Catherine Teo
Senior Care Coordinator
Medical Social Services
Changi General Hospital

Mr TAS*, an 83-year-old gentleman, lives together with his 69-year-old wife in a 2-room flat. Mr TAS’ younger brother visits the childless couple once a month, while his nephew checks in on them every weekend with food supplies. Previously, Mr TAS’ wife had been his primary caregiver till she was diagnosed with dementia a year back. Now, the roles have been reversed and Mr TAS has had to take on the responsibilities of a caregiver.

Faced with mobility issues, Mr TAS uses a quad stick to get around at home. To traverse longer distances, Mr TAS requires the aid of a walking frame or wheelchair. He suffers from a few chronic conditions including diabetes, hypertension, hyperlipidaemia, lumbar spondylosis, congestive cardiac failure with chronic kidney disease and atrial fibrillation. On a daily basis, he has to take 18 varieties of medication to manage his many ailments.

The couple is on full MediFund assistance and had previously been referred to Moral Thye Hua Kwan for their escort and transport service, as well as the Meals-on- Wheels programme. However, Mr TAS declined the escort and transport service, preferring to use taxi vouchers whenever available as the service had no provision for his wife’s inclusion on trips. He too, refused the Meals-on-Wheels service, claiming that his spouse preferred their meals to be home cooked or bought from the food centre. In addition, the elderly gentleman refused home help services and stopped attending social day care for reasons unknown. But he is supported by Home Nursing Foundation’s home nurse who goes weekly to pack his medications into pill box and administer Recormon injection.

Mr TAS’ difficult situation went up a notch when he was hospitalised after a fall. However, it also presented a chance for the Aged Care Transition (ACTION) Team Care Co-ordinator to step in with supportive interventions. Funding was secured and a companion was found to take care of Mrs TAS at night, and for her personal hygiene to be looked after as she had lost all capability to care for herself. His nephew was roped in to transport Mrs TAS to and from the hospital daily while student volunteers were enlisted to clean and rid the house of unused furniture and expired canned food and groceries before his discharge. As such, Mr TAS was able to recuperate peacefully instead of pushing for an early discharge date.

Management Service. They agreed to be re-enrolled in the Meals-on-Wheels programme to see to their meal requirements for dinner and on weekends. Escort and transport services were provided to ferry them to and from their medical appointments. Both the seniors were referred to and accepted by PAP Community Foundation’s Social Day Care where some of their daily needs would be taken care of on weekdays. NTUC Elder Care took charge of seeing to their personal hygiene on weekends. I am glad the interventions put in place were able to make the most out of a tough situation for the elderly couple.

Key Learning Points:

  1. To constantly assess and anticipate the needs of the patient and his environment.
  2. To manage and empower multiple patients each with their own set of complex and diverse needs so as to age-in-place gracefully.
  3. To work in partnership with patients and families on the range of services, schemes and programmes available.