NOVEL APPROACHES TO IMPROVE THE HEALTH
AND WELL-BEING OF OLDER PERSONS :
INTEGRATING CARE, AGEING-IN-PLACE
29 September, 2015
Clinical Professor Chee Yam Cheng, Senior Advisor, National Healthcare
Group (NHG) & President, NHG College
Dr Jason Cheah, Chief Executive Officer, Agency for Integrated Care (AIC)
Dr Anchal Gupta, Assistant Manager, Agency for Integrated Care (AIC)
Mr Wilson Ong, Executive, Agency for Integrated Care (AIC)
Declaration of Interest
• We hereby declare that the disclosed information below is true
and complete to the best of our knowledge (within the period
of 36 months before and known occurring for subsequent 12
months from the date of 29th Sept, 2015) :
• We have not received remuneration from a commercial entity or other
organisation to give any public talks or advice related to the subject of
our presentation
• We have not received any remuneration for expenses incurred to attend
the conference apart from the honorarium that has been set out by BMJ
• We have not received any remuneration from a commercial entity or
organisation to conduct research related to the subject of our
presentation
OVERVIEW OF HEALTHCARE LANDSCAPE
IN SINGAPORE
Quick Facts About Singapore
Population
5.46 million
Residents >65
years of age
9.3%
Life
Expectancy
82.5 years
Total Fertility
Rate
1.25
%GDP spend
on healthcare
4.6%
Source: Department of Statistics Singapore (2015)
SINGAPORE’S HEALTHCARE LANDSCAPE
Wellness Care
Primary Healthcare
• Preventable healthcare
services in community
• First contact point with
patients in community,
referred to medical
specialists hospitals for
further treatment
when needed
• Mainly private sector;
some public sector
involvement , e.g.
Health Promotion
Board
• 80% Private- run by
General Practitioners;
20% public sector run
Polyclinics
Secondary/Tertiary
Healthcare
Intermediate and Long
term Care
• Hospital care
comprising of multidisciplinary inpatient
and specialist
outpatient services,
and 24-hour
emergency services.
• Continuing care for
patients in community.
E.g. community
hospitals, nursing
homes, day care
centres, home care
service, dialysis centers
• 80% Public sector run
acute hospitals
• 70% by People sector
(Charitable
organisations)
Rapidly Changing Elderly Demographics
2014
2020
2030
Old (> 65)
432K
613K
962K
Old Old (> 85)
39K
57K
91K
Old (> 65) w/o
Family Support^
~9%
~11%
~13%
No. of People with
Chronic Conditions*
1.36M
1.54M
1.80M
Elderly consume more healthcare*
•
•
•
Hospital admission rate 5x that of
persons aged 45-54
Inpatient stay 1.6x that of persons aged
45-54
Urgent need to shift away from hospital
centric care
*Utilisation includes both resident and non-resident
admissions at public sector acute hospitals (excluding KKH)
Source: Ministry of Health Singapore, National Health Survey 2010
A very different system beyond
2020
^ Defined as having no caregivers at home
* Refers to estimated number of Singapore residents
aged 20 years and above with diabetes, high blood
pressure or high blood cholesterol only.
SINGAPORE’S APPROACH TO SUPPORT ITS
ELDERLY: AGEING-IN-PLACE
“A key focus of the Ministerial Committee on Ageing (MCA) is ageingin-place. Our survey shows that our seniors prefer to age in place
gracefully and with dignity, within a closely knit community.”
Minister Gan Kim Yong,
Health Minister,
Singapore, in 2012
Our Vision: Ageing-in-Place
 Growing old in the home & environment that one is familiar
with, with minimal change or disruption to one’s life / activities
 Our Solution: Integrated care provision in community as a key
to enable Ageing-in-Place
• Easily accessible health + social care
• Well coordinated and person-centered care
• Affordable care
• Optimal caregiver support
• Community involvement in care provision
A Multi-Pronged Approach
Ministry of
Health (MOH)
Agency for
Integrated Care
(AIC)
Projection of
national level
service demand
National Care
Integrator for health
& social care systems
Healthcare
Financing
Coordinate patient
referrals to
intermediate & longterm care services
Regulatory
frameworks
Standards and
performance
measurement
Policy direction
Capacity and
capability building of
the Primary Care,
long-term care sector
Regional Health
Systems (RHS)
Ministry of Health
Holdings (MOHH)
Platform for
collaboration
amongst service
providers in a
geographic region
Common IT platform
across the care
continuum- National
Electronic Health
Records
Skills transfer from
acute to ILTC sector
Common
employment of
junior doctors across
care continuum
Strategies and
programs to
address needs of
regional population
Direct Implementers of Care Integration
Corporate manpower
development
Enablers- Manpower
and IT platform
CARE INTEGRATION IN COMMUNITY
Examples of some initiatives by AGENCY FOR INTEGRATED CARE (AIC)
Care Coordination and Case Management
Initiatives
Hospital’s Case
Manager
Hospital
admission
Care planning during hospital stay
ACTION (Aged
Care Transition)
Care Coordinators
Care Coordinators are
usually Nurses, Social
workers, or Allied
health professionals
Screening for high
risk patients; Needs
assessment
About 1 month
post discharge
Hospital
discharge
Goal setting and care
planning; Referral to
long-term care services
Community Case
Managers
For more complex, high
risk patients; Long-term
follow up of patients
Follow-up (phone calls/
home visits); Optimize
self-care; Hand over to
long- term care service
Home
visits
comprehensive
assessment;
Formation of
plan
and
case
care
Patient’s
journey
Follow up (phone call+
home visits);
Review of care plan;
Necessary
referrals;
Interdisciplinary team
meetings
Aged Care Transition (ACTION): Outcomes
• Aim: To enable seamless care transition post hospital discharge
 As at
Apr 2015, 120 care coordinators in 6 Restructured Hospitals and 5 Community
Hospitals.
 The teams recruit an average of 14,000 patients per year.
• Evaluation of the Pilot Programme (data from Jan 2009- Jun 2011)
 Odds of readmission within 15 and 30 days for ACTION patients: 40% and 32%
lower than control group
 Odds of Emergency Dept. attendance within 30 days: 21% lower than control group
 Estimated cost savings S$5.4 mil over 6 months.
• Continuing Outcome Measures from the Programme (data from 2012-2014)
 Sustained reduction in utilisation of acute hospitals
• Hospital Readmission Rate (15D) – maintained in the range of 5 to 7%.
• Emergency Re-attendance Rate (30D) – range of 2 to 3%.
*In comparison to hospital-wide double-digit readmission rates
 Better Patient Satisfaction
• Around 800 patients and caregivers were interviewed to understand satisfaction levels.
• 99% of respondents rated ACTION services as “Good or above”.
Integrating Community Based Services
Singapore Programme for Integrated Care for the Elderly (SPICE)
•
•
•
Based on the concept of the Program for All Inclusive Care for the Elderly (PACE) in US
Offers a community based alternative to Nursing Home for frail elderly with high care needs
Semi- capitated funding
SPICE
Centre
Regional network
with Primary Care
and Acute Hospitals
Medical
Social
Worker
Therapist
Meal
Delivery
Doctor
Patient
Therapy
& Nursing
Aides
Patient’s
Home
Home
Nursing
Patient
Transport
Nurse
Case
Manager
Home
Personal
Care
Home
Medical
Caregiver
Home
Assessment &
Modification
Outcomes
Singapore Programme for Integrated Care for the Elderly (SPICE)
• Utilisation of Residential Services
 Statistically lower rate for Nursing Home admissions for the SPICE group compared to
control groups.
 Statistically significant decrease in Community Hospital (CH) utilisation (Length of stay:
average  18 days) and expenditure (Total Cost: average  $4269) was observed after
enrolment into SPICE; statistically significant reduction in CH utilisation for SPICE group
compared to control groups
 A statistically significant decrease in Acute Hospital utilisation (SPICE group Length of
stay: median  17 days) and expenditure (SPICE group Total Cost: median  $9,890)
was observed; however, difference not statistically significant when compared to
control groups
• Clients’ and Caregivers’ Satisfaction
 Improvements in the SPICE participants’ perception of health and (2) decrease in
caregiver stress after 12 months of care from SPICE; however difference was not
statistically significant, likely due to the low number of responses received for the
satisfaction surveys
CARE INTEGRATION AT REGIONAL HEALTH
SYSTEM (RHS)
Example from NATIONAL HEALTHCARE GROUP (NHG), a Regional Health
System serving the central region of Singapore
Formation of Regional Health System (RHS)
15
Care Integration
through the Regional Health System (RHS) – A patient-centric healthcare
ecosystem comprising of partners from the primary, acute and community care sectors working
together to deliver integrated healthcare services to improve population outcomes.
Alexandra
Health
Jurong Health
Services
National
University
Health System
National
Healthcare
Group
Eastern Health
Alliance
“We have decided that we can
achieve a better outcome if we
reduce the size of each
catchment and organize the
healthcare delivery systems at
the regional level…”
Singapore
Health
Services
Source: Ministry of Health, Singapore
“This transformation in healthcare delivery to create a hassle-free healthcare system at the regional level, is a major
strategy that we are pushing. It will make healthcare more convenient, safer, better and at the lowest possible cost….”
Minister for Health (Aug 2004 – May 2011)
National Healthcare Group (NHG)
Our Approach and Our Population
Unknown (70-80%)
Outreach Approach
1. Lower Socio economic Status: Case finding for residents of rental flats
2. School kids : Partner with preventive School Health programmes
3. Working adults : Workplace Health/Partner with MOM (Ministry of Manpower)
4. General population : Community & opportunistic screening
Known – Approx 320,000 in
Central Region (20-30%)
Health
Status
Led by
Health Coordination
Well / At Risk
Community
Chronic Illness Progression/Complication
Primary Care
Automated reminders at set intervals
Maintain health
Goal(s)
Pre-Clinical
Prevent onset
Automated monitoring,
escalation when needed
Delay progression
Hospital
Care Co-ord
by Healthcare
Professional
End of Life
Palliative
Case Management
Maintain function,
rationalize care (FP,
SOC), pre-empt
complications, avoid
admission
Stabilize,
restore
function if
possible,
avoid
admission
Minimise pain,
avoid
admission
(Mobile) Community Health Centre
Services Offered :
Diabetic Retinal Photography
• Provision of ancillary support
services to General Practitioners
(GPs)
• Wider geographical coverage and
hence nearer to residents and GP
Clinics
• Operating on board 24-seater
Diabetic Foot Screening
Nurse Counselling for Chronic
Diseases
Virtual Hospital
Objectives
• Prevent / Reduce avoidable and
unplanned admissions
• Reduce avoidable attendances at
emergency and outpatient clinics
• Reduce length of stays in hospital
• Improve patient’s / care giver’s
satisfaction to care provision
Components
• Telephonic reviews/assessment: in-bound/ outbound calls
• Home visits conducted by Health Manager
• VH team’s daily case discussion on care plan
• Multi-Disciplinary Rounds with the primary
physician, medical social worker, disease managers
• Coordination & liaison with internal & external
partners (inter-departments, community health &
personal care partners)
Virtual Hospital: Preliminary Outcomes
Emergency
Department
Attendances
Readmissions
to Acute
Hospitals
LEARNING POINTS AND NEXT STEPS
Learning Points
• Start with political “buy-in” and leadership (from policy development to
implementation and evaluation)
• E.g. Formation of Regional Health Systems
• Continually remove ‘silos’ and ‘fragmentation’ within various working bodies:
 Change mental model and create new skills amongst professionals:
• Collaboration; Creating “win-win” solutions and approaches
 Incentivize integration via common funding streams
• E.g. Integrated care pilots  enabled integration between acute hospitals and
community providers via a common funding stream
• Start with specific patient populations and demonstrate“quick wins”; evaluate
outcomes & apply to future endeavors; adapt where possible;
• E.g. Virtual Hospital, ACTION (Aged Care Transition), SPICE (Singapore Programme for
Integrated Care for Elderly)
• Shared IT systems play a great role in enabling integration
• E.g. National Electronic Health Records- extending access to Community providers and
Primary care practitioners
Next Steps for Us
• Improve public perception of community care services
• Further align financial models to sustain care integration
• Capitated models
• “Pay-for-Performance” or outcome-based payments
• Develop a standardized needs assessment framework to right site patients to
appropriate community care service
• Increase involvement of General Practitioners to deliver holistic care for elderly
in community
• Leverage on technology as a tool to integrate care. Examples of ongoing pilots
include:
• Singapore Integrated Diabetic Retinopathy Programme (Tele-Ophthalmic Service for
Diabetic Retinopathy Screening)
• Tele-geriatrics Programme (Tele-consultation for Nursing Home patients by Geriatrician
from Acute Hospital)
THANK YOU
Prof Chee Yam Cheng: yam_cheng_chee@nhg.com.sg
Dr Jason Cheah: Jason.Cheah@aic.sg
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