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[National University Health System (NUHS) Transitional Care Program].

Shu Ee Ng, Matthew Zx Chen, Santhosh Kumar Seetharaman

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    Frail elderly patients benefit from the NUH-to-Home transitional care program. This program significantly reduced hospital readmissions, emergency visits, and length of hospital stay for older adults post-discharge.

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    Area of Science:

    • Geriatrics
    • Health Services Research
    • Transitional Care

    Background:

    • Frail elderly patients face significant challenges post-hospitalization due to complex care needs and limited support.
    • Fragmented care and hospitalization hazards increase vulnerability in older adults.
    • Effective transitional care programs are crucial for improving outcomes in this population.

    Purpose of the Study:

    • To evaluate the impact of the geriatrician-led NUH-to-Home (NUH2H) transitional care program.
    • To enhance the quality and safety of home-based post-discharge care for older adults.
    • To reduce hospital readmissions and prolonged hospital stays.

    Main Methods:

    • Implementation of the NUH-to-Home (NUH2H) program, a person-centered, interdisciplinary transitional care model.
    • Geriatrician-led care coordination for older adults discharged from National University Hospital (NUH), Singapore.
    • Focus on enhancing post-discharge care quality and safety at home.

    Main Results:

    • A 67% reduction in hospital readmissions within the first year of program implementation.
    • A 68% decrease in emergency room visits for program participants.
    • A 75% reduction in the length of hospital stay.

    Conclusions:

    • The NUH-to-Home transitional care program effectively improved outcomes for frail elderly patients.
    • The program demonstrated significant reductions in readmissions, ER visits, and hospital length of stay.
    • Geriatrician-led, interdisciplinary transitional care is a viable model for optimizing post-discharge care in older adults.