Ageing-In-Place Programme
Alexandra Health System

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
What major problems and issues needed to be addressed? According to World Bank data, Singapore has the fastest ageing population in Southeast Asia, superseding developed nations such as Australia and the United States. The senior demographic (65+ years) has risen from 7.8% in 2002 to 11.7% in 2013. As people live longer and in an increasingly urban sedentary lifestyle, our growing burden of chronic diseases has translated into greater demand for healthcare and eldercare services. Moreover, the old-age support ratio has fallen from 8.4 (2000) to 5.5 (2013), dramatically increasing the financial burden on the working population. When Singapore was a young nation, healthcare was organized around episodic care in the acute hospital setting. However, to effectively and sustainably cope with the rise of chronic diseases, this must shift to keeping people healthy in the community while maintaining healthcare costs. The Healthcare 2020 masterplan has identified three national challenges: (1) Addressing impact of a growing and ageing population on Singapore’s capacity needs; (2) Changing the way healthcare is delivered to meet the changing needs of its population; and (3) Managing rising healthcare costs. What social groups were affected and in what ways? The impact of an ageing population, especially the chronically ill and low income elderly, is particularly felt in the public healthcare sector, where elderly constitute less than 10% of the population but take up over 40% of hospital bed days. The strain on the acute hospital capacity results in pressure to prematurely discharge patients for other acute patients who are often waiting for prolonged periods in the emergency department for vacant beds. Prematurely discharged patients are often readmitted within a short span of time due to the lack of ready support at home. With increasing specialization and complex medicalized care models, patients are disempowered and over-reliant on professional inputs for their health. This results in a big discrepancy in the quality of care between hospital and home. In the hospital, the patients’ needs and Activities of Daily Living are attended to within the organised environment of the ward. On discharge, they return to cluttered, disorganised home environments, with little support from their caregivers who may be equally old and frail. Even with a rich nation-wide network of assistance schemes and services, patients have difficulties navigating and accessing these services because they operate in silos through different ministries. This produces powerlessness, isolation, malnutrition and illness. Instead of accessing proactive preventive care in the community, patients react at each crisis based on convenience and quick-fix mindset, which often is the emergency department of the nearest public hospital. Only 10% of health is determined by direct healthcare. Modifiable components such as social, environmental and behavioural factors account for 60%, while the rest are unmodifiable. In the community, the chief concerns are poor resources and stretched caregivers. Many areas of neglect adversely impact health outcomes during recuperation at home : unsafe home environments, medication non-compliance and poor adherence to diet and rehabilitation. These are neither surfaced nor adequately addressed during inpatient care.

B. Strategic Approach

 2. What was the solution?
What the initiative is about: Aligning to Healthcare 2020 masterplan to provide accessible, quality and affordable care, the regional healthcare systems need to move away from the traditional way care is delivered. Alexandra Health System is responsible for the northern region with a catchment population of 700,000. We had to address the grim realities of multi-morbidity in an ageing population. The initiative, known as the Ageing-In-Place (AIP) programme, is a 2-pronged approach to address the problem. Firstly, we hot-spot high consumers of bed days and identified patients (termed as Frequent Flyers- FFs) with three or more admissions in a six-month period. Care teams visit these FFs at their homes. Care teams are geographically organized according to the ten political divisions of the northern electorate. The care model is “high touch” in that the care teams first build trusting relationships with patients and their caregivers in their homes, then holistically assess their clinical, social and environmental needs before co-developing individualized care plans to keep them well at home. In line with high touch care, the Community Nurses (CNs) became the patients’ single point of contact for care access and navigation of available assistance schemes and services. Secondly, CNs address the general population health needs at ten designated CN Posts. They are highly visible and easily accessible for basic nursing aid and personalized health and lifestyle advice. Chronic disease and functional limitation are also detected early through comprehensive geriatric assessments. Collaboration with community partners and grassroot leaders bring targeted assistance to those in need. Overall, these two approaches are supported by centralized Design Thinking and Business Analytics units for programme planning and service delivery. How it solved the problem? The above initiative was launched in Sep 2011 and the impact over two years is now evident. To alleviate the strain of an ageing population with high chronic disease load on the healthcare capacity, the model of care had to shift from a doctor-centric, hospital-based, medical model to a patient-centric community-based health-cum-social model. Shifting mindset was the first strategic direction in our programme development. We reframed our care paradigm to focus on “what matters to the patient” as opposed to “what is the matter with the patient.” Because patients make most of their health choices at home, independent of health professionals. Therefore, the key thrust to sustaining care of patients is through building trusting relationships with them in their homes. To make the home, rather than the hospital, the hub for care, care teams visits our FFs, in their homes to build relationships and empower them to achieve mastery at self-management of their health problems. This helped them to understand implications of short-term reactive decisions and develop a proactive approach through lifestyle changes. The care team also orchestrated appropriate health and social services provided by the existing network of community partners for them. A study of 400 FFs who previously occupied 9,000 bed days in a 6-month period experienced a 67% reduction in hospital admissions after our intervention. This translated to freeing up one 32-bedded ward to allow other acute patients to be treated. To deliver preventive care, our CN Posts with a monthly average of 550 walk-ins conduct geriatric assessments and health education for earlier detection and chronic disease management in the community. This service transformation yielded a high return for low investment. This also started a more ambitious population healthcare approach that became less centred around the acute hospital setting.

 3. How did the initiative solve the problem and improve people’s lives?
Our initiative uniquely addresses the problem in four creative and innovative ways: Firstly, it transforms healthcare by shifting care and funding from hospital to homes for holistic care covering modifiable determinants of health. We took the bold initiative to introduce nurses into the community, which is not commonly practiced in urban healthcare settings. Secondly, our care model goes beyond diagnoses, pills and procedures in the hospitals to building trusting relationships between healthcare workers and patients in their homes, where pro-active health decisions can be made with the appropriate guidance. Thirdly, adoption of Design Thinking and Business Analytics to guide programme development is innovative in the healthcare setting where, traditionally, evidence-based scientific approaches are preferred. Business analytics provide actionable insights for decision-making related to patient stratification and geographical concentration, allowing targeted deployment of resources with the appropriate skillsets. Design Thinking approaches issues from a human-centric behavioural/social angle, providing the team with tools and fresh insights to shape care, and motivate patients effectively and holistically. Finally, for real-time care coordination, the IT team moved quickly from Excel sheets to Excel forms while co-designing a permanent front-end mobile patient information dashboard with our CNs, which is targeted for rollout in Apr 2014.

C. Execution and Implementation

 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?
Financial resources 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. Human resources 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. Technical resources 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. Structured evaluation 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.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Key benefits resulting from this initiative Our initiative has improved the delivery of public services with positive impact in the five key areas - patient’s perspective; hospital capacity; hospital service delivery and process re-engineering; business analytics; and design thinking/research. Patient’s Perspective The formula of post-discharge support centered around CNs building relationships and being the sole point of contact of services has consistently delivered impressive outcomes. The initial findings of first 40 FFs show a reduction in admissions by an average of 56% from 3.75 to 1.63 times in the six-month period after our intervention. This result continued to improve, and stabilized at 67% with a sample size of 400. Additionally, 47% of the 400 were not admitted in the 180 days under our care and financially they saved SGD7,000 each after intervention. This is based on an average hospital bill of SGD2,000 per admission for our subsidized class. Qualitatively, patients are empowered and feel more confident to manage their conditions at home, with less dependence on episodic acute care in the hospital. Hospital capacity The reduction in admissions is equivalent to freeing up a 32-bedded ward for every 400 patients under AIP’s care. As a result, the hospital has freed up beds for patients with more acute needs and allowed for higher patient throughput and utilization of capacity. In addition, the reduction in unnecessary admission of our FFs translates to healthcare system savings in terms of government subsidy cost, amounting to SGD32 million over a three-year period. This is calculated based on a norm government subsidy of SGD800 per patient day in our subsidised ward. Hospital Service Delivery and Process Re-engineering The introduction of Business Analytics and Design Thinking/Research to build the AIP programme is a fresh approach to the development of the healthcare process. Business Analytics The AIP is an early advocate of data mining to provide real-time actionable insights for management decision. Traditionally, healthcare professionals manage patients and their outcomes individually in a clinical setting. This environment changed with the AIP community outreach. Business Analytics help to identify and target patients appropriately to maximize manpower allocation. For example, the use of Geographical Information System provides insights to the selection of CN Posts in locations with the highest concentration of FFs and targeted population in the vicinity. Data mining also provides insights to stratify our patient base by medical acuity and division, allowing us to deploy the appropriate level of experience. Business Analytics is also used for backend programme management including monthly reports showing the correlation between Contact vs Admission Rates, which provide nursing supervisors with insights on team performance for early investigation. Similarly, reports showing patients’ Needs Identified vs Admission Rates provide valuable feedback to nurses on the accuracy of their assessment of patients’ needs. With the success of Business Analytics in AIP, the use of data mining has been used in other hospital projects like optimisation study of traffic flow in the emergency department and the stratification of patients in our population health project. In addition, the Business Analytics team is invited to join various projects initiated at national level by the health and finance ministries. Design Thinking/Research Based on the AIP care paradigm of “what matters to the patient,” Design Thinking/Research was widely employed to understand patients’ true needs within their homes. Traditionally, hospitals tend to be process-focused, exemplified by practices like 6 Sigma and Lean Management. Design Thinking/Research, with its user-centric approach, gives a good balance to programme design and problem-solving. Design Thinking/Research focuses on human-centric research, approaching issues from behavioural/social angles, providing our CNs with tools and fresh insights making them more effective in shaping and motivating our patients to manage their health holistically. It also provided us with insights to rescript our enrollment pitch to reduce rejection of our service. We introduced Design Thinking/Research as a problem-solving tool to our partners, e.g. nursing homes and community hospice care. This initiative helps to build closer working relationships with our partners and introduces a new process improvement technique to them. The design team also hosted a Healthcare Innovators Forum at national level and produced workshops teaching the principles of Design Thinking/Research, Behavioural Design and Design by Experience with AIP case studies being featured as examples.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Our initiative is being replicated throughout the public service. At the national level, it has been studied in terms of programme sustainability and transferability. Sustainability The targeted low cost approach of AIP caring for 6000 patients (1200 Frequent Flyers in their homes and 4800 walk-ins at CN Posts) per year at SGD3.6 Million (SGD600 per patient per year) is sustainable, given a SGD10 Million per year cost avoidance in terms of healthcare subsidy saved from unnecessary admissions. The outcome includes freeing up of a 32-bedded ward and it associated manpower for every 400 patients under AIP. Currently, AIP is taking care of 1500 Frequent Flyers in their homes and 850 walk-ins at CNPs. The team is working to increase our walk-in volume in all the CN Posts so that we can reduce our current cost of SGD1,500 per patient to SGD600 per patient as targeted in our RF proposal by 2016. The sustainability of the programme can also be seen in helping our patients to reduce unnecessary hospitalization expenses, which average SGD2,000 per admission. This also has the advantage of preserving our citizens’ Medisave accounts, a national medical savings scheme designed to provide co-payment of services to meet their medical expenditure. AIP is addressing today’s subsidised bed-crunch problem by facilitating patients to age and die at home. It plays an important complementary role to the overall strategy to meet the needs of the ageing population. By focusing on bringing care into homes, we are advocating the future reality of an ageing population being cared for at home through building patient’s capability in self-management. Without this, it may mean building more hospitals and nursing homes to meet future requirements. The AIP model of quality community care builds on a demedicalized model of care to build capacity in the community to sustain the wellness of the population. Transferability The convincing low cost high return model has propelled two other regional health systems in Singapore to replicate it. The DUKE-NUS evaluation of the AIP will provide a template of the sustainable mechanics for easy adoption and rollout across other regional systems. Already in progress is the documentation of the AIP as a case study in evidence-based policy making by the CSC. The use of Business Analytics in AIP is also a forerunner of a growing emphasis by the government to use analytics techniques to unlock significant value from data mining. Both the Health Minister and Deputy Prime Minister recently announced the government’s intent to train more analytics professionals and data scientists in the country. The AIP business analysts are now members of multi-ministries business planning initiatives and data mining task team. The concept of CN Posts that bring nursing care into the community is also scalable across throughout the country, as the formula of collaborating with the grassroot and political leaders to provide residents with health support is a readily welcome strategic step. The AIP programme easily proliferated its CN Posts across all divisions in the north within a short span of time.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
“Think big, start small, dig deep, act fast.” Our guiding principle, adapted from Mayo Clinic’s Center for Innovation, resonated with our corporate management philosophy, and AIP’s success reinforces the value of its wisdom. AIP started small, with a team of four, having the singular aim of reducing demand of subsidized beds by helping patients to manage their health at home. This quickly evolved into a big goal of transforming patients’ homes into hubs of care, reducing/delaying the need to build more healthcare infrastructure to meet the ageing population’s demand. The four members dug deep to ascertain the magnitude of the issues faced in the homes through months of home visits. Once we validated the problem, the team acted fast to develop an intervention programme for our first 50 patients. With the subsequent encouraging outcomes, we secured internal funding within four months for a one-year pilot. “Fly below the radar.” Looking back at the evolution of our programme, one of the main contributing factors to our steady progress was the decision by our management to allow the programme to develop “below the radar,” even though we had the lofty goal of developing a programme with national impact. The willingness of our Board members to invest SGD 2 million for our pilot allow the programme to develop at its own pace and targets. “Stay focused.” In spite of its ambitious target, our team held on to one simple goal developed from the onset - to reduce unnecessary readmissions. This became the single principle transcending our entire care philosophy. This approach is inspired by the successful Aravind Eye Care System, which has the single focus of eliminating avoidable blindness, that guided its founders to expand beyond low cost high quality eye care in India to supporting the same care philosophy internationally. “Sharpen the saw.” The opportunity to “fly below radar” and the autonomy of a single-focused target can easily lead to stagnation and developing a programme below its potential. We were mindful that the first priority was to develop the main thrust and embed our operation both within the hospital and the community to prevent scope creep and dilution of focus. Sharpening the saw is a philosophy of self-renewal to preserve and enhance our asset, the AIP programme. By having a deliberate and controlled pace in expanding our breadth and scope, we keep the programme growing with the capacity to find and meet new challenges while maintaining our single focus. As our understanding of the problems deepened, we included several new initiatives: working with community hospice care and introducing advanced care planning; reducing polypharmacy to save cost and minimise adverse outcomes; piloting the creation of an elder-friendly village to promote communal care. “Teamwork matters.” We do not need to do this alone because partners already exist in various niche services. Teamwork means working together for a common purpose and putting group interests above self interests, sometimes going out of the way to make the other members look good, feel good and be good!

Contact Information

Institution Name:   Alexandra Health System
Institution Type:   Public Organization  
Contact Person:   Wing-Chew Lau
Title:   Chief Transformation Officer  
Telephone/ Fax:   +65 6555 8000
Institution's / Project's Website:  
Address:   90 Yishun Central
Postal Code:   768828
City:   Singapore
State/Province:   Singapore

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