May Chan
Senior Case Manager
Agency for Integrated Care

Mr Hoo, a former farmer, lived with his nephew in a 3-room HDB apartment. However, besides providing Mr Hoo with his only source of income – $10 daily from the rental of a room – the nephew is not involved in his care.

The elderly gentleman was able to manage his basic activities of daily living (ADLs) but required some assistance with his instrumental ADLs like managing his multiple medications. He used to walk daily to the neighbourhood food centre for his meals and to socialise with his friends.

Mr Hoo’s left foot swelled often due to gout and had to take a taxi by himself to the hospital whenever his condition flared up. Under the impression that he lived alone, the hospital admitted Mr Hoo often and was classified as a “frequent flyer”. He had been referred to the Home Nursing Foundation (HNF) previously but not much follow up could be done because he could not be found at home most of the time.

During one of his admissions, Mr Hoo was referred to Ms May Chan, a Case Manager. She got to know him better during his hospital stay and with the trust and rapport built, she became familiar with his social patterns and regular hangout places.

When she paid him a home visit at a time she knew he would be home, she found that Mr Hoo slept in the hall and had numerous packets of medicine on a shelf next to his bed. It came to light that he had not been taking his prescribed medication as he said the pills made him vomit. The flat was dirty and poorly maintained, cluttered with worn-out and spoilt appliances and furniture. It was not a safe and sanitary environment for Mr Hoo to live in.

Thereafter, one of the first measures May undertook was to reduce Mr Hoo’s fall risk. The flat’s dated squat toilet was replaced with a pedestal water closet (WC). A long showering hose was installed in the bathroom which allowed him to sit on the pedestal WC while showering, for safety. Grab bars were installed in the toilet and shower area in the bathroom. Mr Hoo was also gifted a new quad stick and anti-slip sandals. As cataract in both eyes contributed to his impaired vision and fall risk, an eye specialist was enlisted to treat his cataract and improve his vision.

In order to address Mr Hoo’s medication non-compliance, his attending physician was informed of the medications’ side effects. The physician adjusted the medications and the client no longer experience symptoms of nausea.

Additionally, in order to provide long-term medication monitoring support in a cost effective manner, HNF was roped in to provide home visits on top of the regular rounds done by May. These visits helped to ensure that Mr Hoo took at least four dosages of medicines a week.

Due to the care provided, Mr Hoo’s medication compliance improved and his gout flares subsided. He was discharged to the polyclinic for maintenance treatment too. He is also no longer a hospital “frequent flyer”.

Furthermore, the Case Manager helped Mr Hoo apply for MediFund as he lacks caregiver support. In addition, a charity fund was sought out to support his co-payment for a transport and escort service which would bring him to and from his medical appointments.

We are happy to share that with the various interventions in place, Mr Hoo enjoys an improved quality of life and is able to cope with his medical condition under primary care supervision. He was discharged to the Anglican Community Service for continuing community care in 2015.

Key Learning Points:

  1. Case Managers have to be innovative in finding ways to resolve service gaps especially in instances when the normal application system does not work for the client.
  2. As each client is unique, the goals set need to be reflective of their circumstances and evolve with their changing needs. In Mr Hoo’s case, 100 per cent medication compliance may not be possible as the Case Manager had to work round his preferences and the fact that he lacks caregiver support. He managed to achieve a 40 to 50 per cent medication compliance rate from a baseline of 0 per cent and is enjoying a better quality of life due to the care provided by his Case Manager and team of healthcare professionals.
  3. Community case management is a long term commitment integral to enabling ageing in place. This service is especially important for single elderly clients who may eventually need institutional care.