| 4. In which ways is the initiative creative and innovative?
The action plan to implement our strategy comprised three key developmental activities in chronological order.
Stage 1: SEE the need for change (Sep-Dec 2011)
Faced with an over-demand of hospital beds, a task team used business analytics to identify patients with high bed utilization, with the hypothesis that they had unmet needs at home resulting in poor health outcomes and frequent admissions. The team visited 50 homes and identified a pattern where meeting their needs reduced admission rates. Concurrently, at a community centre, we identified opportunities for nurses to befriend and conduct geriatric assessments, chronic disease monitoring and education for the residents.
Stage 2: START small with a pilot (Jan-Sep 2012)
In January 2012, the team presented a funding proposal to our Board of Directors for a two-pronged proof-of-concept: home visits by CNs to help FFs and preventive care at CN Posts, with the goal of reducing unnecessary admissions. Funding was approved with the understanding that we seek long term public funding should the proof-of-concept be successful.
The first priority was to establish a multi-functional AIP team while ramping up nursing resources. By Sep 2012, nursing resources increased to six, while FFs load increased to 400. Subject matter specialists - allied health professionals, analysts, industrial/system designers, finance and community engagement executives - were recruited into the team.
The AIP team actively participated at community events and held roadshows at district meetings to win the support of community leaders, resulting in fast setup of CN Posts. Community leaders also started visiting our FFs in their constituencies and publicity increased when local news featured the participation of these leaders in our programme.
We organized our first AIP networking forum in Jul 2012 as a platform for our service partners to align with our vision and to improve collaboration.
Stage 3: SCALE up the programme (Sep 2012-Today)
The Ministry of Health’s Ageing Planning Office (APO), supported by Agency for Integrated Care (AIC), identified our programme for Reinvestment Funding, a budget set aside for investment in new areas that support cross-agency collaboration and innovation. It channels resources to ministries with proposals for new and worthwhile projects on a competitive basis.
In Apr 2013, a 3-year budget was approved with the understanding that the programme continues to fine-tune operations to achieve financial and outcome sustainability to benefit both the healthcare system and patients.
Operations were ramped up with a target of deploying 40 field staff to manage 1200 FFs and 4800 walk-ins at the CN Posts annually.
With maturity, we expanded our scope to focus on value-added initiatives: introducing Advanced Care Planning and home-based palliative care support; reducing polypharmacy; identifying latent depression for intervention; working with public housing agency on subsidised home-safety enhancement programme; and piloting an elder-friendly precinct to promote communal care.
To develop a sustainable programme, we partnered with:
• Duke-National University Singapore (Duke-NUS) Graduate Medical School, to conduct an independent evaluation of the programme’s effectiveness to facilitate easy adoption by other health organizations
• Civil Service College, to document our programme as a case study for evidence-based planning and policy making in their syllabus
• ACCESS Health Singapore featured AIP as one of the strategies to tackle Singapore’s ageing population and if effective, propose it as a Commonwealth Fund case study of low cost care model for high cost/frequency patients
• Faculty at various polytechnics and universities, collaborating in design thinking and business analytics, to develop patient-centric tools and predictive models.
The AIP received recognition in the public sector when awarded Gold in the PS21 ExCEL Awards 2013 organized by the Public Service Division that showcases innovative and productive programmes benefitting the general public.
| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The design and implementation of our initiative had invaluable stakeholder support at various levels, from national to regional hospital, community and institutional partners.
At national level, support from Ministry of Health and AIC were instrumental in AIP receiving the RF, which propelled it into a regional programme with substantial patient base. Ministry of Finance which approved the funding also took an interest and recommended AIP to be used as a case study by the Civil Service College.
At regional hospital level, support from our Board and senior management provided initial pilot funding from our Endowment Fund and secondment of subject matter specialists to kick-start the AIP team. Senior management actively joined our CNs for home visits, providing valuable insights and impetus for fast-track development of programme initiatives. A case in point is the recent initiative of involving multiple agencies to pilot the creation of an elder-friendly precinct to experiment with communal-supported care for our FFs.
At community level, our division-based operations and active participation in grassroot activities has garnered wide spread support and publicity in the news. This alone opened many doors for our programme, particularly allowing easy establishment of the CN Posts. The willingness of our partners to align to our working model is an important factor. Services integration requires a locus of control and responsibility (the CNs) for the needs assessment, referral to services and follow-up by partners. Our partners agreed to move away from the existing concatenation of loosely-connected providers to a CN-led care delivery process that reduces gaps, redundancy and over/under-utilization.
At the academic institutional level, programme evaluation and documentation has sharpened our focus and refined our objectives, leading to greater programme robustness.
| 6. How was the strategy implemented and what resources were mobilized?
We had a total project funding of SGD11.8 million, with SGD1 million deployed in Stage 1-2, and the rest in Stage 3. The financial cost breakdown associated with Stage 3 is detailed below:
• Manpower (64%) - Recruitment of geriatrician, additional nurses, healthcare workers, administrators, allied health staff.
• Information technology (9%) - Mobile solutions to facilitate the nurses
• Aids, appliances and purchase of services (6%) - Payment of assistive devices for patients
• Community outreach (2%) - Outreach programmes
• Programme evaluation (7%) - Programme effectiveness evaluation
• Curriculum development (1%) - Development of training curriculum for the nurses.
• Other capital and operating expenses (11%) - Workstations, transport and other miscellaneous expenses.
In Stage 1, an initial four-member team - a geriatrician, an administrator, a registered nurse and a social worker - visited FFs at their homes, to look for intervention opportunities. In subsequent Stages, a multi-disciplinary team was formed with a senior administrator and a senior geriatrician as co-directors of the programme providing balanced leadership and focus. The ground staff consisted of CNs, healthcare workers (HCWs) and community volunteers. Subject matter specialists, comprising senior allied health professionals provide developmental roadmaps and training curriculum to equip ground staff with the necessary skillsets to pick up issues and integrate management within the community health and social landscape.
Training manuals have been developed by subject matter specialists to train our ground staff during protected training sessions. Skill training is supplemented at weekly multi-disciplinary meetings, where CNs discuss selected case studies with clinicians and allied health seniors for follow-up action. Our end vision of a CN would be one who is skilled in core nursing as well as functional knowledge that span across basic therapy, social and health services, pharmacology and behavioural science. We are also actively experimenting the effectiveness of different team compositions, which combine trained HCWs and volunteers in CN-led teams. Training manuals and standard work instructions are developed for HCW and volunteer training workshops, prior to hands-on training by the CNs.
How was the project funded and who contributed to the financing?
In Stages 1 and 2, our Alexandra Health Board of Trustees granted the team SGD2 million from the Endowment Fund as seed funding for the programme, of which only SGD1 million was used. In Stage 3, of the total three-year project funding of SGD10.8 million, Reinvestment Fund provided SGD9.8 million, inclusive of an independent programme evaluation to validate its financial and outcome sustainability and portability to other regional healthcare clusters. The remaining seed fund from the Alexandra Health Endowment Fund provided the additional SGD1 million.
| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The following five concrete outputs contributed to the success of our initiative:
(1) Integration of the discharge process: The AIP unified pockets of isolated discharge and post-discharge processes in the hospital and reduced service fragmentation and confusion by having an aligned singular discharge process based on clear patient stratification. Daily reports highlighting new and readmitted FFs are generated for our nursing triage to visit these patients while they are still recovering in the wards. Discharge planning can be started early, with the confidence that post-discharge follow-up at home is available.
(2) Creation of care plans: During home visits, CNs co-develop with every patient an individualized care plan covering clinical, functional, social and environmental needs. This plan is regularly reviewed with patients and caregivers to adjust their goals based on the patients’ progress. With the care plan, CNs decide on the frequency of their contact and the urgency of engaging social community services at the appropriate level.
(3) Collaboration within the concatenation of social and political partners in the north: The AIP mission to support our vulnerable patients in their homes resonated with our partners in the community. With our engagement of the community and political leaders to support our initiative, the programme became the rallying point behind the commitment to support our residents to age-in-place. This facilitated smooth collaboration between AIP and the service support agencies in the community.
(4) Patient and management dashboard: Given the itinerant nature of the care teams in the community, a comprehensive management dashboard is essential for supervisors to monitor their teams’ effectiveness in the community. Dashboards co-relating Contact vs Readmission rates, and Needs Identified vs Readmission Rates, provide early triggers to supervisors on their teams’ performance, for intervention and coaching. Patients’ dashboard on a mobile device is also being developed to provide nurses with real time information to improve efficiency.
(5) Establishment of CN Posts: The CN Posts are bases for our CNs to be visible and accessible in the community. Our CNs assess some 6.600 residents annually for early intervention of medical conditions and functional limitations. Our CN Posts have effectively become the forerunner of the government’s population health initiative. For example, the Health Minister launched the “Healthy City for All Ages” programme in Jul 2013 at one of our CN Posts.
| 8. What were the most successful outputs and why was the initiative effective?
We systematically assessed the implementation and progress of our programme through regular management updates and structured evaluation.
Regular management updates
The AIP team updates our Board of Directors and Board of Trustees quarterly, and our Group Chief Executive Officer and Chief Finance Officer fortnightly, to review the progamme results and to identify areas for growth. Monthly meetings are held with our Deputy Secretary (Health) and senior representatives of the AIC, who monitor the progress based on the RF proposal. Key Performance Indicators (KPIs) stated in the RF are submitted six-monthly to APO and AIC for monitoring.
Internally, the AIP multi-disciplinary administrative team meets every Thursday to review our operational matrices and dashboards to ensure delivery of our contact and outcome KPIs. We use Admission vs Contact Rate, monitoring each division team for performance improvement for the purpose of feedback. Patients with high admission rates while under the AIP programme are also highlighted weekly for discussion and management strategies. In the same afternoon, CNs attends a 90-minute Multi-Disciplinary Meeting with our clinicians and allied health subject matter specialists to discuss case studies with challenging problems.
Externally, the AIP organizes periodic forums for all our service partners as a platform for mutual service updates. These forums give an opportunity to showcase examples of sterling integrated care by the various care agencies. Our grassroot and political leaders are regularly updated of our progress in their divisions. We furnish them with names of their residents who are FFs, so that they can incorporate these FFs into their weekly walkabouts, to render additional social assistance. This is a channel for direct feedback of our services from our patients to their community leaders.
We have engaged the Health Service and System Research programme in Duke-NUS Graduate Medical School to conduct an independent and full evaluation of the AIP programme effectiveness to facilitate potential adoption by other health organizations. This will be done over a 12-month period between 2013 and 2014.
| 9. What were the main obstacles encountered and how were they overcome?
Four major problems that were encountered and addressed were as follows:
(1) Reframing healthcare funding: AIP transformed healthcare by shifting the centre of gravity from hospital to home as hub for holistic care, covering all determinants of health. Traditionally hospitals are not funded to tackle non-medical issues, opting to refer out to social agencies. Our findings convinced policy-makers to recognise that non-medical determinants of health had to be addressed. The approval of AIP represents a recognition of the problem and willingness to shift hospital funding towards the social and environmental determinants of health.
(2) CN as integrator of services: Observations from our home visits show that existing services in the community are often not effectively utilised. Most service agencies understandably have the tendency to emphasize their specialties, resulting in over or under delivery to patient needs. With CN as the sole integrator of service, community partners have to surrender some of their autonomy of operations when collaborating with us. To resolve this, regular dialogue and networking forums were held to align our goals.
(3) CN as a mainstream vocation: Most nurses view work in Inpatient wards, Intensive Care Units and Operation Theatres as choice vocations for career advancements. Community nursing is not attractive. To overcome this, a 6-month rotation of nurses into the programme was introduced. Some of them chose to stay on. The role and successes of CN were celebrated widely in forums, newsletters and the media. AIP also proactively supported our partners developing their own home-based nursing capabilities by sharing our experience and protocols.
(4) Thinning of nursing resource: There were early criticisms to the diversion of scarce nursing resources away from the acute hospital. Results showing bed and staff savings, and pairing HCWs with CNs, were able to convince our detractors that our manpower was efficiently utilised.