What is Transitional Care
Transitional Care (TC) helps to bridge the gap between hospital and home for patients with complex or multiple care needs such as patients with unstable medical condition, recent deterioration of function due to illness, patients requiring assistance with medication management and frail elderly requiring close medical and nursing monitoring/interventions. It aims to stabilise, rehabilitate, and help patients and their caregivers cope with care by managing them at home and providing telephonic support. It also aims to reduce the risk of discharge failure and unscheduled re-admissions to the hospital.
The TC team comprises doctors, nurses, therapists, dietitians, pharmacists and medical social workers. The team works closely with inpatient healthcare team to ensure continuity of care after patient's discharge. Patients who require continuing care after stabilisation of their condition will be linked to appropriate community service providers such as home nursing, home medical and day rehabilitation.
Depending on whether the patient is discharged from a ward or an Outpatient Clinic, a ward nurse will assess in-ward or a home visit may be arranged within 3 working days respectively on whether the patent requires Transitional Care services.
Should Transitional Care services be deemed necessary, a doctor and/or nurse and/or therapist, as well as the frequency of visits may be assigned depending on the needs of the patient.