| 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.
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.