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Heart Health

From Hospital to Home

From Hospital to Home

photo6111635078506457093.jpgHeart Failure Transitional Care Programme

Launched in February 2014, the Heart Failure Transitional Care (TC) Programme was established to facilitate safe, smooth and quality transitions for heart failure patients from hospital to home setting. Ms. Karen Koh and Ms. Lee Choy Yee expound on this integrated care approach to reduce readmission and improve quality of life for heart failure patients.

Integrated Care Approach

Heart failure patients are often rehospitalised as they are unaware of self-care and do not inform their healthcare provider when their symptoms worsen. Due to an overwhelming number of hospital readmissions, efforts such as the TC programme are underway to support and educate them during hospitalisation and after discharge.

Nurse-led intervention programmes have been shown to reduce rehospitalisations and improve quality of life for heart failure patients (National Healthcare Group, 2003).

Our cardiac advanced practice nurses (APNs) and heart failure cardiologists developed the TC Programme under the umbrella of National University Hospital to Home (NUH2H). It aims to reduce readmission rates and rehospitalisation duration, and improve the quality of life for acute, chronic and end-stage heart failure patients. Through the collaboration of doctors, nurses, allied health professionals and community partners, the programme optimises patients’ conditions and empowers them to exercise strategies to cope with their conditions in the comfort of their own homes.

Transitional Care – The New Normal

Under the TC programme, the APNs and TC nurses actively provide review, management and education to selected inpatient and outpatient heart failure patients. 47 patients were recruited from February 2014 to 2015 and the team measured the clinical outcomes (results shown in Figure 1). These results support that TC programmes are the way forward and have become the new normal for heart failure patients as they increase continuity of care and quality of life, and decrease readmissions and healthcare costs for them.


By Ms. Karen Koh
Assistant Director of Nursing (Advanced Practice Nurse), NUHCS


By Ms. Lee Choy Yee
Advanced Practice Nurse, Department of Cardiology