New scheme offers patients in Jurong with serious organ failure more help at home

SINGAPORE – Patients in the Jurong area with advanced organ failure, including chronic kidney disease, liver cirrhosis and heart failure, will now get more support at home after their hospital discharge.

Under a new scheme rolled out on Aug 16, retired nurses and trained carers will regularly check on patients who have been sent home after treatment at Ng Teng Fong General Hospital, and monitor their health, including through home visits.

The aim is to cut the likelihood of patients getting re-admitted to the hospital within the 60-day window after discharge.

Speaking at the launch of the Care Connect Hub at the Loving Heart Community Day in Jurong East Street 32, Minister for Sustainability and the Environment Grace Fu said the programme will also free up critical hospital capacity, and allow hospitals to direct their resources to the most acute cases.

Older seniors, she noted, often see their health go through ups and downs.

Fu, who is an MP for Jurong East-Bukit Batok GRC, said: “You find them rapidly dropping from a healthy and active lifestyle to being bed-bound, and they find it hard to recover, which I find it a pity… If given the confidence and support, they can recover better and regain the quality of life that is so important to us.”

Jurong East ranks among the top five areas in Singapore with the highest proportion of seniors, which underscores the need to bring care arrangements closer to home, she said.

The Care Connect Hub initiative, rolled out by Ng Teng Fong General Hospital after a two-month trial in 2025, will involve experienced nurses from the hospital who are retired.

The nurses will screen high-risk patients and sign them up for the scheme, provide clarifications on medications or follow-up appointments, and help them navigate care options in the community, among other things.

Care Connect Hub is a tie-up between Ng Teng Fong General Hospital and social service agency Loving Heart Multi-Service Centre, under which 25 Loving Heart volunteers will train to serve as community carers.

The volunteers will regularly visit the homes of high-risk patients in the Jurong East area, and check the patient’s blood pressure, look out for early signs of complex chronic conditions, and encourage the patient to keep up with medical appointments.

The volunteers are not medically trained, so they will largely carry out non-clinical functions, and stick to standard procedures. If the patient shows warning signs of illness, the volunteers will alert a clinical team at Ng Teng Fong General Hospital.

Dan Yock Young, who is chief executive of Ng Teng Fong General Hospital and Jurong Community Hospital, said: “As healthcare needs become increasingly complex, supporting patients well requires care that extends beyond the hospital.”

He added that the initiative aims to help patients recover more confidently at home, and prevent avoidable hospital readmissions. It also lets retired nurses and volunteers from Loving Heart play a meaningful role in supporting seniors who need help, he said.

Among the 3,252 kidney, heart or liver failure patients who were readmitted within one year after discharge, 68 per cent had at least one unplanned readmission within 60 days of their discharge, a study by Ng Teng Fong General Hospital found.

Key reasons included inadequate social support, and poor adherence to medication and appointments.

In the trial the hospital conducted in the last two months of 2025, it found that among the 200 patients who got a structured post-discharge follow-up, the 60-day re-admission rate was cut from 40 per cent to 31 per cent.

About 6,670 of its patients live with kidney, heart or liver failure, which is a late-stage chronic disease, the hospital added.

It also said the disease progression trajectory for organ failure can vary, and patients can remain well for extended periods, but that will depend on how closely they stick to their diet, medication and fluid management.

Failing to follow the care plan can result in the medical conditions getting worse quickly, and the patient might need to be hospitalised for conditions like having too much fluid build-up in the body, which is often preventable with the right support.

The Care Connect Hub programme is expected to benefit about 1,000 high-risk patients aged 45 and above in the western region, over the two-year pilot, which will run until 2028.

Among these patients, about 50 are expected to require added support through the home visits by community carers.

Ng Teng Fong General Hospital also plans to work with more active ageing centres in the western parts of Singapore, with an eye on expanding the Care Connect Hub scheme.

It will also look at whether it can extend the programme to include more patient groups with similar care needs.

Retired nurse Ranjit Kaur, 72, who ended her contract work at Ng Teng Fong General Hospital in March, was offered the chance to be a care connector under the new programme.

With 48 years of nursing experience, she decided to take on the role and continue caring for patients.

She said she makes phone calls to about 20 patients each week, including those who were discharged from hospital over the last three to five days, to check on how they are doing.

For patients who need more support, such as those who lack family support or live with only a helper, she will refer them to the Loving Heart team to follow up with home visits.

Loving Heart community health head Elaine Ho, 48, usually handles these cases and schedules home visits.

Ho, who is also a practising nurse, said carers were chosen mainly based on their aptitude and ability to spot red flags.

They get training in senior care, empathy and managing patients with organ failure.

This includes looking out for a checklist of 10 red flags that could require further medical or social interventions, such as high blood pressure or signs of delirium – a condition in which patients are confused, disoriented and cannot think or remember things clearly.

Full-time private tutor Germaine Soh, 51, who has volunteered with Loving Heart for several years, said she has done home visits to care for patients with dementia.

She finds time for volunteer work and sees it as a challenge to step out of her comfort zone, she said.

“I find it very fulfilling and rewarding,” she added.