| The Health Management Unit (HMU) serves as a central hub in the integrated disease management approach to monitor patients between medical visits. Dedicated nurses at the HMU work closely with healthcare partners in the East to enable timely follow-up and coordinated care for the patients who need it the most. |
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The nurse telecare coordinators will help patients to manage their medical condition through tele-monitoring and tele-education. Supported by a patient relationship management (PRM) IT system, the nurses will be able to access past clinical indicators and information & also capture each interaction with the patient. This will build continuous relationships with patients and their caregivers, so that the HMU will be able to support the patients better in their care. |
The HMU will work closely with the patients’ medical team. This will help to ensure patients with chronic and long-term diseases are well-monitored between doctors’ visits.
The HMU has started with the Diabetes programme. Other programmes for Chronic Obstructive Pulmonary Disease (COPD), Ischemic Heart Disease, Heart Failure, Stroke and Hip Fracture patients will be rolled out progressively. The nurse telecare coordinators will speak to the patients or their appointed caregiver to:
- Educate them on how to monitor their condition, keep healthy and look out for signs of deterioration
- Provide advice on what to ask the doctor to check on their progress.
- Recommend practical changes to their current lifestyle that can better manage their condition(s)
- Inform them to call HMU as a point of contact if they have any doubts or queries about their condition(s)