"It is natural for patients to feel unsure and anxious as they try to adjust to recuperating at home after their hospitalisation. To better prepare them to age-in-place at home, I assess their psychosocial needs, provide counselling and connect them with relevant community organisations.

I remember a 88-year-old patient who lived alone and suffered from pain in both legs.  She would confine herself to bed or chair as she had difficulties walking and was afraid of falling.  These issues were picked up when the transitional home care team visited her at her home. We quickly arranged for her to receive rehabilitation at a transitional convalescent facility to boost her confidence.

The prompt follow-up during the critical post-discharge period helped to prevent her from falling and being hospitalised again. This intervention may sound simple, but she was thankful that we listened to her and helped her to receive care at home and at the transitional convalescent facility.  She felt comforted that her wishes and preferences were being respected."

Christine Hindarto Lim
Medical Social Worker
Singapore General Hospital

Tags: Medical Social Worker, Allied Health