The Virtual Hospital (VH)
Tan Tock Seng Hospital Pte Ltd

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
The Virtual Hospital (VH) is designed to target patients who are frail, and have chronic illnesses that render them susceptible to hospital re-admissions. Majority of the patients are elderly. Started in August 2012, the VH aims to create a safety net for those with compromised social and community support networks. This provides the patients with the clinical supervision, knowledge and skills that they need to better manage their health, thus enabling them to receive care that is better delivered in the community and reduce the frequency of readmission into the hospital. TTSH’s Emergency Department (ED) is the busiest in Singapore with more than 400 patients a day. Each year, the ED sees 700-800 patients who have 5 or more admissions in the preceding 1 year. Many of these patients have underlying psycho-social issues that contribute to their inability to cope with the burden of their medical conditions and the challenges in their day-day living in the community. In fact, 60% of these patients visit the ED for feeding tube changes, wound dressings, patient education, and chronic disease management while the remaining 40% of patients, they require care in areas like daily functional care, companionship/human interaction, and community integration. These do not require acute care in the ED and can be managed at home. Furthermore, the hospital is not always the safest place to care for the stable but susceptible patients collectively. Visiting the ED so frequently can render them vulnerable to additional diseases and infections from within the hospital. The VH serves to help this group of patients by ensuring that they are able to receive the community support which they lack by collaborating with various community and social care partners. The VH coordinates with these social care partners to provide services like befriending patients to create direct meaningful relationships, while others offer assistance such as blister-packing of medications to make it more convenient for patients in managing their medications at home, thereby improving their compliance. Hence the vision for the VH is simple yet powerful: Patients need not be alone and healthcare need not be confined to the hospital setting. As long as the hospital and the community come together as one healthcare provider, “Singaporeans in need of care [will] have access to a seamless continuum of healthcare and … services, ensuring that the dignity and quality of life…are maintained.” (Source: Committee on Ageing Issues: Report on the Ageing Population (Feb 2006), p. 33.)

B. Strategic Approach

 2. What was the solution?
The solution was proposed by a team of clinicians, operations staff, and statisticians, taking into consideration TTSH’s historical data, best clinical practice, and operational sustainability. Piloted from August 2012, data analytics have shown that there was a sizeable number of patients who repeatedly attended ED and/or were admitted non-electively to TTSH in 2010. This 700-800 patients, despite only representing 1.4% of total patients, make up almost 4,702 inpatient episodes, and contributed to 34,319 inpatient stays in the hospital. This group of patients accounted for 6% of the total expenditure for inpatients in 2010 and as a heavy utiliser of hospital resources. Hence, the VH seeks to provide the correct combination of medical and community care resources to patients who are frail, elderly and/or suffer from chronic disease(s), in order to increase the quality of life of the patients, to empower patients to trust the healthcare system and their own abilities. Currently, still in pilot phase, the VH team is composed of Health Managers (HMs), with a consultant family physician as programme director for clinical oversight as well as programme development. They are also supported clinically by pharmacist support for reconciliation of medications. The clinical team is also supported by operations executives for data management, tracking and monitoring, process and policy development, and project and budget administration. The VH uses the Porter’s Five Forces strategic framework: 1)Industry competitiveness: The service must be as responsive as the Emergency Department - therefore Health Managers (HMs) are rostered on-call with a 24hour telephone advisory hotline. 2) Suppliers: There must be a team capable of delivering this service, available in the system – therefore HMs are hybrid case managers/nurses capable of titrating medication, reviewing clinical status, and driving evidence-based care. 3) Buyers: The service must be priced better than current care, OR attract higher willingness-to-pay from payers e.g. Ministry of Health (MOH) – therefore the Virtual Hospital (VH) is positioned for adequate care at approximately $1,000 per patient per year compared to historical recorded hospital admissions of average $5,500 per episode of care. 4) New entrants: There must be significant reach and scope to prevent mushrooming of multiple new (fragmented) versions – therefore each HM works with 200 patients per year, alongside 1 senior doctor (advisor) and 1 dedicated pharmacist. 5) Substitutes: The patients must derive enough value from the service to stay on it long enough to improve clinical outcomes compared to “easier” or “cheaper” services that are not designed for the same outcomes – therefore a timeframe of 3-6 months was calculated to stabilize and empower patients, inclusive of time taken to reconcile medication, cut back inappropriate follow-up, and arrange social support. The duration under VH was projected at 3-6 months, for the HM to reorganize care as follows: • A long-term care plan • Medication reconciliation and titration • Medical appointment reconciliation • Put in place monitoring/investigations • Lifestyle moderation • “Overhaul” of other health-related behaviours • Introduce the patient to volunteers (who have been trained in a standardized course) Upon stability, the patient’s care would be handed over to a community-based case manager (CCM), who can continue to oversee the patient’s progress. If the patient’s condition required escalation of care, the CCM could contact the HM to tap upon acute resources. This can prevent unnecessary trips to the ED, and in some cases, a needless admission. Communication channels would be kept open among the HM, the CCM, the volunteer(s), and the patient himself. Using the telephone, a simple device, the patient could activate his care network - a more viable and appropriate alternative to dialling for an ambulance.

 3. How did the initiative solve the problem and improve people’s lives?
The project is particularly innovative because of its holistic collaborative nature. Not only does it involve healthcare workers from the hospital, but it also involves social workers from the different community social services, both from healthcare and non-healthcare. Rather than simply “medicalizing” all of the patients’ needs, the VH addresses both health and social issues of the patients. This breaks the mould of silo health/social teams and re-aligns resources across ministries according to the patient’s needs. Furthermore, through interaction with the community social workers and the Be-frienders, each patient is encouraged and empowered to be better aware of their needs and the type of healthcare that they require. This wraps the care around the patients’ normal daily environments and makes it possible for them to function both at home and within the community. The VH programme thus takes the best elements of hospital care and integrates it with the community care to ensure: a round-the-clock access to the right healthcare, a multidisciplinary team and constant case reviews of the patients’ progress. This makes possible for the patients to be cared for at home. It is a “hospital without walls.”

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
As this is the first time that such a strategy was implemented, the team studied and reviewed extensively the mature systems of care outside of Singapore. Building on their reviews of the various healthcare systems, the team then extended their research into professional journals and conducted experiments on the best type of strategy that they can incorporate into the implementation of the VH. Implementation was done systematically as follows: 1) Pick the right implementation team (2 months): After initial studies of programmes such as The Torbay Care Trust (TCT) (United Kingdom, UK), The North West London Integrated Care Pilot (NW-ICP) (UK), and The Toronto East Virtual Ward programme (Canada), the concept passed to the Division of Integrated and Community Care (DICC), and Operations (Community) (TTSH). Manpower was thus drawn from TTSH departments. 2) Maximize the availability/efficiency of the existing resource you need (2-3 months): Specified full time equivalents (FTEs) were dedicated by experienced staff (doctor, case managers, pharmacist, operations lead) for setup of processes, and to run the service. The clinical programme director (CPD) and operations lead set out specific tasks and deadlines e.g. completion of standard care protocols, necessary forms etc. Non-value-adding tasks were automated, e.g. daily computer-generated list of admitted patients with more than 5 previous admissions. Staff were also trained for cross-functionality. 3) Plan the workflow and required elements (present and future) (6 months onward). This was done through: 1)Risk stratification for recruitment of patients- This was done using the most practical and obvious identifying trait with the most significance, in this case, 5 or more previous admissions. 2) Maintenance of a patient registry, and longitudinal follow-up of patients- This was designed with minimal free-text and maximal checkbox/drop-down list functions to minimise time spent, with standardized terms and definitions. Tracking of patients was embedded. 3)Clinical protocols and evidence-based care plans- Existing best practices were imported, as were innovative tools from other programmes. This cut down the team’s learning curve. 4)Care oversight and resource deployment that is piloted by HMs- Deliberate outreach efforts were taken to strengthen existing collaborations and partnerships with external organizations. New partnerships were formed for access to complementary resources. Joint workflows and agreements of shared responsibilities were confirmed, and simplified and standardized where practicable. 5)Ongoing case reviews- This was done using daily case discussions and specific case conferences with partners/other departments – not all cases were reviewed, hence a flagging system was created. Role responsibility (e.g. doctor versus HM) was clearly defined in order to keep meetings short and actionable. In addition, simple workflows were implemented – developing and improving as you progress. This was done by building up the care of the patients from point of recruitment. The workflow was designed to be modular in nature, so that each portion can be changed without affecting the previous or the following, e.g. a change in best practice for systolic blood pressure control will only change the numerical definition, but not the action following it to alert the HM in charge. Finally, Regular feedback was gathered through surveys were created for patients and feedback forms for partners.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The VH concept was based on healthcare operations work done by the National Healthcare Group’s (NHG’s) Health Services and Outcomes Research (HSOR) together with a professor (senior consultant) in Respiratory Medicine. Based on their preliminary data, a clinical care model was built by a TTSH team comprising Community and Continuing Care (CCC), Nursing Service, Operations, and Case Management Unit. This team drew up the care delivery processes, policy documents and forms, care pathways, and patient management strategy. The VH was then operationalized using HMs, a programme director, and the Operations team. In addition to patient care, the team also reached out to build working relationships within the public healthcare sector like the National Healthcare Group Polyclinics and the Institute of Mental Health, Government Ministries like the Ministry of Health to help in the funding of the programme, the Agency for Integrated Care and the Ministry for Social and Family Development (which includes the Central Singapore Community Development Council and the North East Community Development Council) and as well as Volunteer Welfare Organisations like Ang Mo Kio Family Services Centre, Home Nursing Foundation, Tsao Foundation- Hua Mei Centre for Successful Ageing and the Thye Hua Kwan Moral Society.
 6. How was the strategy implemented and what resources were mobilized?
From the research, the team realized that similar models of care had run into difficulties in proving financial sustainability, scale, and clinical follow-through. Because of this, the VH chose to incorporate LEAN-based operational processes which aim to provide more value to patients with fewer resources. The team thus focused the resources on the crucial elements of the programme, in a tightly-monitored schedule of care timing and outcomes. The manpower resources required, in Full Time Equivalents (FTEs), were 2 HMs, 0.5 Clinical Programme Director, 0.8 pharmacist support, and 2 operations personnel. The base of operations is at TTSH as its central location provides easy access to patients who continue to require hospital-based services and staff who need to access the clinical IT databases and applications to monitor each patient’s case. The VH also taps into the Integrated Health Information Systems (IHIS) to integrate digitally with our care partners. Through the IHIS, information on each patient’s case is easily available across all partners and information is standardized and harmonized. Furthermore, all communications with patients are done through phone. This use of “good old fashioned” communication coupled with a shared information system thus ensures a cost-effective and efficient healthcare delivery. Financially, manpower represented 90% of the cost. The remaining 10% were consumed in communications, travel and transportation, medical consumables and equipment, and volunteer training. Running costs as low as possible, without carrying other fixed costs. There is no transactional fee among any of the other partners and agencies external to TTSH. In terms of service resources, the VH began work by utilizing (and negotiating re-purposing if required) of existing services. For example, the strong national nursing presence of the Home Nursing Foundation was used to provide coverage for care such as chronic disease monitoring. The VH requires approximately $0.5 million per year including start-up costs (in 2012 Singapore dollars) to run. The programme is currently co-funded by the Ministry of Health (80%) and National Healthcare Group (20%). The VH does not collect payment from the patients as many of the VH patients come from come from the lowest income group.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
1. Expanding beyond healthcare: A “Hospital Without Walls”- The collaborative approach of the VH programme, integrating hospital care with the community care, is an excellent showcase of how healthcare and social resources can come together to better benefit patients. The VH takes the best elements of hospital care and incorporates it with the community care to ensure: a round-the-clock access to the right healthcare, a multidisciplinary team and constant case reviews of the patients’ progress. It makes possible for the patients to be cared for at home. It is a “hospital without walls.” 2. Navigating the network of partners with the appointment of a Health Manager: Playing a central role in the running of the VH are the Health Managers (HMs). Once a patient is enrolled into the VH, they will be assigned to a HM who bears the responsibility of monitoring and managing each patient’s cases. They are the main point-of-contact for the patient and are also responsible for conducting home visits and bringing in a network of like-minded community partners to co-manage these patients and give them support in many areas. 3. Leveraging and Involving the community in care: When VH patients are stable enough, they will be transferred to the care of community partners for follow-up. These community social workers play the role of a Be-friender who will provide social services like giving a listening ear, conducting basic physiotherapy exercises, and ensuring that patients are adhering to their medications. They will also function as a source of feedback to the HMs who continues to maintain active working relationships with the Be-frienders to ensure that the patient will always have access to the right healthcare and not be neglected even upon discharge. 4. Empowering patients: Unlike the acute care setting of the hospital, patients in the VH are able to play an active role in monitoring their health. HMs and Be-frienders set goals for the patients, encouraging them to be more proactive in their healthcare. Through constant encouragement, this gradually changes patients’ perception and approach to their illness, motivating them to take control of their health. Thus, the VH recognises that the hospital in itself cannot provide for the total care of these patients. Instead of functioning in isolation, the VH’s multidisciplinary team works alongside the community, to provide a holistic and continuous patient-centric care stretching from the hospital to the homes of the patients and the community.

 8. What were the most successful outputs and why was the initiative effective?
The effectiveness of the VH were monitored and evaluated through 2 key areas namely 1) Clinical Outcomes and 2) Process Design. 1) Clinical Outcomes: For clinical outcomes, we monitor by ensuring no unexpected re-attendances and readmissions (HMs may advise ED attendance/admission when warranted), maintaining consistent compliance, maintaining consistent quality of life of patients and maintaining consistent quality of care for the patients 2) Process Design: For the process design, we progress is monitored through the number of referrals made to community resources, and time to transfer the patient to a Be-friender. Progress is also evaluated through maintaining turnaround times from eligibility to recruitment, and from recruitment to first home visit In order to monitor and evaluate the above points, the following systems are in place: i) A database (known as the patient registry) of VH patients This is stored into the hospital’s ED Web System and the National Electronic Health Record (NEHR). It is a powerful tracking tool and updates to current status if the patient continues to re-visit the ED or requires immediate medical attention. ii) Personal assessment by the HM Once a patient has been enrolled into the VH, they are assigned a HM. The HM bears overall responsibility for case management, in person or by marshalling community/hospital resources. iii) Ongoing case reviews Such assessments are led by HMs, with attendance from other care teams e.g. consultant physician or pharmacist, as required. Once a patient is deemed stable and confident, care is handed over to a Community-based Case Manager who continues in this role. iv) Open channel for escalation Communications are kept open among the HM, the community case manager, Be-friender and the patients themselves. By using a telephone, the patient can call upon his network of care as required, as a more viable and appropriate care alternative to dialling for an ambulance. v) Operational data reports The operations team regularly compile, trend and analyse ED attendances, admissions, handover states, turnaround times, volume of telephonic follow-ups and more. These give much-needed visibility and accountability on behalf of the team. In addition, financial data is tracked in order to improve ongoing sustainability. In this way, there are always systems in place to ensure that progress can always be monitored and evaluated to ensure more room for continuous improvement and that the VH is performing at its optimum level to cater to the patients’ needs.

 9. What were the main obstacles encountered and how were they overcome?
i) Defining the problem: Although we knew recurrent readmissions were not meeting patients’ needs, it took a combination of statisticians, clinicians, and administrators to distil the issue down to the group of patients affected, and begin the search for answers. ii) Finding root causes: Prior to launch, 1.5 years were spent analyzing the health behaviours and precipitants which resulted in recurrent readmissions. This culminated in a hypothesis that better case management and longitudinal engagement were needed, as opposed to episodic fast medicine. iii) Searching for solutions: Once fairly certain, we trawled other countries for lessons, referencing UK, USA, Canadian and Alaskan models, aside from local partial examples. This gave us initial blueprints for discussion and adaptation. iv) Obtaining buy-in and support: With an initial proposal, we went to senior management and sought financial and in-principle backing for a pilot service. This was supplemented by multiple concept briefings, question-and-answer sessions, and meetings with potential partners and funders. The pilot was launched using internal funds from NHG, later partially supplemented by MOH funding. v) Implementation: The first 6 months were an uphill task, as mindsets of patients and community partners had to be changed. Additionally, the team was new, and had many workflow and clinical protocol issues to overcome. Eventually, with cycles of continuous improvement and patient feedback, the VH stabilized. vi) Ensuring scalability and sustainability: The next step, where the VH is at now, is to scale beyond the pilot pool of patients, to capture the true volume within the central region of Singapore. This will mean a cautious expansion from 120 patients to about 1,700 patients over the next 3 years, with further refinements and collaborations as the model gains more traction, and there is more data.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
1.Impacting the individual: Since its inception, the VH is beginning to see changes in the trends of patient behaviour. To date, over 100 patients have been recruited into the VH and although newly implemented, the preliminary results have been encouraging. Over the last six months, 60% of the enrolled VH patients managed to stay safe without needing urgent treatment while 30% did not need to be re-admitted. The subsequent care from the community social workers further ensure that the patients continue to receive help in their daily tasks, medication, and more importantly, that they have someone to talk to so they do not sink into depression. The VH is meeting a level of need of patients that was previously undiscovered, and unmet. This included day to day concerns, stemming from inability to manage health, which affected social interactions and the social roles of the patients. For example, a patient who was unable to walk because of pain in the knee was excluded from meeting with friends at the void deck, leading to social isolation. Another patient with poor dietary understanding and poor eyesight (and could not measure food items or administer her own medication) was given simple guidelines and tools that helped her to manage her daily intake. This controlled her diabetes to a degree that she no longer suffered sudden decompensating episodes that warranted hospital admission. The patients are gradually empowered by such care, and regain both their trust in the system, as well as confidence in themselves. This is the most satisfying outcome that any public institution can have, especially for a hospital – to see those we care for being able to “fly” without us. Feedbacks from the HMs so far have been encouraging. Patients who were previously unresponsive began to demonstrate more willingness, the longer they interacted with the HMs and Be-frienders. Patient’s feedbacks have also been positive. Some of the feedbacks include: •“Simple household chores and going to the bathroom proved to be very difficult for me and I often landed in the Emergency department at TTSH, but with the help from the community partners near my home, my be-friender and my health manager, I feel much better. I take my medications regularly and travelling by the bus to church is no more a problem.” Mr Gerard Palaniappa, a 75 year old VH patient. Since his enrolment in VH and his eventual transfer to community partners, he has started to be more mobile and regained a positive outlook on life. •“It’s a lot more convenient now for me and I’m very thankful for the VH programme.” Mr Tan Beng Hock, a 67 year old VH patient. Since joining the programme, he has only been awarded twice. (Source: The New Paper: Treating the problem at home) Hence by closing the service gap and working together as one healthcare provide, the VH not only ensures that patients receive the necessary help both in and out of the hospital, it also helps to improve the patient’s quality of life. 2.Impact on the hospital and society: By removing the mindset of a segregated healthcare system and replacing it with a linkage between hospitals and the network of community-based care services, the VH ensures that patients are properly treated in the hospitals and thereafter properly linked to follow-up care within the community. By doing so, reduces the risk of re-admission into hospitals or unnecessary visits to the ED. Furthermore, by reducing the number of re-admissions, hospital resources are freed up for more acute care cases. The initial results have been very encouraging. From August 2012 (its implementation) to July 2013, there has been a significant reduction of 32% in the number of ED attendances and 36% in the number of hospital admissions for patients enrolled into the VH. More importantly, by coming and working together, the VH focuses on building and maintaining positive relationships beyond economic and material success, thus working in line with the Ministry of Health’s vision of: “Championing a healthy nation with our people - To live well, live long & with peace of mind” to become a more compassionate, gracious and kinder Singapore.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
At present, TTSH is the first in Singapore to implement the VH. However, results from the initial phase have been very encouraging and it does provide an insight to the potential that the VH has to translate to other healthcare institutions throughout the country. There has been a rising demand for the VH. Our partners also manage patients from other healthcare clusters in Singapore, and from their feedback, we understand that there are similar cases of patients with recurrent admissions occurring at other hospitals and healthcare. We have been requested to help develop similar care with their partners. Overall, the VH is beginning to see a change in mindsets in healthcare and moving toward a trend of one that provides a holistic healthcare for patients both in the hospital and at home. Our main strategy for the VH is to focus on 3 aspects of the patient’s life: 1) Clinical/health needs 2) Social/psychological support 3) Functional/livelihood enablement Other guiding principles which can be replicated in other healthcare include: 1) Patient’s Quality of Care should not be compromised and in fact should be improved through the programme 2) Patients should experience improved access and equity of care. 3) Patients should feel no additional burden when empowered for their own care. 4) The new model of care must be embedded in the current system, utilizing and re-purposing current resources. The healthcare system should feel no additional burden unnecessarily. Before, many patients fall through the cracks as there was no integration between the hospital care and community care. With the launch of the VH, that gap is closed. The VH functions as the link between the hospital community and by doing so, forges a closer integration that ensures that patients are able to get the necessary help they need even after discharge. By providing a safety net for patients to turn to when in need of clinical supervision or education on skills that they need to better manage their health, the VH gives patients a new found confidence and a renewed trust in the health and social care systems. With the VH, the hospital hopes to gradually create a true network of care that wraps around the real needs of patients, be they frail, elderly, or with chronic diseases. This is because healthcare forms a part of the daily lives for the patients and their environment. Thus assistance for daily life should be available and provided from within the patients’ environment. We do not see value in sequestering our patients in hospital beds when they should be empowered to live their lives to the fullest, even within the limitations of their conditions. Because of the above, through the VH, we hope to get closer to achieving the Ministry of Health’s vision of: “Championing a healthy nation with our people - To live well, live long & with peace of mind.”

 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)
From what we have learnt, we have come to realize that even in developed countries with stable healthcare systems, there is always the potential for emerging gaps as the profile and demographics of the population change with time. Referencing the Partnerships Management articles on the World Health Organisation website that shared lessons on success like “An introduction to Multi Agency Planning using the Logical Framework Approach”, “Tackling Health Inequalities: New Approaches in Public Policy” and “Crossing Sectors – Experiences in Intersectoral Action, Public Policy and Health”, we found ourselves fortunate that we had a timely combination of opportune factors, namely: An environment conducive to inter-agency care had emerged; there were shared values, interests, and objectives among partners and potential partners. There was positive political and policy support, and key partners were keen for engagement and alliance, and consensus was strong in the planning phase. Furthermore, there was opportunity to built horizontal linking across sectors, as well as vertical linking of levels within sectors and we were clear on concrete objectives and visible results. There was also leadership, accountability and reward-sharing among partners. There were stable teams of people available and willing to work together, with appropriate support systems and practical models, tools and mechanisms available to support the implementation of inter-agency action. Most importantly, the patients were receptive to participation, education, and awareness of health issues. Although we faced initial challenges in articulating a common purpose, and getting things up and running, the experience has taught us much about being mindful of the balance among cost, benefits and effectiveness of the VH. Only with these in mind, could we add value to patients’ lives. However, the most important lesson may be to always listen to our patients and caregivers in order to be truly patient-centric – and understand what is important to them, and not just what is medically-relevant.

Contact Information

Institution Name:   Tan Tock Seng Hospital Pte Ltd
Institution Type:   Public Organization  
Contact Person:   Jeraldine Koh
Title:   Award Secretariat  
Telephone/ Fax:   (65) 63578414/ (65) 62569707
Institution's / Project's Website:  
Address:   11 Jalan Tan Tock Seng
Postal Code:   Singapore 308433
City:   Singapore
State/Province:   Singapore

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