Transitional Care Programme Evaluation
– The Singapore Experience
12th April 2013
Dr Patsy Chow (Patsy.CHOW@aic.sg)
Dr Loong Mun Wong
Dr Jason Cheah
Agency for Integrated Care
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What is Transitional Care?
“Care transitions” refers to the movement patients make between
health care practitioners and settings as their condition and care
needs change during the course of a chronic or acute illness.
In its position statement in 2003, the American Geriatrics
Society defined transitional care as “a set of actions designed to
ensure the coordination and continuity of health care as patients
transfer between different locations or different levels of care
within the same location”.
Source: Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care Systems
Committee. Improving the quality of transitional care for persons with complex care needs. Journal of the
American Geriatrics Society. 2003;51(4):556-557.
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Some Classical Models
The Care Transitions Intervention® spearheaded by Dr Eric A. Coleman
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Aims to empower patients/care-givers to assume greater and active role in self
management as they transit across settings
4-week programme led by Transitions Coach®
The Four Pillars®

Medication self management

Dynamic patient-centric health record

Timely primary care/specialist care follow-up

Knowledge of ‘red flags’ and appropriate responses
The Transitional Care Model (TCM) by Dr Mary D. Naylor
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8 -12 week programme directed by Advanced Practice Nurses
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Patient assessment and development of care plan begin within 24 hours of
hospital admission
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Regular home visits with telephonic support (7 days a week) after discharge

First post discharge visit with the physician accompanied by the
Transitional Care Nurse

Interdisciplinary approach; close collaboration with physician
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Defining Transitional Care in Singapore
 Transitional care initiatives are nascent in Singapore; most are in pilot
phase.
 Transitional care (TC) in our local context is defined as care and/or
services to support patients’ transfer from the acute care to community
setting.
 Objectives
 To support post discharge patients to transit from hospital to community by
streamlining and coordinating care services.
 To optimise patients’ outcomes following an episode of illness.
 To minimise hospital utilisation by facilitating timely discharge and
reducing unnecessary hospital readmissions and/or ED visits.
 Key features
 Time-limited
 Coordinates services according to individualised care plans
 Handover to community based partners for follow-up care
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Transitional Care Initiatives in Singapore
 Existing programmes can be broadly classified into two categories:
Predominantly Care Coordination
Predominantly Skilled Care
Interventions
Caters to patients with complex social care
Targets at patients with higher level of
needs and those at risk of functional
acuity in terms of physical care needs
decline
Focuses on direct intervention or care
Emphasis rests on care coordination and
provision (e.g. medical, nursing, functional,
patient/caregiver empowerment
pharmaceutical)
Minimal provision of direct skilled care
Less emphasis
activities
FOC
Fees for service
on
care
coordination
All are hospital-led at present (3 in total)
E.g. Aged Care Transition Team
E.g. Post Acute Care at Home
• The first transitional care pilot in
• Slightly
more
advanced
in
Singapore inspired by The Care
development compared to the other
Transitions Intervention®
hospital-led TC programmes
• The most mature programme by far
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• Demonstrates positive results
Aged Care Transition (ACTION) Teams

ACTION is a government funded project started in 2008.
Aim:
To help patients make a safe and
smooth transition from hospitals
into their homes or community,
by streamlining and coordinating
care services to optimise patients’
outcomes throughout and after an
episode of illness.
Scale:
 81 care coordinators in 6
Restructured Hospitals (RHs), 1
Tertiary Centre & 5 Community
Hospitals.
 More than 28,731 patients
recruited since 2008.
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Patient Screening Criteria of ACTION
Elderly above the age of 65 yrs
 Multiple co-morbidities
 Polypharmacy
 Impaired mobility or significant functional decline
 Impaired self care skills
 Poor cognitive status
 Lives alone or has poor social support
 Catastrophic/Chronic illness and injury with anticipated long
term health care needs
 Multiple admissions / ED visits over the last 6 months

Note: Provision of 80/20 rule for exceptions (e.g. young patients)
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ACTION Process
High-risk hospital
inpatients
Residential Facility e.g. community hospital
Discharge
Admission
ACTION
Team
Care
Coordinators
•Nurses,
Social
workers, Allied
health
professionals
Home with supporting services
• Day rehabilitation services
• Home Medical & Home nursing services
• Social support services
Discharge
Hospital
About 1-3 months post discharge
Community
• Screening high-risk patients
• Assessment of needs
• Referral to appropriate ILTC
services
• Develop and implement care plan
• Goal setting and evaluation of
care plans
• Telephone follow up, home visit and assessment
• Optimize a patient’s self-care capabilities at home
• Caregiver education and support
• Monitoring of high risk clients
• Hand-off to other services 9
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Mixed-Method Evaluation Approach
Care recipient/
caregiver survey
Administrative
data analysis
Validation of 15item Care
Transitions
Measure (CTM)
in Singapore’s
context
Comparison of
hospital
utilisation
ACTION vs.
Controls
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ACTION Clients are Elderly and Frail
Based on 2009Q1 to 2011 Q2 administrative database (N=14,025)
77% above 70 years
old
38% are main carer
of themselves
Patient profile is
heterogeneous
across sites
65% taking > 5
medications
72% have 3 or more
co-morbidities
 27% with history of >1 fall
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Source: RHIME Administrative Data Analysis
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Does ACTION Reduce Hospital Utilisation?
 Retrospective case-control study to compare the number
of readmissions and ED visits within 6 months after index
hospitalisation
 Cases from ACTION cohort (Feb 09 - Jul 10)
 Controls were selected from MOH Casemix and
Subvention Database
 Inclusion criteria – at least 1 of the following



≥3 diagnoses
At least 1 of these diseases: diabetes, hypertension,
hyperlipidemia, dementia, COPD, stroke and schizophrenia
≥1 hospitalisation or ED visit in past 6 months prior to index
hospitalisation
 Exclusion criteria



Social over-stayer / absconder
Age <65y
Non-subsidised patients
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Baseline Characteristics of Clients
(after weighting by propensity score)
ACTION (N=4132)
Control (N=4132)
Age (years)
Mean (SD)
79.2 (7.7)
79.2 (7.7)
Gender
Male
1795 (43.5%)
1797 (43.5%)
Female
2335 (56.5%)
2333 (56.5%)
Charlson Index
Mean (SD)
1.6 (1.8)
1.5 (1.8)
Length of stay (days)
Mean (SD)
11.6 (13.0)
11.1 (15.4)
Past Hospitalisation history
No. of admissions within 180 days before index hospitalisation
Mean (SD)
0.79 (1.4)
0.81 (1.4)
Patients with ≥ 1 admission within 180 days before index hospitalisation
n (%)
1731 (41.9%)
1847 (44.7%)
No. of 180-day ED attendances within 180 days before index hospitalisation
Mean (SD)
1.9 (2.0)
1.9 (3.1)
Patients with ≥ 1 attendance within 180 days before index hospitalisation
n (%)
4004 (96.9%)
3781 (91.5%)
P-value
0.37
0.25
0.51
0.014
0.89
<0.001
Propensity score used to adjust for Age, Gender, Charlson’s index, Length of Stay, Number of admissions in 180 days prior to index
admission, Number of ED attendances in 180 days prior to index admission
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Source: RHIME-MOH Comparison with Comparator Group
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Comparison Results

ACTION patients significantly less likely to be readmitted, and less likely to
visit ED.
The odds of unplanned readmission within 15, 30 and 180 days for
ACTION patients are lower than the odds for control patients.
The odds of ED attendance of ACTION clients within 30 days are lower
than that of controls.
Odds ratios of hospital readmission and ED attendance - ACTION vs. Controls (after
weighting by propensity score)
Outcome
Readmission
within 15 days
within 30 days
within 180 days
ED attendance
within 30 days
within 180 days
Adjusted Odds Ratio (95% CI)
P-value
0.5 (0.4, 0.5)
0.5 (0.5, 0.6)
0.6 (0.6, 0.7)
<0.001
<0.001
<0.001
0.81 (0.72, 0.90)
0.90 (0.82, 0.99)
<0.001
0.027
Propensity score used to adjust for Age, Gender, Charlson’s index, Length of Stay, Number of admissions in 180 days prior to
index admission, Number of ED attendances in 180 days prior to index admission
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Source: RHIME-MOH Comparison with Comparator Group
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ACTION Clients are More Likely to be
Readmission-Free
0.95
1.00
180-Days Readmission-free Survival by Groups
Hazard ratio (95% CI) = 1.3 (1.2 - 1.5),
P<0.001
CONTROL
0.90
ACTION
0
50
100
150
200
Days from Index Discharge
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Source: RHIME-MOH Comparison with Comparator Group
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Estimated Cost Savings
Estimating cost savings from the difference in reduced hospital days and
programme implementation costs
 ACTION saved 6283 bed days of unplanned admissions over 6
months
 Estimated S$5.3m saved from these reduced bed days
 Operational cost of ACTION programme over six months (Apr to Sep
2010) was S$1.94m (>95% the care coordinators’ salary)
 Hence overall cost savings = S$3.4m over 6 months
 Assumes no net additional healthcare cost used by ACTION care
recipients compared to the control group**.
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More Evaluation of ACTION
ACTION clients/ caregivers were surveyed in Feb/ Mar 2011 after
discharge from service
 Exclusion
Those who lodged a hospital complaint
Social overstayer
Cognitively impaired without a caregiver
Those transferred to community hospital/ inpatient in rehabilitation ward/
sub-acute ward/ sheltered home/ nursing home

1st interview: 1 week post-discharge
Health-Related QoL (EQ-5D)
2nd interview: 4-6 weeks post-discharge
Care Transitions Measure (CTM-15), Health-Related QoL (EQ-5D),
satisfaction ratings

451 completed both surveys
70% of responses by caregiver proxy
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Source: RHIME-IMH Survey
Quality of Care Transition
 CTM-15 measures four domains
Information transfer
Patient and caregiver preparation
Self-management support
Empowerment to assert preferences
 Total score ranges from 0 to100
Higher scores indicate better transition
 Overall mean CTM-15 score of surveyed clients/ caregivers
was 63.8.
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Source: RHIME-IMH Survey
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Perception in Health-Related QoL (EQ-5D)
 Analysed for surveys completed by same person (n=296)
 Higher proportion reported having ‘no problems’ at 4-6 weeks for all
5 dimensions (P<0.05)
70.0%
65.2%
57.8%
60.0%
49.7%
50.0%
40.9%
40.2%
30.0%
48.6%
42.2%
39.2%
40.0%
57.4%
29.7%
20.0%
10.0%
0.0%
Mobility*
Self-Care*
Usual Activity*
Interview 1
Pain/
Discomfort*
Interview 2
Interview 1
‘Self’-rated health
(0=worst health, 100=best health)
Source: RHIME-IMH Survey
Anxiety/
Depression*
60.4
Interview 2
64.1
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P<0.05
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Majority were Satisfied with ACTION
50%
44%
(N=451)
46%
44%
40%
30%
27%
24%
24%
24%
22%
20%
19%
10%
2%
2%
0%
3%
0.4%
0.4%
0%
Knowledge of CCs
Excellent
Care and concern shown by CCs
Good
Satisfactory
Poor
Overall satisfaction
Very Poor
70% rated ACTION service overall as good or excellent.
68% rated care and concern shown by ACTION care coordinators as good
or excellent.
63% rated knowledge of care coordinators as good or excellent
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Source: RHIME-IMH Survey
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Conclusion of ACTION Analysis
 The ACTION, a hospital-based transitional care
program, significantly reduced acute care utilization
for up to 6 months post discharge.
 Improved care recipient well-being, and positive
responses to quality of care transition and service
satisfaction ratings
 Findings confirmed the effectiveness of the Care
Transition Intervention in Singapore’s public health
system.
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Post Acute Care at Home (PACH)
 A tertiary hospital pilot programme that delivers transitional care
to patients that requires multi disciplinary team interventions
post discharge
Key objective include:

Reducing unnecessary ED attendance and readmissions and
hence burden on hospital resources
 Services provided are time limited with an average duration of
3 months
 Encourages handover of patient management to the community
whenever possible
 The hospital had conducted the first phase of its evaluation to
assess the effectiveness of the programme
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Initial Results: Bed Days Saved
Based on the analysis of administrative database of PACH client cohort
(Apr 11 – Dec 11),
 2.9 bed-days can potentially be saved per patient, from
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ED visits and readmission averted through timely response by
team to urgent calls made by clients
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Management of certain conditions at home (which in the absence
of PACH would have led to hospital admissions), e.g.

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Behavioural problems from persons with dementia staying at home
Facilitation of timely discharge from acute hospital through the
provision of post discharge support
AIC and Ministry of Health will work with the hospital on the second phase
of the evaluation in acquiring mortality and health service utilisation data
to facilitate further analysis.
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Source: PACH Administrative Data Analysis
Challenges of Current TC Programmes
There are currently 3 hospital-led transitional care programmes that provide
multidisciplinary interventions to help patients transit from hospitals to community.
Common challenges faced by this category of TC programmes
 Patients were not keen to be enrolled into such community
programmes due to high out-of-pocket charges
 Difficulties in recovering cost from patients and hence services were
highly subsidised by hospitals
 Problems in discharging patients to community partners who are not
well-equipped
 Limitations in performing robust evaluation by hospitals due to lack of
access to comprehensive data
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Moving Forward
 Expansion of ACTION service in other segments such as specialist
outpatient clinics and ED
 ACTION teams will collaborate and align more closely with other local
projects within respective hospitals
 Revision of funding model for hospital-led TC programmes to ensure
affordability and sustainability
 A unified evaluation will be conducted under the oversight of AIC and
Ministry of Health to assess programme outcomes in-depth.
 Emergence of new hybrid models taking reference from, for instance
Project BOOST and UK Virtual Ward
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Acknowledgement
 ACTION Managers, ACTION Care Coordinators, ACTION
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Clinical Champions and ACTION Heads of AH, CGH, NUH,
KTPH, TTSH, SGH, NHC, RCCH, SLH, AMKCH, SACH and
BVH
Colleagues from Health Services Research and Health
Information Department, Ministry of Health
Colleagues from Research Division, Institute of Mental Health
Dr Ian Leong, PACH Programme Director, TTSH
Dr Wong LM, Chief, CID, AIC
Ms Polly Cheung, Deputy Chief, CID, AIC
Dr Wee Shiou Liang, Head (RHIME), AIC
Colleagues from Regional Integration Office, AIC
MOH and AIC Management
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References
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Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care
Systems Committee. Improving the Quality of Transitional Care for Persons with
Complex Care Needs. Journal of the American Geriatrics Society. 2003;51(4):556557.
The Australian Government. National Evaluation of the Transition Care Program.
Final Evaluation Report. 2008.
The Care Transitions Program [Internet]. [Cited 2013 Feb 18]. Available from:
http://www.caretransitions.org/index.asp
Health Workforce Solutions LLC and Robert Wood Johnson Foundation. Transitional
Care Model [Internet]. 2008 [cited 2013 Feb 18]. Available from:
http://www.innovativecaremodels.com/care_models/21/overview
Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results
of a randomised controlled trial. Arch of Int Med. 2006;166:1822-8.
Coleman EA. The care transitions intervention [Internet]. [Cited 2013 Feb 20].
Available at:
http://www.cfmc.org/integratingcare/files/Care%20Transitions%20Intervention%20for
%20CFMC.pdf
Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS.
Transitional care of older adults hospitalised with heart failure: a randomised,
controlled trial. JAGS. 2004;65:675-684.
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Thank you
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