SingHealth One Medifund Assessment
Singapore Health Services Pte Ltd

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
At Singapore’s public tertiary healthcare institutions, one of the medical social workers’ (MSWs) key roles is to assess patients’ eligibility for Medifund, the main form of government assistance for the medical expenses of financially needy Singaporeans. These patients may not only have financial concerns, but also other issues such as illiteracy and discrimination. Since the introduction of Medifund in 1993, healthcare institutions were given the autonomy to assess and assist patients beyond the standard criteria set out by the Ministry of Health. With this policy, issues arose due to the fact that SingHealth, the largest healthcare cluster in Singapore consists of ten healthcare institutions, with each institution having its own Medifund Committee – the custodians of the Medifund monies, funding mechanism for specific drugs and assessment criteria for funding. The patients and MSWs bore the brunt of the inconveniences arising from such an institution-specific financial assessment system. This resulted in: • inconvenience to patients, especially those who were referred to doctors in different institutions as they needed to make multiple appointments with the MSWs at each institution for Medifund assessment. • confusion for patients, as there were different work processes at each institution, and the information collected by the different institutions for the Medifund assessment varied. • unhappiness and frustration as the patients had to share their social and financial circumstances repeatedly, and the amount of Medifund assistance rendered to patients may differ across the institutions, depending on the criteria that were used for assessment. • MSWs spending a significant amount of time processing patients’ Medifund assessments, thus leaving them with very little time to attend to patients’ psycho-social issues. Over the years, SingHealth patients have voiced their frustrations with the need for repeated Medifund assessments, especially within the Singapore General Hospital (SGH) Campus and SingHealth Polyclinics (SHP) where most institutions were of close proximity. Currently, there are about 2,000 patients who have more than 2 appointments within the SingHealth institutions. With the increasing trend of comorbidities and rising medical cost, the number of cross-institution Medifund patients at SingHealth is expected to grow, leading to a growing number of patients being affected by this issue.

B. Strategic Approach

 2. What was the solution?
The solution was proposed by a taskforce that was set up to review if the Medifund assessments could be harmonised across SingHealth institutions. The One Medifund Assessment Taskforce was set up in July 2013, consisting of MSWs from the respective institutions, SingHealth Group Allied Health Office and the Office for Service Transformation. The objective of the taskforce was to harmonise the financial assessments and reduce the need for repeated Medifund assessments for patients within SGH Campus and SHP. The Taskforce was structured to comprise the Steering Committee and three workgroups. The primary role of the Steering Committee was to provide leadership inputs and maintain oversight of the different workgroups, at the same time to engage different domains and senior management so as to ensure smooth execution of the project. The three workgroups established to support the project were tasked to look at different aspects of the project, namely 1) workflow and system enhancements 2) assessment and training 3) approval guidelines The above areas were identified by the project team to be pertinent and instrumental to achieving the project’s aims. By addressing these areas, it allowed for institutions to recognize and honor the Medifund assistance rendered by each other, and thus supporting the new patient-centric workflow where patients do not need to see MSWs each time they visit another SGH Campus or SHP institution. As the boundaries of the three workgroups overlapped, an anchor workgroup was also set up, consisting of the Leads from the three workgroups. This served as a platform for the workgroups to discuss their recommendations, and evaluate the impacts of each proposal on the other workgroups. In order to identify and mitigate possible issues when implementing the changes, the project was split into two phases. Phase 1a involved revising the workflow for only straightforward cases where patients are eligible for 100% Medifund assistance. This served as a pilot where lessons learnt from this smaller scale implementation then led to necessary refinements being made before Phase 1b implementation was carried out on a broader scale involving all Medifund patients. With the workgroups working collaboratively, the Medifund assessment criteria were aligned among the institutions such that it would be applicable for patients visiting the different SingHealth institutions. The financial assessments done by MSWs would be stored on a shared electronic system, allowing for instant sharing of this information with MSWs across institutions where they would be able to review the patient’s status and proceed to allocate the appropriate funding based on the shared assessment.

 3. How did the initiative solve the problem and improve people’s lives?
SingHealth is the first healthcare cluster in Singapore to explore alignment of Medifund assessment criteria and approving authorities within its institutions. Team members had to think beyond the existing model practiced for the past 20 years, so as to solve the increasingly emergent problem of multiple Medifund assessments for cross-institution patients. It is creative because such a harmonised financial assessment tool did not exist, and had to be created to fulfil common requirements set by the Medifund Committee for funding approval. Another aspect of the project that was new and different was the collaboration and teamwork amongst the institutions’ MSWs. While the different institutions’ MSWs are theoretically under one healthcare cluster, they operate independently of each other, which is the same across all public hospitals in Singapore. The MSWs shared their existing practices, deliberated and came to a consensus on the best practice, and went on to establish the milestones, timeline and governance structure. All were committed to making the change happen soonest possible. The initiative is innovative as it resolved the issue of multiple Medifund assessments with no adverse impact on the Medifund Committee’s approval or funding mechanism. The initiative introduced was well received by patients and staff alike.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
1. Forming the Taskforce Our SingHealth Group CEO appointed the Taskforce, with a Steering Committee that would directly report the results and progress to her and the SingHealth Core Leadership. Three workgroups were established to work on different aspects of the project simultaneously, with the members in each workgroup being MSWs from the various institutions. 2. Harmonising the assessment form and creating the shared MSW electronic system The first workgroup was tasked to review the workflows and processes that existed at each of the institutions. Following that, they were to consider which of the practices was most suitable for adoption, or if necessary, to re-design the workflow in order to facilitate patient-centric care. They were also to explore possible enhancements to the MSWs’ electronic system to support the revision of processes. The second workgroup focused on the alignment of the Medifund assessments across institutions. The workgroup members had to consider the patient profiles at each institution, with special mention of the unique cases that were experienced before in the past. The members then discussed on how best to align the assessment guidelines and criteria in such a way that the patients’ financial and social circumstances could be considered in a more holistic manner. The next task for this workgroup was to develop a new training manual for the MSWs. Revised guidelines and criteria were clearly noted in the manual which was shared with the various institutions. To facilitate easy understanding of the changes, training sessions were conducted for all MSWs before the implementation of the project through a train-the-trainer approach, whereby the Workgroup Leads trained one or two MSWs from each institution, who would then go on to train all the MSWs at their respective institutions. The third workgroup looked into the harmonisation of approval processes and authorities to support the workflow and assessment changes. As changes in this aspect would impact the institutions’ management, representatives from each institution were tasked to seek their respective management’s support and buy-in for any proposed changes. 3. An anchor workgroup The anchor workgroup was set-up midway through the project when the taskforce leaders recognized that decisions made by each workgroup had implications on the work of others. At the anchor workgroup meetings, Leads from each workgroup would share the status and recommendations from their area of work, and together they would evaluate the proposals and study the implications that these may have on other workgroups. 4. Engaging senior management and other stakeholders for support Senior management’s support was sought at the beginning as well as before implementation. This served as a platform for the taskforce leaders to update on the progress of the project so that everyone in the organization would be aware of the changes and timelines. Communication sessions were arranged with finance, business office, IT, pharmacy and operations departments to ensure that stakeholders were updated and on the same page. Patients were also kept informed of the changes when they visited the MSWs. They were assured that their information would only be shared among the MSWs at different institutions, and could opt out of the information sharing if they so desired. 5. Implementation in phases After the smaller-scale implementation of Phase 1a, the taskforce came together to resolve teething issues and identify how implementation of Phase 1b could be improved. Feedback and lessons learnt from the pilot phase were incorporated during the planning for the next phase to ensure that the same issues would not surface again, at the same time to allow better preparation for the roll out of Phase 1b on a larger scale to all Medifund patients.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The main stakeholder involved in both the design and implementation of the initiative were the MSWs, patients and IT staff from the various institutions as they have the experience and knowledge to facilitate workflow re-design and enhancement of the MSW’s electronic system to allow information sharing. Pharmacists and Finance staff, whose work would be impacted by the Taskforce’s decisions, were also engaged early on in the project for their feedback on the new workflows and processes. Another group of stakeholders that were important were the institutions’ authorities and SingHealth senior management, as without their approval and support it would have been much more challenging to implement the initiative and with much delay as well. Project administrators were engaged to help problem solve issues that occurred, especially if the issues required cross-institutional solutions and changes. Updates were presented at the various senior management meeting forums, where members include the CEOs, Chairman of Medical Boards, COOs and CFOs of all SingHealth institutions. Heads of departments as well as the leadership of the Ministry of Health were also engaged. These helped to garner widespread leadership support and buy-in for the initiative.
 6. How was the strategy implemented and what resources were mobilized?
Key resources used were funds for IT enhancement so that the revised harmonised financial assessment form could be created on the MSW’s electronic system and shared across the institutions. The electronic system enhancement costs a total of S$41,345, which was funded through SingHealth’s IT fund. Administrative manpower was provided on an ad-hoc basis (about 1 to 2 days a week) from 3 departments namely MSW, Group Allied Health office and Office for Service Transformation to support the Steering Committee and the 3 workgroups. There were no other additional costs incurred as part of this initiative. However, in recognition of the fact that this initiative will raise productivity, the group was given a grant from the Ministry of Health to expand this project further to cover other assistance schemes.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The key outputs that enabled the success of our One Medifund Assessment initiative were 1. the creation of a seamless and improved experience for financially needy cross-institution patients, in the aspect of seeking financial assistance. Besides being able to have only one Medifund assessment regardless the number of institutions visited, any duplicate and redundant work is eliminated as well leading towards reduced touch points between patients and the MSWs. 2. the standardization of the Medifund assessment guidelines and criteria. Through standardizing the Medifund assessment guidelines and criteria, MSWs at different institutions would now require the same information from the patient, ensuring that the assessment being conducted at any institution would result in the same amount of assistance rendered. 3. the development of a shared MSW electronic system that allows accessibility to patients’ information and history. This, coupled with the standardised guidelines and criteria, enabled MSWs at the different institutions to now recognize the financial assessment done by each other and reduce the need for patients to be re-assessed when visiting a new institution. 4. the comprehensive training manual that was developed for the MSWs. The manual contained clear and concise information on the procedures, new guidelines and aligned criteria, and was made available to the institutions’ MSWs. Together with the training sessions, it facilitated a smooth implementation as everyone understood the changes and were able to adapt to it quickly. 5. a very highly motivated and collaborative team of MSWs, administrators and senior management. The task of harmonising the different Medifund assessment forms, guidelines and criteria were initially deemed too big a challenge to be resolved, almost impossible even. However, the commitment and motivation shown by the team members led to a strong collaboration, making it easier for the team to achieve success.

 8. What were the most successful outputs and why was the initiative effective?
Both qualitative and quantitative evaluation strategies were employed to monitor and evaluate the implementation of the initiative. 1. Review by MSWs For the qualitative aspect, three surveys were conducted with the respective institutions’ MSWs – pre, one-month post and six-months post implementation. These were to study the impact of the initiative on the MSWs’ job satisfaction. 2. Review by patients Additionally, a patient survey will be conducted one year after roll out to find out how the initiative has impacted on patients’ experience and satisfaction. It is currently in progress, and results would be consolidated and analysed by February 2015. 3. Review of number of patients benefiting from such a shared facility As for the quantitative aspect, system reports were generated to provide information on the number of touch points between patients and MSWs, and patients who had multiple Medifund assessments. With these data, the team is able to evaluate the benefit of the implementation of the initiative.

 9. What were the main obstacles encountered and how were they overcome?
Initially, the main obstacles were getting buy-in from the institutions’ Medifund Committees and getting the MSWs to change their mindset and share the information that they have collected from patients for financial assessment. However, once they were able to comprehend the benefits that the change would have on patients in the long run, it was easier to get volunteers to participate in forming the workgroups. During the course of the project, there was a strong preference by some institutions to continue with their existing frameworks, and they did not see why they should adopt other institutions’ practices. To address this issue, the Taskforce examined the concerns raised and met with the institutions’ management for discussions. An agreement was reached that we would adopt an 80-20 rule, to align the majority of the common processes while allowing deviation of 20% or less for specific situations. As the changes proposed under this initiative would have wide-ranging impact on other stakeholders’ workflows and processes such as the Pharmacy and Business Office staff of the various institutions, the other major obstacle faced by the Taskforce was in garnering buy-in and support from these stakeholders. Recognizing this, the team members always made it a point to consider how each of the proposed changes may impact others, and sought to minimize it whenever possible, without compromising on patients’ experience. The stakeholders were engaged consistently from early stages of the project to ensure that their views, concerns and possible challenges were heard, and that they were updated on the progress of the project periodically so that they too would be ready when implementation was carried out.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
1. Benefits to patients As a result of the One Medifund Assessment project, patients are assessed only once for Medifund assistance and the assistance will be valid at all SGH Campus institutions and SHP for six months. With the reduction of between one to three repeated visits to the MSWs per patient, patients would save a total of 899 hours which used to be spent on waiting for and seeing the MSWs at every institution visited. The time saved could be used for resting and to focus on recuperating from their medical conditions. There would also be cost-savings for the patient where they do not need to travel multiple times to the hospital. These unnecessary expenses could be used by the patients for their daily necessities instead. In addition, reduced number of assessments for Medifund would result in less anxiety for patients since they do not have to worry about the different requirements at the various institutions or the outcome of their Medifund applications. The patient and the caregiver would also not be required to take leave from work to make an extra visit to the hospital for the MSW appointment. Furthermore, patients would also receive more holistic care as the MSWs will have more time to attend to patients’ psycho-emotional issues besides processing the financial applications. As a result of the improved patient experience, SingHealth’s image and branding may indirectly be strengthened. From the organization’s perspective, the project has resulted in cost-savings and more efficient use of resources. Based on data collected, there were about 2,000 patients who visited multiple institutions at SGH Campus and SHP. With the shared Medifund assessment and new workflows being implemented, it was calculated that there would be a reduction of about 4,000 patient touch points with MSWs and Pharmacists, which translates to about 168 MSW man-days saved per year since cross-institution patients do not need to be re-assessed for Medifund assistance. There would also potentially be less patients waiting for appointments with MSWs, which would be a significant benefit particularly to the smaller institutions such as SHP, which only has six MSWs managing the nine polyclinics situated at different locations. At SHP, the waiting time for an MSW appointment could be up to 25 weeks. 2. Benefit to staff A comparison of the surveys conducted with the MSWs before and after implementation of the One Medifund Assessment project showed positive results: • More than 2-fold decrease in the percentage of respondents who felt that the Medifund application process is time-consuming for patients. • More than 4-fold increase in the percentage of respondents who felt that there is now more time to cover the psycho-emotional issues faced by patients. The post MSW survey also revealed that • 96% of respondents agreed that patients have benefitted from the initiative • 91% of the respondents did not find it difficult adapting to the new guidelines and criteria Besides the key benefits explained above, the project also resolved several existing challenges. Many of the processes in place were crafted to the convenience of the organization or healthcare personnel; this has led to duplicative work as well as fragmented care for patients. For instance, patients had to see the MSW each time they visited a new institution, and had to share the same financial and social information. Through this project, not only were such duplicative and redundant processes eliminated, it also facilitated the provision of seamless service and patient-centric care to patients. In addition, resistance to change had been prevalent and an obstacle in many instances. With the successful implementation of this project, it demonstrated that it is necessary and possible to create a shift in paradigm for healthcare professionals and management to work collaboratively and embrace change for the betterment of patients and play an active role in it.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
This initiative is highly sustainable and transferable. In terms of financial sustainability, there is no additional cost required besides the initial cost to enhance the MSW’s electronic system’s functions to enable the cross-institution sharing of assessment and assistance. As long as the government continues to provide financial assistance to the financially-needy patients, such a shared electronic system would be required since it is a requirement to assess patients for their eligibility for financial assistance. Furthermore, the benefits to patients are in line with SingHealth’s priority of providing seamless care to patients, thus there would be continued support from the respective institutions’ management teams. In terms of social and cultural aspects, patients would continue to benefit from the reduced MSW visits for Medifund application and assessment. This also means that patients do not have to go through the very humbling experience of sharing their financial and social information repeatedly to the MSWs. Even when patients’ financial status changes, they only need to inform one institution and it will be updated across the other institutions automatically. During the course of the project, the Ministry of Health was also consulted to ensure that revised processes and guidelines meet the regulatory requirements of the Medifund financial scheme. The harmonized Medifund assistance form and processes were shared with other healthcare clusters in Singapore, and now the Ministry has formed a new committee looking to harmonise similar processes across other public and community healthcare organisations. The next phase of the project is to extend beyond Medifund to include other government financial assistance schemes such as Medication Assistance Fund (MAF) and MAF Plus. Additionally, this SingHealth effort has become an important model and large-scale prototype for current national efforts to align Medifund assessment criteria and assistance across all public healthcare institutions.

 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)
1. Putting the patients first also puts us on the same side of the team On the overall, this was a humbling and encouraging experience for the team, being able to improve patients’ experience in our healthcare institutions. There were several lessons learnt through the course of this project. As earlier mentioned, there was resistance to change when this project first started. However, when the need to reduce the burden on the patient was brought forth, all staff agreed to give the project a try. 2. Getting support from all the stakeholders, including the patient Support and buy-in from senior management and stakeholders, including the patient, were important, and should be garnered as early as possible. For projects involving different institutions, it would be important for members to have an open mind and be willing to embrace change for the better of patients. 3. Forming a clear project structure and effective teams to ensure smooth operations More importantly, the different institutions should not work in silos, but collaboratively in response to a more nimble and responsive healthcare landscape we are building in view of the ageing population. Various healthcare professionals within and beyond the institution worked together closely in order to achieve seamless service and patient-centric care for patients. 4. Important to celebrate small success to motivate and inspire others to do more for the patients’ benefit The success of the initiative would not have been possible without the hard work and dedication of the members. It is crucial to ensure that small successes are celebrated along the way, as this would help to keep the team members motivated. Additionally, sharing the testimonials and encouraging feedback from patients with others would spur others on to do more to improve the patients’ experience. 5. Leadership Open communication, setting of clear goals and keeping everyone’s sight on the goals were among the key thrusts that led to the success of the project.

Contact Information

Institution Name:   Singapore Health Services Pte Ltd
Institution Type:   Public Agency  
Contact Person:   Celia Tan
Title:   A/Prof  
Telephone/ Fax:   63265281
Institution's / Project's Website:  
Address:   168 Jalan Bukit Merah, Surbana One, #03-02
Postal Code:   150168
City:   Singapore
State/Province:   Singapore

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