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How do we involve patient / NOK in care planning?

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How do we involve patient / NOK in care planning?

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What is the expectations of patient? What is the expectations of NOK?

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JCH Referral Team reviews patient using a set of criteria

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JCH Referral Team reviews patient using a set of criteria

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The set of criteria consist of....?

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NTFGH Mobile Team assess & inform Patient of Transfer

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NTFGH Mobile Team assess & inform Patient of Transfer

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What did the Mobile Team inform the patient?

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NTFGH Mobile Team inform NOK of the transfer

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NTFGH Mobile Team inform NOK of the transfer

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What did the Mobile Team inform the NOK?

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NTFGH recommends patient for transfer to JCH

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NTFGH recommends patient for transfer to JCH

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What did NTFGH Dr say to Patient regarding the transfer to JCH?

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What did NTFGH Dr say to NOK regarding patient's transfer to JCH?

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What did NTFGH Dr say to NOK regarding patient's transfer to JCH?

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Upon receiving FC order in EPIC, MT will generate Care Cost Form (CCF) based on the information provided by the listing doctor such as JCH admitting specialty and planned length of stay. If patient is fit to go through financial counselling (FC), MT will conduct FC with patient, otherwise, FC will be performed with spokesperson. Before commencing the FC, MT will check with patient/spokesperson if they are aware of the JCH admission plan. If patient/spokesperson are aware, proceed with the FC, clarify any concerns patient/spokesperson have relating to the estimated charges shared. If patient/spokesperson are unaware, MT will inform NTFGH Ward nurse to inform NTFGH Dr to inform the Patient/NOK first before MT team engage Patient/NOK. After completing the FC, MT will update in the FC order and FYI in EPIC and create JCH admission for bed assignment purpose.

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To have a comparison of the charges for different CH so NOK is able to mk a better decision

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how does care of patient differ between the 2 institutions?

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how does care of patient differ between the 2 institutions?

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Difference btw acute & CH subsidy & charges

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Difference btw acute & CH subsidy & charges

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Eg: view, set up, beds

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Why I need? Why can’t I do it in NTFGH? (LL)

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are there benefits to my current health status if I were to move to CH? What do I need to go through?

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What is the alternative should the patient refuse?

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What if I reject ? Insisted for rehab in NTF? -Yunnice-

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What if I reject ? Insisted for rehab in NTF? -Yunnice-

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Patient: why do I need to go to CH? How much is it?

How long do I need to stay?

What is the difference between CH and NTFGH? E.g. Will dr see me everyday? Will I do therapy daily?

Can I go to other CH?

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To share the value (rationale) in transferring pt to JCH. Explain the charges and the estimated LOS. How would patients benefit?

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Having staffs to actively promote, be it verbally or showing visual aid

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Having staffs to actively promote, be it verbally or showing visual aid

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Will the same care team take care of me?

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NTFGH can go out from the ward without home leave, however JCH need pre-plan Home Leave by primary team Dr

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Short video clip of the JCH admission journey

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Short video clip of the JCH admission journey

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What do I need to achieve before discharging home?

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If there’s options to other CH. Then what to expect for the transfer? -Yunnice-

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If there’s options to other CH. Then what to expect for the transfer? -Yunnice-

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will the process same as JCH transfer?

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1. Purpose of transferring to CH (Why you need sub-acute care? Unique Selling Points)

2. Healthcare Financing Information

3. Roles and Responsibilities of care team in JCH (Goals of care

4. Length of Stay

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Near mrt and malls - For caregivers (shermaine)

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Near mrt and malls - For caregivers (shermaine)

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tower A clinics/ ambulance to external TCUs

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Ease of transportation if care is done within JHC (e.g. TCU appointment) - No additional fee if within JHC. Fees will be incurred if transferred is from another CH

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Ease of transportation if care is done within JHC (e.g. TCU appointment) - No additional fee if within JHC. Fees will be incurred if transferred is from another CH

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Continuity of care. Same campus. One care team (rb)

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Family can stay over to spend more time with patient

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Family can stay over to spend more time with patient

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Familiar environment to patients

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Mobility Park!! (rb)

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Introduce MDT members and their role

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Integration and transition for home - use of Space@JCH, 3 room flat at at Lifehub

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Integration and transition for home - use of Space@JCH, 3 room flat at at Lifehub

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This is an internal process. Need not include into JCH Admissions guide

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This is an internal process. Need not include into JCH Admissions guide

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Patient will have 2 sessions of therapy unless otherwise indicated by JCH therapists

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Patient will have 2 sessions of therapy unless otherwise indicated by JCH therapists

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Elizabeth

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E.g. how often doctors will see them (Shermaine)

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Frequency of therapy,schedule of therapy

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Frequency of therapy,schedule of therapy

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(Shermaine)

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Rehab timing, Dr rounding time, meals timing, medication rounds timing, (Sq)

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Cost and subsidy

(Shermaine)

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1. # of therapy sessions per day/frequency/timimg

2. food options

3. availability of wifi

4. showering time-timing ( ren)

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hours, how many pax, how to register

(Shermaine)

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If i want to meet my grand children below age of 12, how do I go about it ( renjala)

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What patient engagement activities there are (SL)

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What patient engagement activities there are (SL)

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The wall at tower C L2 from kampung was created to provide a visual guide to prepare patients being transferred from B to C. Perhaps a shorter, more visual guide given to patients and caregivers at Tower B upon referral. Aka marketing kit. (Hweeping)

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The wall at tower C L2 from kampung was created to provide a visual guide to prepare patients being transferred from B to C. Perhaps a shorter, more visual guide given to patients and caregivers at Tower B upon referral. Aka marketing kit. (Hweeping)

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Enhance the JCH website information to be more self explanatory

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Enhance the JCH website information to be more self explanatory

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Standby to print hard copies through the e-copies but not to be used as mainstream media when needed

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A video charting patient's journey @ JCH. somewhat similar to SQ safety briefing video. Standby ipad if patient is not able to view from phone ..(renjala)

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Use the admission guide to explain to patients and caregivers so that they will realise how important/helpful the guide is

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Use the admission guide to explain to patients and caregivers so that they will realise how important/helpful the guide is

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(Shermaine)

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Make the guide colourful and easy to read

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Make the guide colourful and easy to read

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(Shermaine)

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1. use simple language and incorporate visual aids

2. personalized assistance to patient and caregivers by offering to walk them thru the guide.

3. train staff to promote the use of admission guide and to assist patients and caregivers in understanding the contents. Explore volunteers if staff no bandwidth.(renjala)

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How do we validate if the patient / NOK understands what the care team communicated?

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How do we validate if the patient / NOK understands what the care team communicated?

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How can the care team know the patient better?

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How can the care team know the patient better?

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Patient like to be address by? Patient favourite food & drink. Preferred language. Anything else? How do we share these info with all care team members?

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A nice to have - to introduce More About Me (MAM) at every ward, for every patient. Comms Relations can supply MAM Form and instructions to every ward. Currently application of MAM is very manual, inconsistent, dependent on volunteers, who are not deployed to every ward. - Hwee Ping

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How can the care team find out what matters to patient & NOK?

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How can the care team find out what matters to patient & NOK?

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How do we introduce the different members of care team to patients & NOK?

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How do we introduce the different members of care team to patients & NOK?

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How do we establish two way communication between Patient/NOK and Care team?

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How do we establish two way communication between Patient/NOK and Care team?

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What's the preferred mode and frequency of update to NOK?

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What's the preferred mode and frequency of update to NOK?

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Face to face? Phone call?

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How do we align the care plans to what matters to patient / NOK?

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How do we align the care plans to what matters to patient / NOK?

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How do we encourage patient / NOK to ask the care team questions? 

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How do we encourage patient / NOK to ask the care team questions? 

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How do we explain to patient / NOK if their expectations could not be met?

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How do we explain to patient / NOK if their expectations could not be met?

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How can the care team better coordinate and communicate?

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How can the care team better coordinate and communicate?

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How can the care team help patient / NOK prepare for discharge?

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How can the care team help patient / NOK prepare for discharge?

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What resources / support does patient / NOK need when patient is discharged?

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What resources / support does patient / NOK need when patient is discharged?

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Will be nice to discharge certain patients with more complex post discharge needs (e.g. patients with dementia) with a Discharge Kit for NOK on top of discharge summary, which is in English. Kit can include caregivers training resources, contact card, a list of songs/activities patient enjoys and responds positively during his/her admission and resources available in community for pt to continue activity. Introduce some form of social prescribing. - Hwee Ping

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Evaluating how ready is patient / NOK for discharge

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Evaluating how ready is patient / NOK for discharge

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Is Patient / NOK confident for discharge? Patient is cared for in terms of daily needs? Wound care? Social support in the community?

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How do we ensure patient / NOK is well supported after discharge?

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How do we ensure patient / NOK is well supported after discharge?

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Discharge to home? Transfer to step-down care facility?

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What is the consent process for discharge / transfer to step-down care facility?

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What is the consent process for discharge / transfer to step-down care facility?

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How do we align discharge planning to what matters to patient / NOK?

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How do we align discharge planning to what matters to patient / NOK?

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Visibility of Patient's Preference and info on PIB

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Visibility of Patient's Preference and info on PIB

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I.e. language, 5 senses and mobility level, etc. - Phyllis

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MyChart bedside - to capture personal info of the patients (in EPIC as well as by the bedside)

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MyChart bedside - to capture personal info of the patients (in EPIC as well as by the bedside)