​"As care providers, we need to ensure that the individual does not fall through the gaps when they transit from one care setting to another.  Building an integrated care network like Sweden's Esther Network does not necessarily mean pumping in more money and manpower.  We could begin by changing our mindset towards care delivery.

For example, clinicians in hospitals can work with community partners like the Tsao Foundation by sharing all they know about the patient's health and social conditions, before the patient is discharged.  Such timely exchange of information would equip us to be able to take better care of the patient once he/she leaves the hospital. It also ensures continuity of care and can keep high-risk patients out of the hospital.

If the patient's condition deteriorates, it would set our minds at ease to know we can approach a familiar face in the hospital to discuss what needs to be done.  Currently, many of our patients turn to the A&E whenever their condition takes a bad turn and this is not ideal."

Ms Peh Kim Choo
Chief, Programmes
Tsao Foundation

Tags: Administrator