating a community nurse-supported hospital discharge programme trialled in Hong Kong for older patients with chronic heart failure (Kwok, Lee, Woo, Lee, & Griffith, 2008). Community nurses visited these patients before discharge, within seven days post discharge, once a week for four weeks, and then once a month for six months. The trial successfully reduced the number of unplanned readmissions for up to six months post discharge.

In light of resource constraints, this programme could specifically target patients at greater risk of unplanned hospital readmissions. This could include patients with financial difficulties, patients who had been previously admitted to hospital, and patients who were already receiving nursing and social care (Williams & Fitton, 1988). It is also possible to use the Hospital Admission Risk Profile (HARP) to identify, at the point of admission, older patients who would be at risk of functional decline after being hospitalised. The HARP is a simple instrument that uses age, Mini-Mental Status exam scores at admission, and information on pre-admission instrumental activities of daily living functions to stratify patients into groups of low, medium, and high risk of functional decline (Sager et al., 1996). Patients in the high risk category would be likely to benefit the most from follow-up interventions post discharge.

Beyond physical wellbeing. Much focus was placed on addressing the physical wellbeing of patients after they were discharged from Ren Ci. For instance, there were follow-up actions to ensure that their medical conditions were stable, and that their health conditions improved.

However, attention also needs to be paid to other areas, such as patients’ emotional and social wellbeing. The findings of this study attested to the value that


patients placed on carrying out social activities and interactions after their discharge from the hospital. One of the patients, for instance, lamented that he was no longer able to meet up with his friends or visit the temple due to his immobility. This comment is in line with the findings of a longitudinal study carried out in four South Australian acute hospitals, on the experiences of older patients transiting to independent living after being discharged. The study found that the social contacts that the patients previously valued—such as from being involved in community groups, taking part in voluntary activities, and visiting friends—often decreased significantly after their discharge (Grimmer, Moss, & Falco, 2004). In addition, despite the decrease in their social wellbeing from pre-admission, many participants were reluctant to consider alternative activities, citing reasons such as fatigue, loss of mobility, or future health constraints. Therefore, prior to discharge, staff should provide concrete suggestions on ways in which patients could remain socially active.

In terms of emotional wellbeing, possible grief over the loss of previous abilities should also be addressed. Grimmer, Moss, and Falco (2004) found that many patients had to come to terms with permanent changes in their physical abilities, often for the first time in their lives. Yet, it was observed that neither the hospital nor community resources had provided the necessary support for those older patients to come to terms with the fact that they would never fully regain their pre-morbid status (Grimmer, Moss, & Falco, 2004).

Beyond Ren Ci. On a national scale, there is a pertinent need to develop more barrier-free and older person-friendly living environments, especially with Singapore’s ageing population. While upgrading efforts are already being carried out in many HDB estates, more must be done to ensure a barrier-free and older person-friendly built environment for all to live in. Close collaboration between hospitals and related agencies is hence necessary, so that a ‘many helping hands’ approach can be adopted to assist older persons in recovery and rehabilitation. This approach encourages the active involvement of non-state actors to meet the needs of community members who are less fortunate (Yap, 2008). Inspiration could be sought from Age UK, a charity organisation with a network of branches in different localities that provided vital direct services to older persons throughout the United Kingdom. Local services provided include day centres, home help, as well as running of campaigns like the Fall Awareness Week (Age UK, n.d.).


Conclusion and Future Directions

With the help of the GHSH work group, this research project completed the preliminary development phases of a customised discharge resource file. However, GHSH’s vision of enhancing patient- and family-centred care was not limited to the community hospital. I had discussions with staff at two of Ren Ci’s other operating units to explore how useful and relevant the discharge files or other GHSH initiatives might be for them.

Operating Unit Description Potential Relevance of GHSHNursing Home Residential wards providing

convalescent care for older persons from low socio-economic backgrounds

• Had a few discharge cases • Promoting GHSH through the concept of group

living could be explored for two groups of residents:

• New residents who might be more flexible about their living arrangements

• Existing residents who were independent enough but did not have a physical home

• There were resident volunteers, which was a good start to encouraging mutual help

Long-Term Care A step-down care facility providing long-term care for chronically sick residents with multiple illnesses

• Rarely had discharge cases • A few cases were possible with family

commitment and caregiver training

Table 10. Relevance of GHSH to Ren Ci’s other operating units

GHSH could be relevant for Ren Ci’s other operating units. Some possible directions are outlined in Table 10. For instance, the customised discharge file could be rolled out in both the nursing home and long-term care units, which might be less resource-intensive since both units handle fewer discharge cases compared to the community hospital.

In the case of Ren Ci’s nursing home, staff members could promote the concept of GHSH through independent group living. Group living brings together a group of residents in a small-scale homelike environment. Each resident would have his or her own private area, while sharing common living areas with other residents. While increased independence would be encouraged, there would still be supervision over these residents (Alfredson & Annerstedt, 1994). This system has been pre-empted by the initiative of having resident volunteers in each ward in the nursing home, which


encourages the concept of mutual help. Resident profiling has also been conducted, which could be used to shortlist residents who might be suitable for group living. Therefore, future research can examine the feasibility of applying the GHSH concept to the nursing home operated by Ren Ci, by exploring the idea of group living to encourage communal independent living among its residents.


Age UK. (n.d.). Health & wellbeing. Retrieved from http://www.ageuk.org.uk/health-wellbeing/

Alfredson, B. B., & Annerstedt, L. (1994). Staff attitudes and job satisfaction in the care of demented elderly people: Group living compared with long‐term care institutions. Journal of Advanced Nursing, 20(5), 964–974.

Grimmer, K., Moss, J., & Falco, J. (2004). Experiences of elderly patients regarding independent community living after discharge from hospital: A longitudinal study. International Journal for Quality in Health Care, 16(6), 465–472.

Ho, H. K. (2009). Transforming healthcare delivery in Singapore. Singapore Medical Association News. Retrieved from http://news.sma.org.sg/4110/Healthcare%20Delivery.pdf

Kwok, T., Lee, J., Woo, J., Lee, D. T., & Griffith, S. (2008). A randomized controlled trial of a community nurse‐supported hospital discharge programme in older patients with chronic heart failure. Journal of Clinical Nursing, 17(1), 109–117.

Ren Ci Hospital. (2014). Ren Ci Annual Report 2013/2014. Retrieved from http://www.renci.org.sg/wp-content/uploads/Year-2013_14.compressed.pdf

Sager, M. A., Rudberg, M. A., Jalaluddin, M., Franke, T., Inouye, S. K., Landefeld, C. S., . . . Winograd, C. H. (1996). Hospital admission risk profile (HARP): Identifying older patients at risk for functional decline following acute medical illness and hospitalization. Journal of the American Geriatrics Society, 44(3), 251–257.

Williams, E. I., & Fitton, F. (1988). Factors affecting early unplanned readmission of elderly patients to hospital. The BMJ, 297(6651), 784–787.

Yap, M. T. (2008). Singapore’s response to an ageing population. In H. G. Lee (Ed.), Ageing in Southeast and East Asia: Family, social protection, and policy challenges (pp. 66–87). Singapore: Institute of Southeast Asian Studies.

References


Appendix A: Interview Questions

Introduction

Hello, I am an NUS student working on a project with Ren Ci. We are trying to develop materials (e.g. brochures) that patients and their families will find useful. We would also like to understand some possible gaps in services provided after discharge from hospital. Could I ask you a few questions?

For Patients

1. What are your possible concerns/worries about life in the community after discharge?

a. Financial / housing b. Home care / nursing c. Medical / rehab

For Families

1. What are your possible concerns/worries about life after your family member’s discharge?

a. Financial / housing b. Home care / nursing / rehab

i. Who will be taking care of the patient at home?ii. What kind of services do you think you will need?

1. Day care? 2. Home help?3. Meal delivery?4. Day rehab?

iii. Are there some limitations that may possibly prevent you from using any of these services (e.g. no escort service)?

2. What do you think about having resource booklets like this?

a. Would you take such booklets?b. What may be useful / not useful for you?c. How can it be made more useful for you? d. Possibly contrast with edited pamphlets - would these pamphlets be more useful?


Appendix B: Questions for Post-Discharge Calls

Introduction

Hello, I am an intern working in Ren Ci, and I spoke to you to understand your discharge concerns while you were staying in the hospital. This is a follow-up call to find out more about how you are coping after returning home.

General Questions

1. How are you doing?

2. Are there any problems at home after discharge?

Specific questions were asked according to the responses obtained during the previous interview with the patient.


Appendix C: Summary of Interview Results

Ward Interviewed Discharge Concerns (if any)Opinion on Useful Numbers

Opinion on AIC Booklets

11 SonCaregiving: New domestic helper; no experience working with older persons

-Found AIC booklets useful, thought domestic helper could understand

12Son & domestic helper

No concerns: Confident of domestic helper’s abilities

-

Domestic helper did not seem to understand booklets as she could not read English

11Daughter-in-law

Daily activities: Patient had limited mobility but was quite stubborn about doing things herself

-

Found AIC booklets useful and had taken them from the lobby; thought domestic helper could understand

11Patient (Female)

No concerns: Used to staying at home alone while children were out at work

UsefulCould neither read nor understand what the pictures meant

11Patient (Male)

Financial: Depleting his Medisave, son had financial need, needed to renovate new flatNursing: Needed help dressing his woundServices: Needed transport to dialysis centre, which was in the midst of being arranged

Not useful, thought that numbers could not solve problems

-

11Patient (Female)

No concerns: Domestic helper arriving 2 weeks later, daughters stayed nearby

Useful

Could neither read nor understand the pictures, family spoke mostly Mandarin

11Patient (Female)

Personal: worried about her daughter, who was sick herself

Useful (Gave her SOS and SAGE numbers as she talked about not being able to share her problems with neighbours)

Could not read, seemed to understand the pictures but said that the exercises were too difficult


Ward Interviewed Discharge Concerns (if any)Opinion on Useful Numbers

Opinion on AIC Booklets

12Patient (Male)

Daily activities: Household chores, but he stayed with a friend who could help him

UsefulCould not read nor understand the pictures

12Patient (Male)

No concerns: Stayed with his wife, home was prepared for his return

Useful

Understood the pictures, but he remembered the exercises so the pictures were redundant

11Patient (Male)

No concerns: Stayed with wife and son

Not useful (May not have understood question as he went on to talk about the service in Ren Ci)

Understood the pictures

11Patient (Female)

No concerns: Stayed with three sisters, and one of them was not working

Useful Said the pictures would be useful

11Domestic helper

- -Could not read, but seemed to understand the pictures

11Patient (Male)

Financial: Worried about losing his job

Not useful Understood the pictures

11Patient (Male)

Daily activities: Faulty equipment at home had to be replaced

Useful

Understood the pictures, but said he would be going to the day rehabilitation centre for exercises

11Patient (Female)

- Not useful Might have dementia, was hard to engage her in the conversation


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Appendix E: List of VWOs for Employment Opportunities and Transport

Employment Opportunities for Persons with Disabilities

Employment Opportunities

Bizlink CentreHandicaps Welfare

AssociationSociety for the

Physically Disabled

Vocational assessment Yes No No

Employment placement Yes Yes Yes (upon completion of training programme)

Training courses No Yes Yes (6 months, fully subsidised)

Sheltered workshop Yes No Yes

Other Information Bizlink CentreHandicaps Welfare Association

Society for the Physically Disabled

Age group 16 to 65 16 to 60 16 to 55, thereafter on a case-by-case basis

Transport availability Island-wide, subsidised Island-wide, subsidised Island-wide, subsidised

Meals Not available - Not available

Half / full day Half / full day - Full day

Operation days/hours Monday to Friday8.30A.M. to 5.30P.M.

- Monday to Friday9.00A.M. to 5.00P.M. (training courses)8.00A.M. to 5.30P.M. (sheltered workshop)


Transport for Persons with Disabilities

Transport Details / Services Caring FleetHandicaps Welfare Association (HWA)

Silveray Transport Services

Travel purposes applicable All All All

Travel destinations applicable Island-wide Island-wide Island-wide

Ad hoc services Yes Yes Yes

Regular collective transport Yes Yes (for HWA clients going for rehab or training courses)

No

Bus charter Yes Yes Yes

Driving instruction scheme No Yes No

Rental of mobility scooters No No Yes

Automatic hydraulic lift Yes Yes Yes

Accompanying caregiver First free, subsequently $10 per trip

First free, subsequently $5 per trip

Healthcare attendants No No Available at a fee


Appendix F: Versions of Eldercare Services Information

Version 1

Version 2

Version 3

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