The Transitional Community Care Programme that was created within the last year to help people with chronic diseases better manage their conditions, has so far been a success, Acting Director of Medical Services at the Queen Elizabeth Hospital (QEH) Dr Clyde Cave reported on Wednesday.
Updating the House of Assembly on the programme during debate on the Appropriation Bill, 2022, he said initial data show a reduction in the number of readmissions and scheduled visits to the hospital.
“What we have found in the first year where we have onboarded nearly 600 of these vulnerable frequent flyer patients, is that the exclusive visits to the Accident & Emergency Department (A&E) which used to be very high – they used A&E as an outpatient clinic – those decreased to 26 visits that were not part of a planned readmission or reassessment.
“One of the other KPIs [key performance indicators] … was readmission to hospital within 30 days of discharge. For the nearly 600 of these highly vulnerable patients, there were only four admissions within 30 days of discharge,” Dr Cave reported.
The Acting Director emphasised that the results so far highlighted the need for more community outreach projects, such as this, to assist vulnerable patients before they reach the stage of requiring immediate medical attention.
“In my view, this is an incredible achievement for not only will it increase the quality of care for these vulnerable patients and address the deficit in secondary care which we have always known exists, but it really does help reduce the burden on our Accident & Emergency Department from these patients who really took up a lot of time and resources.”
Dr Cave explained that though the programme initially only covered persons suffering with cardiovascular disease or diabetes, it has subsequently been expanded to cover amputees and others discharged from the hospital earlier than customary.
“The concept of this programme was to develop a cadre of healthcare workers who could visit them in their home and in liaison with their managing consultants at the hospital, implement the treatment, monitor the treatment, help further educate the patients and their families, assist in nutrition, exercise, and encourage them to become invested in in their own care,” he explained. (SB)
