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Analysis: The importance of care integration

Gan Kim Yong, Singapore’s minister for health, explains why integrated care is important in the context of an ageing population.

Integrated care is increasingly important in the context of an ageing population. By 2030, one in four Singaporeans will be aged 65 and above. An ageing population will mean growing needs for healthcare. As we age, we may not have just one health issue, but have multiple chronic conditions. We may have multiple specialists treating us and also have multiple episodes of admissions to the hospital. On the other hand, there are fewer caregivers to care for us, because family sizes are shrinking. Without good family and social support, the conditions of seniors may deteriorate, resulting in readmissions to hospitals.

Our healthcare system was initially designed for a much younger population. We need to transform the way we deliver care urgently, if we want our healthcare system to continue to deliver appropriate and effective care. We need to move to a seamless integration of care services organised around the patient.

What does it take to achieve integrated care? First, we must take a multidisciplinary, person-centric approach. It entails doctors working hand in hand with other healthcare professionals to identify the common care goals for patients and to prioritise and streamline interventions.

One early example is the initiative introduced in 2014 to help consolidate appointments for patients with multiple Specialist Outpatient Clinic (SOC) visits that spanned different specialties, and multidisciplinary teams and primary care partners also share in the care for the patient, where appropriate. By assigning the care of each patient to a single coordinating physician, patients received more holistic care, as their physicians had oversight of their various conditions. Patients and their family or caregivers also avoided the inconvenience of multiple trips when medical appointments were co-ordinated well. Furthermore, patients benefitted from designated primary care physician and a care coordinator who would help to coordinate the transition between SOC and primary care, facilitated by shared protocols and workflows.

We have seen positive results in some of the pilots so far. For example, successful implementation by the National University Health System saw enrolled patients achieve better outcomes, with fewer SOC visits, fewer emergency department admissions and shorter lengths of stay. This has yielded significant overall cost savings for the system as well. We are now in the midst of gleaning learning points from this and other similar pilots, to see how we can scale this up to benefit more patients across the country.

Second, integrated care is about joining up care in a seamless manner across settings – between acute and intermediate and long-term care, between acute and primary care, and between primary and community care. This is a key part of our goal to shift care beyond the hospital into the community and closer to home. The Agency for Integrated Care has been working with the RHSes to implement the Hospital to Home (H2H) programme. This programme consolidates the care transition arrangements of our hospitals with the aim of facilitating the discharging of patients back home in a timelier and more seamless manner. Under the H2H programme, a multi-disciplinary team works in the community to provide care and services such as rehabilitation and nursing for patients in their own homes. Subsequent referrals will be made to Community Care providers if necessary. 8,000 patients have benefitted since the programme was launched in April last year.

Last but not least, integrated care is about connecting social- and health-related services. For example, seniors who are socially withdrawn might face poorer health outcomes if they have no one to remind them to take their medication, or to do simple maintenance exercises with them, or to engage them in mind-stimulating activities. Health and social care must therefore transcend boundaries, to help seniors to age confidently. In 2013 for these reasons, we merged the aged care functions of the Ministry of Social and Family Development, with those of the Ministry of Health, to facilitate service planning at the national level and pilot new models that integrate social and health care.

Under the Care Close to Home (C2H) programme, we enable seniors in ageing rental precincts to age-in-place, by effectively turning these precincts into in-situ care homes with assisted living support. A care team, comprising trained care staff and programme coordinator, is deployed to serve the seniors in the rental blocks under this programme. To date, we have C2H at 11 sites, and have benefitted more than 2,500 clients. We will be expanding C2H to more sites this year. 

We need to build new capabilities to achieve better care integration. First, deepening our manpower capabilities to support care integration. Good integrated care requires a skilled workforce that is trained and competent in the delivery of good community care. A recent initiative is our effort to develop community nursing, to underpin the care transformation needed. Community nurses are familiar with the services both in hospitals and the community. They can bridge patient care needs across the two settings. They can support patients discharged from our healthcare institutions, as well as cases surfaced by the community (or what we call “community up” cases). We envisage them supporting a range of functions, to help pre-empt re-admissions, retard frailty, and to also support palliative care, among others. 

To provide nursing graduates opportunities to deepen their skills and knowledge in providing community care, Nanyang Polytechnic and Ngee Ann Polytechnic have also rolled out new programmes such as the Specialist Diploma in Nursing (Gerontology) and the Specialist Diploma in Community Gerontology Nursing. Around 20 nurses enrolled in the first intake of the programmes last year. We are also growing our pool of community nurses through initiatives such as the Community Nursing Scholarship, and exposing nursing students to community nursing during their pre-registration period. 

General practitioners also play a key role in delivering more holistic care to patients. For example, GPs who are closest to the community and easily accessible, can help provide palliative care during a patient’s end-of-life journey. Through the Community Care Manpower Development Award, we are helping more GPs keen to collaborate with the community care sector to up-skill in the areas of family medicine, geriatric medicine, mental health and palliative medicine. AIC has awarded 25 such awards to date.

Next, healthcare IT will enable care to be integrated across care settings much more easily. Information should flow beyond hospitals to care professionals at the community, to enable better management of patient conditions. Our National Electronic Health Record (NEHR) System, and Care and Case Management System are two platforms that help us achieve this. In particular, as patients visit multiple healthcare providers over their lifetime, our vision is to achieve “One Patient, One Health Record”, with NEHR serving as a central repository of a patient’s medical record.

Finally, our funding arrangements must provide the flexibility to optimize care and allocate resources flexibly and efficiently to achieve better outcomes for patients. We need to move away from per day or per visit funding and move towards funding the bundles of services needed for an episode or event. For example, the “Hospital to Home” programme which I mentioned earlier was funded on a per episode rate to give flexibility for providers to provide different services and frequencies, to better tailor care to each patient’s unique circumstances.

With changing demographics and increasingly complex healthcare needs, care integration is paramount in providing holistic and patient-centric care. What we are doing in Singapore mirrors a global trend in healthcare reforms to re-organise care in a more coordinated and integrated fashion, and to do so at a faster pace.

This article is an edited version of a speech given in Singapore at the Global Conference on Integrated Care on 2 February.

Posted on: 06/02/2018 UTC+08:00


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