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

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.