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Aged Care TransitION (ACTION) Project

AIC has set up the Aged Care Transition (ACTION) team made up of Care Coordinators, stationed at 5 acute hospitals (NUH, CGH, TTSH, SGH and AH) and 1 national centre (NHC) to help patients make the important transition from hospital to their home and community. They help in the discharge and arrangement of appropriate community services for the patient and caregiver at home, thereby optimising the patients’ health and functional outcomes throughout an episode of illness. This is a 4-year project funded by the government.

The ACTION team is tasked to:

• Improve post discharge health outcomes
• Enhance patient and family caregiver satisfaction
• Prevent unnecessary emergency room visits
• Prevent avoidable re-hospitalisations for primary and co-morbid conditions
• Improve post discharge clinical outcomes including quality of life, physical function and safety

By placing these Care Coordinators to these pilot sites, the project aims to establish a single contact point for these patients in acute hospitals, AIC office and the community service providers.

Back in AIC office, we have a team of Care Consultants who specialise in referral management. They assess referrals from public hospitals for Community Care services and arrange for the placement of patients in the right community care facilities/services. They also foster partnerships among hospitals and community care service providers and thus contribute to the continuous improvement of Community Care in the healthcare delivery system.

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