Hospital to Home (H2H) is a nationwide programme that supports patients’ safe and timely transit back home, so that they can stay well and age gracefully in the community. It is targeted at patients with complex health and social needs, and a high risk of readmissions.
During the patient’s hospital stay, a multi-disciplinary care team comprising doctors, nurses, therapists and medical social workers assesses the patient’s post-discharge needs and puts together a personalised care plan. Depending on each individual’s needs, the plan would cover medical and social support services such as home and day care, psychosocial support, medication reconciliation, financial assistance, interim caregiving, and meals-on-wheels. Once the patient is discharged from hospital, the H2H care team conducts home visits for those with higher care needs and calls them regularly to ensure they are recovering well. We also work closely with community health service providers such as NTUC Health, Thye Hua Kwan Moral Charities, and Montfort Care to ensure that patients receive the support services that they require to get well and keep well.
Multi-Disciplinary Team: Doctors, Nurses, Allied Health Professionals, Medical Social Workers and Community Partners
Duration of care transition: Up to 6 months post-discharge
Eligibility: Recently discharged from hospital (within 1 month) and requires a multi-disciplinary team to manage the sub-acute and chronic medical conditions post-discharge
Find out more about Hospital to Home programme >
