Bridging Hospital and Home — The Singapore Home Ventilation and Respiratory Support Service (HVRSS) Model

Introduction: The increasing number of patients requiring chronic ventilation presents significant challenges across the continuum of care. Historically, patients needing invasive long-term ventilation in Singapore remained hospitalised until end-of-life, as community healthcare teams lacked the ability to manage ventilator-dependent individuals.

To address this gap, the Home Ventilation and Respiratory Support Service (HVRSS) was established to deliver a nurse-led, integrated care model that enables safe transition from hospital to home, while ensuring ongoing multidisciplinary medical support within the community.

 

Methods: A multidisciplinary team, led by specialty nurses in collaboration with physicians from multiple specialties(anaesthesia, respiratory, rehabilitation and family medicine) , allied health professionals, and medical social workers, enabled ventilator-assisted individuals (VAIs) to safely return home and remain supported within the community through a hospital-to-home pathway.

Nurse leads coordinated discharge planning, delivered simulation-based caregiver training with competency assessments, and provided ongoing post-discharge support through home visits and tele-consultations.

 

Nurses also acted as the primary liaison between hospital specialists, community providers, and family caregivers, ensuring timely communication, equipment readiness, and safety escalation when required.

 

Other key components that contributed to the successful transition from hospital to home included:

1.Early identification and discharge planning in acute care;

2.Comprehensive and ongoing caregiver training incorporating simulation exercises and visual learning materials delivered through a mobile application

3.Regular home visits and tele-consultations for clinical monitoring and reinforcement.

VAIs receive financial support through national schemes such as MediSave, MediShield Life, and means-tested subsidies, with additional assistance facilitated by medical social workers when required.

 

Results: The HVRSS care model consistently achieves the following outcomes each year:

• 90% emergency admission avoidance from ad hoc home visits or tele-consultations;
• 84% reduction in hospital admissions, saving an estimated 145 bed-days;
• 24,000 days at home for ventilator-assisted individuals;
• Estimated cost savings of S$25.9 million to the healthcare system.

 

Discussion: The establishment of the Home Ventilation and Respiratory Support Service (HVRSS) shows how a nurse-led, multidisciplinary model can successfully operationalise integrated care for ventilator-assisted individuals (VAIs).

Nurses played a pivotal role as care coordinators and ensuring safe continuity of care and caregiver preparedness.

Comprehensive caregiver training and a supportive medical team reduced emergency admissions and re-hospitalisations, while enhancing caregiver confidence and patients’ quality of life.

This is a significant shift from institution-based care to community-based living, aligning with Singapore’s ageing-in-place vision.

 

Beyond clinical impact, the model achieved notable economic value, saving 145 hospital bed-days and an estimated S$25.9 million annually.

These outcomes reinforced that a nurse-led service, supported by a multidisciplinary medical team and strong family partnership, is central to the success of the hospital-to-home model.

 

Conclusion: The HVRSS exemplifies a scalable, sustainable model of integrated care for complex-ventilator dependent patients in Singapore.

The programme demonstrates measurable health and cost benefits, while emphasising nursing leadership and fostering a sustainable, collaborative partnership between healthcare teams and families.

Future plans include advancing digital monitoring and extending training opportunities to community nurses and medical staff to support sustainable, integrated care.