Yang Dongmei
Heart Failure, Case Manager
Changi General Hospital

I first met Mr J* in 2013 when he was first hospitalised at Changi General Hospital (CGH) for heart failure. In our follow-up sessions, I invested a substantial amount of time walking through Mr J’s medical condition with him and instilling the importance of self-care monitoring and adherence to his treatment plan.

Throughout our sessions together, Mr J exhibited a cheerful and receptive demeanour. He shared that he faced a fair amount of work stress in his job as a café manager but it was at a level he was able to cope with.

After his discharge, Mr J did not turn up for any of his follow-up appointments at the hospital and I lost touch with him. My next encounter with him was a year later when he called out to me while I was making my rounds in the ward. Unfortunately, Mr J had suffered his second heart failure. He expressed his regret at not having taken better care of himself and requested my assistance in supporting him during his recovery period. Our patient-care manager journey re-started at that point and has continued since then.

Having had a few heart-to-heart talks with Mr J, I identified his non-compliance with daily medication as the cause of his relapse. Together, we came up with an action plan that would encourage greater compliance on his part. Mr J had taken on a new job as a taxi driver and faced difficulties taking his water pill due to long hours on the road.

I approached the ward pharmacist to educate him on medicine preparation and steps to take whenever his supply of medicine ran low. I kept in touch with the patient over the telephone after his discharge to monitor his progress. I realised that words of affirmation and praise was integral in motivating Mr J and enhancing his receptivity to my further recommendations and suggestions.

I impressed upon him the importance of turning up for follow-up appointments and empowered him with the ability to take charge of his own appointment schedule by teaching him how to re-schedule and manage his own appointments. Mr J’s accountability to himself and to me has improved tremendously and he never fails to inform me whenever he experiences heart-failure related symptoms or when he is unable to make a hospital appointment.

With the appropriate interventions, Mr J’s medical condition has improved and we have observed a decrease in clinical symptoms. As a result, he no longer requires as frequent follow-ups at the hospital. Mr J has taken ownership of his own health and is fully committed to adhering to treatment plans. Witnessing the transformation in Mr J has imbued me with a great sense of satisfaction and achievement for my work.

Key Learning Points:

  1. To continue working with the patient even when they regress and suffer setbacks.
  2. Take the time to talk to them to uncover and understand the root cause behind their regression and non-compliance.
  3. Empower them with taking ownership of their own health and journey towards recovery.