NOVEL APPROACHES TO IMPROVE THE HEALTH AND WELL-BEING OF OLDER PERSONS :INTEGRATING CARE, AGEING-IN-PLACE

Clinical Professor Chee Yam Cheng, Senior Advisor, National Healthcare Group (NHG) & President, NHG College Dr Jason Cheah, Chief Executive Officer, Agency for Integrated Care (AIC)Dr Anchal Gupta, Assistant Manager, Agency for Integrated Care (AIC)Mr Wilson Ong, Executive, Agency for Integrated Care (AIC)

29 September, 2015

• We hereby declare that the disclosed information below is true and complete to the best of our knowledge (within the period of 36 months before and known occurring for subsequent 12 months from the date of 29th Sept, 2015) :• We have not received remuneration from a commercial entity or other

organisation to give any public talks or advice related to the subject of our presentation

• We have not received any remuneration for expenses incurred to attend the conference apart from the honorarium that has been set out by BMJ

• We have not received any remuneration from a commercial entity or organisation to conduct research related to the subject of our presentation

Declaration of Interest

OVERVIEW OF HEALTHCARE LANDSCAPE IN SINGAPORE

Quick Facts About Singapore

Wellness Care

• Preventable healthcare services in community

• Mainly private sector; some public sector involvement , e.g. Health Promotion Board

Primary Healthcare

• First contact point with patients in community, referred to medical specialists hospitals for further treatment when needed

• 80% Private- run by General Practitioners; 20% public sector run Polyclinics

Secondary/Tertiary Healthcare

• Hospital care comprising of multi-disciplinary inpatient and specialist outpatient services, and 24-hour emergency services.

• 80% Public sector run acute hospitals

Intermediate and Long term Care

• Continuing care for patients in community. E.g. community hospitals, nursing homes, day care centres, home care service, dialysis centers

• 70% by People sector (Charitable organisations)

SINGAPORE’S HEALTHCARE LANDSCAPE

Population5.46 million

Life Expectancy82.5 years

Total Fertility Rate1.25

Residents >65 years of age

9.3%

%GDP spend on healthcare

4.6%

Source: Department of Statistics Singapore (2015)

2014 2020 2030

Old (> 65) 432K 613K 962K

Old Old (> 85) 39K 57K 91K

Old (> 65) w/o Family Support^ ~9% ~11% ~13%

No. of People with Chronic Conditions* 1.36M 1.54M 1.80M

Elderly consume more healthcare*• Hospital admission rate 5x that of persons

aged 45-54• Inpatient stay 1.6x that of persons aged

45-54• Urgent need to shift away from hospital

centric care

Rapidly Changing Elderly Demographics A very different system beyond 2020

Source: Ministry of Health Singapore, National Health Survey 2010

*Utilisation includes both resident and non-resident admissions at public sector acute hospitals (excluding KKH)

^ Defined as having no caregivers at home* Refers to estimated number of Singapore residents aged 20 years and above with diabetes, high blood pressure or high blood cholesterol only.

“A key focus of the Ministerial Committee on Ageing (MCA) is ageing-in-place. Our survey shows that our seniors prefer to age in place gracefully and with dignity, within a closely knit community.”

Minister Gan Kim Yong, Health Minister, Singapore, in 2012

SINGAPORE’S APPROACH TO SUPPORT ITS ELDERLY: AGEING-IN-PLACE

Our Vision: Ageing-in-Place

Growing old in the home & environment that one is familiar with, with minimal change or disruption to one’s life / activities

Our Solution: Integrated care provision in community as a key to enable Ageing-in-Place• Easily accessible health + social care• Well coordinated and person-centered care• Affordable care• Optimal caregiver support• Community involvement in care provision

Ministry of Health (MOH)

Common IT platform across the care continuum- National Electronic Health Records

Common employment of junior doctors across care continuum

Corporate manpower development

National Care Integrator for health & social care systems

Coordinate patient referrals to intermediate & long-term care services

Capacity and capability building of the Primary Care, long-term care sector

Projection of national level service demand

Healthcare Financing

Regulatory frameworks

Standards and performance measurement

Platform for collaboration amongst service providers in a geographic region

Skills transfer from acute to ILTC sector

Strategies and programs to address needs of regional population

Agency for Integrated Care (AIC)

Regional Health Systems (RHS)

Ministry of Health Holdings (MOHH)

Direct Implementers of Care Integration

Policy direction Enablers- Manpower and IT platform

A Multi-Pronged Approach

CARE INTEGRATION IN COMMUNITYExamples of some initiatives by AGENCY FOR INTEGRATED CARE (AIC)

Care Coordination and Case Management Initiatives

Hospital’s Case Manager

Care planning during hospital stay Hospital discharge

Hospital admission

Patient’s journey

For more complex, high risk patients; Long-term follow up of patients

ACTION (Aged Care Transition)

Care Coordinators

Community Case Managers

Home visits and comprehensive case assessment; Formation of care plan

Screening for high risk patients; Needs assessment

Goal setting and care planning; Referral to long-term care services

Follow-up (phone calls/ home visits); Optimize self-care; Hand over to long- term care service

Follow up (phone call+ home visits); Review of care plan; Necessary referrals; Interdisciplinary team meetings

About 1 month post discharge

Care Coordinators are usually Nurses, Social workers, or Allied health professionals

Aged Care Transition (ACTION): Outcomes• Aim: To enable seamless care transition post hospital discharge

As at Apr 2015, 120 care coordinators in 6 Restructured Hospitals and 5 Community Hospitals.

The teams recruit an average of 14,000 patients per year.

• Evaluation of the Pilot Programme (data from Jan 2009- Jun 2011) Odds of readmission within 15 and 30 days for ACTION patients: 40% and 32% lower than

control group Odds of Emergency Dept. attendance within 30 days: 21% lower than control group Estimated cost savings S$5.4 mil over 6 months.

• Continuing Outcome Measures from the Programme (data from 2012-2014) Sustained reduction in utilisation of acute hospitals• Hospital Readmission Rate (15D) – maintained in the range of 5 to 7%.• Emergency Re-attendance Rate (30D) – range of 2 to 3%.

*In comparison to hospital-wide double-digit readmission rates Better Patient Satisfaction • Around 800 patients and caregivers were interviewed to understand satisfaction levels.• 99% of respondents rated ACTION services as “Good or above”.

Patient

Patient

Integrating Community Based ServicesSingapore Programme for Integrated Care for the Elderly (SPICE)

Transport

SPICE Centre

Patient’s Home

• Based on the concept of the Program for All Inclusive Care for the Elderly (PACE) in US• Offers a community based alternative to Nursing Home for frail elderly with high care needs• Semi- capitated funding

Regional network with Primary Care

and Acute Hospitals

• Utilisation of Residential Services Statistically lower rate for Nursing Home admissions for the SPICE group compared to control

groups.

Statistically significant decrease in Community Hospital (CH) utilisation (Length of stay: average 18 days) and expenditure (Total Cost: average $4269) was observed after enrolment into SPICE; statistically significant reduction in CH utilisation for SPICE group compared to control groups

A statistically significant decrease in Acute Hospital utilisation (SPICE group Length of stay: median 17 days) and expenditure (SPICE group Total Cost: median $9,890) was observed; however, difference not statistically significant when compared to control groups

• Clients’ and Caregivers’ Satisfaction Improvements in the SPICE participants’ perception of health and (2) decrease in caregiver

stress after 12 months of care from SPICE; however difference was not statistically significant, likely due to the low number of responses received for the satisfaction surveys

OutcomesSingapore Programme for Integrated Care for the Elderly (SPICE)

CARE INTEGRATION AT REGIONAL HEALTH SYSTEM (RHS)Example from NATIONAL HEALTHCARE GROUP (NHG), a Regional Health System serving the central region of Singapore

“This transformation in healthcare delivery to create a hassle-free healthcare system at the regional level, is a major strategy that we are pushing. It will make healthcare more convenient, safer, better and at the lowest possible cost….” Minister for Health (Aug 2004 – May 2011)

Formation of Regional Health System (RHS)15

“We have decided that we can achieve a better outcome if we reduce the size of each catchment and organize the healthcare delivery systems at the regional level…”

Source: Ministry of Health, Singapore

Singapore Health Services

National University Health

System

Eastern Health Alliance

National Healthcare

Group

Jurong Health Services

Alexandra Health

Care Integration through the Regional Health System (RHS) – A patient-centric healthcare ecosystem comprising of partners from the primary, acute and community care sectors working together to deliver integrated healthcare services to improve population outcomes.

Chronic Illness Progression/Complication End of LifePre-ClinicalWell / At RiskHealth Status

Unknown (70-80%) Outreach Approach1. Lower Socio economic Status: Case finding for residents of rental flats 2. School kids : Partner with preventive School Health programmes3. Working adults : Workplace Health/Partner with MOM (Ministry of Manpower)4. General population : Community & opportunistic screening

Led by HospitalPrimary Care Palliative

Health Co-ordination

Case ManagementCare Co-ord

by Healthcare Professional

Automated monitoring, escalation when neededAutomated reminders at set intervals

Community

Goal(s)

Stabilize, restore

function if possible,

avoid admission

Minimise pain, avoid

admissionMaintain health Delay progression

Maintain function, rationalize care (FP,

SOC), pre-empt complications, avoid

admission

Prevent onset

Known – Approx 320,000 in Central Region (20-30%)

National Healthcare Group (NHG) Our Approach and Our Population

(Mobile) Community Health Centre

• Provision of ancillary support services to General Practitioners (GPs)

• Wider geographical coverage and hence nearer to residents and GP Clinics

• Operating on board 24-seater

Services Offered :

Diabetic Retinal Photography

Diabetic Foot Screening

Nurse Counselling for Chronic Diseases

Virtual HospitalObjectives• Prevent / Reduce avoidable and

unplanned admissions • Reduce avoidable attendances at

emergency and outpatient clinics• Reduce length of stays in hospital• Improve patient’s / care giver’s

satisfaction to care provision

Components• Telephonic reviews/assessment: in-bound/ out-

bound calls• Home visits conducted by Health Manager• VH team’s daily case discussion on care plan• Multi-Disciplinary Rounds with the primary

physician, medical social worker, disease managers• Coordination & liaison with internal & external

partners (inter-departments, community health & personal care partners)

Virtual Hospital: Preliminary Outcomes

Readmissions to Acute Hospitals

Emergency Department Attendances

LEARNING POINTS AND NEXT STEPS

Learning Points• Start with political “buy-in” and leadership (from policy development to

implementation and evaluation)• E.g. Formation of Regional Health Systems

• Continually remove ‘silos’ and ‘fragmentation’ within various working bodies: Change mental model and create new skills amongst professionals:• Collaboration; Creating “win-win” solutions and approaches

Incentivize integration via common funding streams• E.g. Integrated care pilots enabled integration between acute hospitals and community

providers via a common funding stream

• Start with specific patient populations and demonstrate“quick wins”; evaluate outcomes & apply to future endeavors; adapt where possible; • E.g. Virtual Hospital, ACTION (Aged Care Transition), SPICE (Singapore Programme for

Integrated Care for Elderly)

• Shared IT systems play a great role in enabling integration• E.g. National Electronic Health Records- extending access to Community providers and

Primary care practitioners

Next Steps for Us

• Improve public perception of community care services

• Further align financial models to sustain care integration• Capitated models• “Pay-for-Performance” or outcome-based payments

• Develop a standardized needs assessment framework to right site patients to appropriate community care service

• Increase involvement of General Practitioners to deliver holistic care for elderly in community

• Leverage on technology as a tool to integrate care. Examples of ongoing pilots include:• Singapore Integrated Diabetic Retinopathy Programme (Tele-Ophthalmic Service for Diabetic

Retinopathy Screening)• Tele-geriatrics Programme (Tele-consultation for Nursing Home patients by Geriatrician from

Acute Hospital)

THANK YOUProf Chee Yam Cheng: yam_cheng_chee@nhg.com.sgDr Jason Cheah: Jason.Cheah@aic.sg

Bibliography (1)• Journal References

• Ada C. Mui. The Program of All-Inclusive Care for the Elderly (PACE)- An Innovative Long-Term Care Model in the United States. Journal of Aging & Social Policy 2002. Volume 13, Issue 2-3.

• Alwan A et al. Monitoring and surveillance of chronic non-communicable diseases: progress and capacity in high-burden countries. The Lancet, 2010, 376:1861–1868.

• Coleman EA, Boult C; American Geriatrics Society Health Care Systems Committee. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc 2003;51:556-7.

• Coxon K. Common experiences of staff working in integrated health and social care organisations: a European perspective. Journal of Integrated Care 2005;13(2):13–21.

• Hammar T, Rissanen P, Perälä ML. (2009) The cost-effectiveness of integrated home care and discharge practice for home care patients. Health Policy. 92(1):10-20.

• Hirth et al (2009) Program of All-Inclusive Care (PACE): Past, Present and Future; J Am Med Dir Assoc 2009; 10:155-160• Huey Ling Pang, Loong Mun Wong, Faezah Shaikh, Harbans Kaur Integrating aged care in Singapore—the ACTION

framework” International Journal of Integrated Care. 2010 Oct-Dec; 10(Suppl): e101. • Kodner DL. All together now: a conceptual exploration of integrated care. Healthcare Quarterly (Toronto, Ont.) 2009,

13 Spec No:6-15• Murray M. Process improvement and supply and demand: the elements that underlie integration. Healthc Q 2009. 13

Spec No:37-42.• Peikes D, Chen A, Shore J, Brown R. (2009) Effects of care coordination on hospitalization, quality of care and health

care expenditures among Medicare beneficiaries. JAMA;301(6):603–18.• Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M. Comprehensive discharge planning in the

hospitalized elderly: a randomized clinical trial. Ann Intern Med 1994;120:999-1006. • Suter E, Oelke ND, Adair CE, Armitage GD Ten key principles for successful health systems integration. Healthc Q 2009.

Oct; 13 Spec No:16-23. • World Health Organization (WHO). (1996) Integration of health care delivery: report of a study group. Geneva,

Switzerland: WHO; Technical Report series, No. 861.

Bibliography (2)

• Website References• Agency for Integrated Care – www.aic.sg• International Journal for Integrated Care - www.ijic.org• Ministry of Health, Singapore- www.moh.gov.sg• National Healthcare Group- https://

corp.nhg.com.sg/RHS/Pages/RHS-for-the-Central-Region.aspx• Singapore Silver Pages- www.aic.sg/silverpages/• Tan Tock Seng Hospital, community health programmes-

https://www.ttsh.com.sg/community-health-programmes/