Optimising care transitions with Integrated General Medicine (IGM)

Healthcare needs of an ageing population with rising chronic disease burden will exert increasing pressure on limited hospital resources in the coming years if care delivery stays status quo. Many of such patients also have complex psychological and socio-economic needs that are closely related to their medical conditions. Medical training through specialisation and even subspecialisation has contributed significantly to clinical excellence in treating single dominant acute conditions.

Contributed by
Xie JiaJing Kim, Integrated General Hospital programme, MOHT
Dr Tay Wei Yi, Singapore General Hospital
Clinical Assoc Prof Low Lian Leng, Singapore General Hospital

However, the needs of complex patients go beyond single disease, organs or systems and there is now growing interest and urgency to identify a group of generalists who are able to deliver cost effective, holistic care to patients with multiple co-morbidities and multi-faceted needs. The skill sets and philosophy of care of these generalists will be most relevant for hospital in-patients who no longer require subspecialised care, but whose unresolved issues still require attention. These patients should therefore be stepped down and managed at the right intensity, hence reducing the utilisation of limited hospital resources.

Care integration has been promoted as a strategy to overcome challenges associated with growing complexity in health and social care needs. However, this seemingly simple concept of integrated care not only requires multicomponent delivery strategies that target various levels of the healthcare system, but also the engagement of various stakeholders for these strategies to actualise. This poses a great challenge in implementation.

With the aim of finding a way to operationalise inpatient general medicine for the holistic care of patients with multiple needs, MOHT and Singapore General Hospital (SGH) collaborated on a pilot that is built on the concepts and insights derived from the Integrated General Hospital – Alexandra Hospital’s (IGH-AH) care model. IGH patients in this pilot had their acute care and rehabilitation care provided on site by the same team of healthcare provider, with resources adjusted according to their acuity level. Findings from this care model showed a lower overall length of stay and healthcare utilisation in IGH compared to the control group: National University Hospital (NUH) and Ng Teng Feng General Hospital (NTFGH). The longer overall length of stay in the control arm were primarily driven by longer length of stay in community hospitals.

Findings from the IGH-AH study contributed new knowledge to the pool of evidence validating this new model of care, especially in the local context where evidence is lacking. Given that insights of this study included outcomes such as clinical efficiency, manpower sustainability and healthcare financing, policy owners can make a highly informed decision on hospital care redesign and whether such an integrated care model is feasible and sustainable to be developed as mainstream care models.

The IGH-AH model has shown positive outcomes in a generalist led model in allowing resource optimisation without compromising on the quality of patient care by minimising hand offs and dynamically resourcing the care according to their acuity levels. Additionally, functional and social care needs such as discharge planning, patient education and referring to the right community resources were identified as vital components that contributed to a successful comprehensive IGH-AH model. With insights from the original model, focusing needs of a complex patient, the development of the next iteration (renamed Integrated General Medicine, IGM) leveraged on the strengths of an Internal Medicine – Family Medicine (IM-FM) collaboration.

This is the first in a two-part series on the IGM model of care – part two will look at the results of an observational study conducted with SGH.