care coordination is an important aspect of nursing care especially for elderly patients admitted to an acute care setting . in singapore care coordination and transitional care nursing is a new concept of care nevertheless important but unexplored .
the objective of this paper is to explore the characteristics of elderly patients receiving care coordination , determine care gaps and intervention during home visit and telephonic review .
a designed questionnaire was used to collect information on the patient s demography , social and clinical profile and determine post discharge activities using eric coleman s four pillars tool .
the retrospective data from the patient s index admission from the last six months ( nov 08april 09 ) was analyzed using spss version 16 .
majority , 69% were above 70 years old of which 57% female and 76% lives with their children .
clinical information demonstrates that 53% had 36 co - morbidities and 58% were taking more than five medications .
the abbreviated mental test score were 6.2 , 6% were depressed and delirium was present in 14% of patients .
only 65 patients ( 0.1% ) had home visits and telephonic review done whilst 97% of the remaining had only telephonic review done .
those who had both telephonic and home visit review , medications advice and compliance were checked only in 0.8% ( at one week ) and 1.6% ( at one month ) whilst during home visit this was done in 12.2% of patients as medication discrepancy were apparent at home . as for appointment compliance and compilation were done in 0.8% at one week and 51% at four weeks of telephonic review compared to during home visit only 4.8% .
caregivers education was emphasized in 14% of patients at home visit , 2% at one week and 4% at one month of telephonic review .
the result showed that home visit is effective in exploring medication compliance , advice and emphasizing caregiver education , managing appointments can be effectively done through telephone review .
this study demonstrates the vital role of home visit for elderly patient to safely transit between hospitals to home .
 introductioncare coordination is an important aspect of nursing care especially for elderly patients admitted to an acute care setting . in singapore care coordination and transitional care nursing is a new concept of care nevertheless important but unexplored.aim/objectivesthe objective of this paper is to explore the characteristics of elderly patients receiving care coordination , determine care gaps and intervention during home visit and telephonic review.research design and samplinga designed questionnaire was used to collect information on the patient s demography , social and clinical profile and determine post discharge activities using eric coleman s four pillars tool . 
 a pilot study of ten questionnaires was conducted . 
 the retrospective data from the patient s index admission from the last six months ( nov 08april 09 ) was analyzed using spss version 16.resulttotal of 517 patients were recruited from october 2008 to march 2009 . 
 majority , 69% were above 70 years old of which 57% female and 76% lives with their children . 
 clinical information demonstrates that 53% had 36 co - morbidities and 58% were taking more than five medications . 
 the abbreviated mental test score were 6.2 , 6% were depressed and delirium was present in 14% of patients.only 65 patients ( 0.1% ) had home visits and telephonic review done whilst 97% of the remaining had only telephonic review done . 
 those who had both telephonic and home visit review , medications advice and compliance were checked only in 0.8% ( at one week ) and 1.6% ( at one month ) whilst during home visit this was done in 12.2% of patients as medication discrepancy were apparent at home . as for appointment compliance and compilation were done in 0.8% at one week and 51% at four weeks of telephonic review compared to during home visit only 4.8% . 
 caregivers education was emphasized in 14% of patients at home visit , 2% at one week and 4% at one month of telephonic review.discussionthe result showed that home visit is effective in exploring medication compliance , advice and emphasizing caregiver education , managing appointments can be effectively done through telephone review.conclusionthis study demonstrates the vital role of home visit for elderly patient to safely transit between hospitals to home . 
Introduction
Aim/objectives
Research design and sampling
Result
Discussion
Conclusion