Analysing the effectiveness of Integrated General Medicine (IGM)
The IGM care model taps on the expertise of 2 medical teams – an Internal Medicine team providing the initial acute care and a Family Medicine team taking over in the sub-acute period. It aims to anchor a generalist-led approach for delivering productive and coordinated hospital care to patients with multiple needs, i.e., medical, functional and psycho-social needs. Such care could potentially be provided by a future-ready workforce with the right skills-mix, supported by the relevant enablers (e.g., technology for better information sharing).
Xie JiaJing Kim, Integrated General Hospital programme, MOHT
Dr Tay Wei Yi, Singapore General Hospital
Clinical Assoc Prof Low Lian Leng, Singapore General Hospital
Primarily, the IGM pilot aims to reduce average length of stay (ALOS) of patients by focusing on care transitions of patients going home, as well as those requiring Community Hospital (CH) care (Figure 1). The primary aim was balanced with hospital readmission rates to look at potential harm with faster discharges. Secondary outcome measures include cost-effectiveness, healthcare cost, and utilisation. Together with the Department of Internal Medicine (DIM), Department of Family Medicine & Continuing Care (FMCC) and Population Health and Integrated Office (PHICO) at SGH, we conducted a prospective observational study on inpatients admitted to an Internal Medicine ward. One of the Geographical Team (GT) was identified to be the intervention arm with DIM and FMCC working closely in this IGM pilot. The rest of the GT wards were identified as controls and continued with standard care.
Figure 1. Role of IGM in right-siting patients from acute/restructured hospital
RH – Restructured Hospital | AH – Acute Hospital | CH – Community Hospital
Table 1. Average length of stay of patients in IGM ward in comparison to non-IGM ward
Soft launched in December 2020 and officially launched in January 2021, interim data analysis was done in June 2021 to ensure that the interventions were effective, no harm was done and the outcomes were aligned with the intended objectives. There was a statistically significant decrease in the overall average length of stay (ALOS) for patients in the IGM ward compared to the non-IGM ward, 7.193 (95% CI: 6.642, 7.744) vs 9.279 (95% CI: 8.711, 9.847); p-value = 0.0000). The ALOS was further stratified into discharges to Community Hospitals (CH) and Nursing Homes (NH) as the wait time for services in the Intermediate and Long Term Care (ILTC) can be long and varied due to differences in capacity, capabilities, administrative processes of the care providers. There was also shorter ALOS for patients discharged to the community hospitals in the intervention group, 18.152 days (95% CI: 14.814, 21.491) vs 26.165 days (95% CI: 21.821, 30.508; p-value = 0.0041) in the control group; and nursing homes 7.667 days (95% CI: 4.639, 10.694) vs 12.629 days (95% CI: 9.091, 16.168; p-value = 0.0335).
Table 2. Post 30 days re-admission rate in IGM ward in comparison to non-IGM ward
Faster discharges with shorter ALOS can potentially be harmful to patients. This can manifest as hospital readmissions, which have economic cost implications and exposes patients to more harms of a re-hospitalization. The 30-day re-admission rate was measured as a counterbalance indicator to monitor the safety of the interventions. Despite shorter ALOS in the intervention group, there was a significantly lower 30-day re-admission rate in the intervention group (Table 2) 0.221 (95% CI: 0.1788, 0.2623) vs 0.282 (95% CI: 0.2478, 0.3156; p-value = 0.0257) in the control group.
Qualitative feedback was also gathered from clinicians, nurses and Allied Health Practitioners (AHPs) to understand their perspectives of such implementation, and its potential facilitators and environmental barriers. Feedback gathered from the ground were mainly positive and pointed towards the direction of a smoother transition for patients into step-down care facilities. It was revealed that trust and effective communication among the IGM team was the key component. Examples were shared as follows:
“…we were able to identify the potential problems earlier. Hence, it helps to facilitate the discharge planning early...” (P0170)
“I learnt about discharge planning through my rotation in FMCC… and they know what to ask and what kind of support (patients) actually need through this IGM programme.” (P0120)
“…(IGM) is built on trust that you know (the referred cases) have already been verified by somebody who knows the criteria.” (P0110)
“…(IGM) is easy for us because we don't really have to scrutinise the referral, so all we need to do is just accept the referral.” (P0170)
However, some expressed their concerns regarding the scalability of IGM due to existing limited resources. One shared that:
“I think (resources that are lacking) would definitely be manpower, because if you were going to escalate IGM to hospital wide, for SGH, as of now I don't think FMCC has the capabilities to actually do a hospital wide IGM programme.” (P0120)
Findings from this IGM pilot are encouraging and have identified opportunities to improve productivity and surfaced gaps to enhance coordination for complex multi-morbidity patients within a hospital setting. However, questions of scalability still remain to be explored. Our next steps will look into analysing and qualifying the components of the intervention, training and knowledge transfer to relevant stakeholders, expanding IGM into other wards within SGH and determining the potential barriers to scalability and spread.
This is the second in a two-part series on the IGM model of care. Read part one here.
Assoc Prof Low recently shared insights on population health strategies at the 2021 Hospital Management Asia conference (via YouTube).