Follow-up Monitoring and Care for Discharged Mentally Distressed Patients
Ministry of HealthSpeakers
Summary
This question concerns Ms Joan Pereira’s inquiry into follow-up systems for discharged mentally distressed patients, specifically those without caregivers to ensure medication and treatment compliance. Minister for Health Mr Gan Kim Yong stated that such patients are referred to community outreach teams and provided with scheduled outpatient follow-up appointments. The Institute of Mental Health manages stable cases through phone calls and home visits, while intensive cases receive care from multidisciplinary teams and mobile crisis services. To strengthen community support, the Ministry of Health and the Agency for Integrated Care implemented the Aftercare Programme to facilitate smooth transitions from hospital to community. This programme, which includes training for community partners, has expanded to multiple sites including Ang Mo Kio-Sin Ming, Kembangan-Chai Chee, and Kreta Ayer-Henderson.
Transcript
44 Ms Joan Pereira asked the Minister for Health (a) when a mentally distressed patient requiring continued medication and supervision is discharged, whether there is a follow up system to ensure that the patient will continue with the prescribed treatment; and (b) how does the Ministry follow up on such cases where there is no caregiver who is able to manage the patient adequately to ensure the necessary supervision and help.
Mr Gan Kim Yong: The Ministry of Health (MOH) works closely with our healthcare and community service providers to support persons with mental health conditions after they are discharged. Discharged patients who require further support in the community, can be referred to the community outreach teams for the necessary supervision and help. This includes persons with no caregivers.
Typically, after a patient has been discharged from the hospital, an outpatient appointment to follow-up on the patient’s condition will be arranged. For patients with moderate or severe but stable mental health conditions, they would be case managed by the Institute of Mental Health (IMH). This involves post discharge monitoring, mainly through regular follow-up telephone calls and home visits, to ensure that patients attend their outpatient reviews and comply with medication. If required, patients can also be referred to other agencies and community outreach teams for social support.
For patients who require more intensive follow up, IMH deploys multidisciplinary teams to the patients' homes to provide treatment and counselling. A 24-hour crisis intervention helpline service and mobile crisis team are available when their mental health issues escalate.
To complement IMH's work in providing post-discharge care and follow-up, MOH has also been building the capability of healthcare professionals and community partners to provide better supervision, treatment and support for persons with mental health issues within the community.
Together with the Agency for Integrated Care (AIC), the Aftercare Programme was implemented in 2015, in parts of the central and south of Singapore. The programme aimed to support clients' smooth transition from IMH into the community. In collaboration with the community mental health partners, IMH and AIC co-develop joint workflow and protocol to facilitate the referral of these clients, and also build the partners' mental health capability through training and case discussions. The Aftercare Programme has since expanded from the first site at Ang Mo Kio-Sin Ming, to Kembangan-Chai Chee and Kreta Ayer-Henderson sites as of end June 2018.