The IGH programme strives to deliver sustainable acute-to-community care by consolidating care at hospital settings and improving shared care between hospital and community settings. Within the programme, pilots set out to inform approaches that address fragmentation, which is a growing area of relevance in view of the increasing prevalence of patients with multiple needs.

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The Integrated General Medicine (IGM) project is based on earlier work by MOHT which found that certain groups of patients who are cared for by a single care team and facilitated in their transition back to the community, experienced better recovery.

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As part of the project, MOHT is partnering both Singapore General Hospital and Outram Community Hospital to develop an implementation where selected patients are co-managed between the two institutions as they progress along their recovery journey. MOHT has also partnered Alexandra Hospital on another implementation, where selected patients are cared for by one care team at one bed with minimal transfers.

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Another project is iConnect, a solution with digital modules that enable shared care. iConnect hosts a portfolio of use cases by bridging and convening capabilities so that consumers can collaborate more effectively with carers, in making decisions on their care. iConnect‘s modules are customisable and rapidly deployable. It is supporting national care redesign pilots such as One-Rehab across more than 100 sites in Singapore. As part of Singapore’s response to COVID-19, selected modules were re-purposed to support iConnect.COVID, a workflow automation tool to assist all 20 polyclinics in managing the registration, results management and patient notification for COVID-19 testing.

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The IGH programme also promotes the use of benchmarked tools to inform care delivery according to patients’ psychosocial needs, abilities and attitudes towards caring for themselves. The aim is to put patients in better control of their health. Care can then be individually tailored to the needs, choices, knowledge, skills, and confidence of each patient in managing their health.

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MOHT is also facilitating a set of Hospital at Home projects, where consenting patients are right-sited safely from a hospital to a home setting. The model utilises digital tools such as remote monitoring to enable hospital-level care to be delivered in conjunction with community medical partners. This model has the potential to result in better patient outcomes and relieve ongoing capacity constraints on hospitals.

Partners:

• Agency for Integrated Care

• SingHealth (Singapore General Hospital, Singapore Community Hospitals, SingHealth Polyclinics)

• National Healthcare Group (National Healthcare Group Polyclinics)

• National University Health System (Alexandra Hospital, National University Hospital, National University Polyclinics)

• Integrated Health Information Systems

• DesignSingapore Council

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Current Initiatives:

• Integrated General Medicine pilots at SingHealth and NUHS

• iConnect pilots at multiple settings and use cases around Singapore

• Hospital at Home pilot at NUHS and SingHealth