Care Model Evaluation

Care solutions include the Integrated General Medicine (IGM) care model, which focuses on acute-subacute transitions that involve proactive discharge planning. The target patient segments are those with multiple needs.

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Alexandra Hospital - Integrated General Hospital Evaluation

IGM launched with an implementation at Alexandra Hospital (AH). AH-IGH site aims to manage patients through a one-bed-one-care-team approach. AH-IGH care has shown promising results in shortening inpatient stays by providing holistic and coordinated management among patients who typically require acute-to-community care transition.

 

MOHT has been partnering NUHS to evaluate the AH-IGH implementation. A prospective study is in progress. The study aims to validate if generalist-led care will lead to more favourable inpatient and post-discharge outcomes.

 

Singapore General Hospital - Integrated General Medicine Evaluation

MOHT is also collaborating with Singapore General Hospital (SGH) on another IGM site implementation. The stakeholders are Internal Medicine (IM) and Family Medicine (FM) doctors who function within a single care team to co-manage, coordinate and ensure the smooth transition of care episodes from the acute to subacute phase, as well as allow for timely discharge of appropriate patients with active links to downstream community programmes and services. The project is currently adopting an observational evaluation approach and can eventually consider a randomised controlled trial to improve evidence on causality.

 

Home Hospital Evaluation

The care solutions also include the Home Hospital. Home Hospital delivers coordinated hospital-level inpatient care in safe and scalable community-anchored settings such as patients’ homes. MOHT is partnering NUHS, Yishun Health, SGH, and private healthcare providers to implement and evaluate pilots seeking to provide a substitute for inpatient care safely and effectively for selected consenting patients who would otherwise require inpatient ward hospitalisation. Preliminary results have shown promising potential. MOHT is collaborating with partners to adopt a multi-pronged, multi-stakeholder, multi-site validation approach. Findings from pilots can inform conversations to identify key building blocks needed to establish an integrated community-anchored, technology-enabled and policy-empowered ecosystem.

 

Digitalisation and Data Sharing

The digital solutions are anchored by iConnect, which is a set of care redesign services for enabling transitional care through data sharing across settings. Through iConnect, consumers can collaborate more effectively with carers in making decisions on their care. The goal is to deliver care transitions with less friction, harness technologies at scale, and empowering individuals to make informed decisions. iConnect enables this by curating use cases that demonstrate data sharing and build a critical mass of reusable capabilities:

 

One-Rehab Solution

iConnect was selected by MOH to digitally enable the National One-Rehab initiative. iConnect’s One-Rehab solution will provide one common digital interface for data entry for six key rehabilitation pathways. Providers can harmonise the collection, sharing and benchmarking of core care outcomes across settings. The scale of the programme is national, involving more than 100 settings and more than 15,000 patient episodes across Singapore annually. The project will be launched in 4Q2021 in phases, starting with SingHealth.

 

One-Care-Plan Solution

iConnect’s One-Care-Plan solution supports Regional Health Systems’ push for seamless patient transitions across community and hospital settings, starting with SingHealth’s Empowered Communities of Care. The redesigned processes enable shared decision making across providers within a given geography. The launch version will feature an auto-population of selected fields and a small geographically sorted registry of resident needs. When launched, the app for SingHealth (PopUP!) will be integrated with NeHR NHIS and SCM Community Nursing notes.