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Community Care Team - Hospital to Home

CareHub - Hospital to Home

The NUHS Community Care Team is a multi-disciplinary team that helps patients transition smoothly from our hospitals to the community with provision of transitional care such as the Hospital-to-Home programme. 

The Community Care Team has benefitted more than 15,000 enrolled patients, ensuring that they receive appropriate care in the comfort of their homes. 

Where necessary, the Community Care Team may also refer patients to suitable care providers to ensure continuity of care.     

Hospital to Home Programme

  1. Prior to the patient’s discharge, our community care team assesses the patient according to their risk of re-admission, and enrolls high-risk patients into the programme.

  2. After their discharge, the team calls the patients to check on how they are adjusting at home and discuss their post-discharge care needs to develop a personalised care plan for each patient.

  3. The team keeps in touch with the patients through phone/video calls, home visits and monitors their recovery closely. If necessary, the team may also refer patients and caregivers to community services. 

  4. The team looks after each patient until care issues have been resolved and the patient’s medical conditions have stabilised. 


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