SingHealth Regional Health System Study Visit to Sweden

Oct – Nov 2017

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2

ACUTE/SECONDARY

INTERMEDIATE/LONG TERM

SingHealth

PRIMARY CARE

TERTIARY/QUATERNARY

SingHealth

Total Population in the East: 1.36 Million 35% of Total Resident Population

Pop: 350,000

Pop: 745,000

Pop: 270,000

SingHealth

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Voluntary Welfare Organisations

Community Development Councils (CDC) & Grassroots Organisations

Other Community Hospitals & Nursing Home

National Agencies

SingHealth Community Partners

Expanded Community

Partners

Beyond Programmes to Holistic Person-Based Care

Focusing on the needs of the population Moving from provider-centric (setting) to

person-centric (care themes)

Preparing our Healthcare System for Person-Based Communities Of Care

Outpatient to Community

Community Health Hospital Care Community Care

Community Health Screening

Primary Care Network

Falls and Frailty Screening

Mental Health Promotion

Community Health Post

Polyclinics

FMC/CHC

Community Nursing

Hospital To Home

Health Management

Unit (Biomedical) Geriatric Service Hub

End Of Life Care

Community Hospital

Nursing Home

Community Networks for Seniors

Care Line (Psychosocial)

Community Health Screening

Population segmentation

Population health and disease

prevention

Continuing Community Care

Synergising and Scaling Services

Objectives Increase accessibility of health screening and preventive health services to residents in the Eastern RHS through closer collaboration with grassroots and social agencies

Early detection of chronic disease conditions or risk factors for early intervention to prevent or delay onset of chronic diseases

3 KEY FOCUS AREAS

1 To improve follow up rate for individuals who

have been referred to GP for abnormal results (at least 65%)

2 Strengthening health screening intervention and follow-up at CHPs (~85%) or Pre-DICTED

Programme*

*Pre-Diabetes Interventions and Continued Tracking to Ease-out Diabetes (Pre-DICTED) programme

3 Transition to Enhanced Screen For Life (SFL) in FY17

Increased awareness of health conditions and predisposing bio-psychosocial risk factors

Increase adoption of healthy lifestyles • Healthy diets and regular exercise

Outcome

Prevent or delay onset of chronic diseases

10,424 10,083 9,288

Hospital to Home (H2H)

Population segmentation

Population health and disease

prevention

Continuing Community Care

Synergising and Scaling Services Communities of Care

Objectives • Provide holistic patient-centric care to support

patients’ safe and timely transit from hospital to home

• Reduce necessary hospital utilisation • Target frail patients with complex care needs,

high healthcare utilisation, and/or have risk of future readmission that are preventable through H2H Intervention

Bukit Merah

Telok Blangah Tiong Bahru

Chinatown Katong

Aljunied

East Coast Marine Parade

Tampines Pasir Ris

Punggol

Sengkang SOUTHEAST

NORTHEAST

EAST

Geographical Team-Based Approach Organise care delivery along

Communities of Care Zones

Ensure sustainability by working within MOH

Programme funding for care integration

Align care delivery model to encompass the biomedical,

nursing, functional and psychosocial components

Neighbours for Active Living

Community Nursing

Three-Year Projection

FY18

Care Line

Health Management Unit

FY19 FY20

Southeast: 5,020 5,310 5,460 East: 4,000 4,100 4,200 Northeast: 268 673 764

Community Case Management (e.g. PNs & CCAs)

End of Life Programmes Enhancing Advance Care Planning (ACP), Geriatric Care and End Of Life (EOL) care in the Eastern Region

Population segmentation

Population health and disease

prevention

Continuing Community Care

Synergising and Scaling Services

• Establish a Palliative Care Model and Ecosystem to provide holistic and integrated EOL care

• Promote ACP awareness in the community • Support Nursing Home to perform ACP and develop capability

with NHs to provide geriatric and EOL care

Objectives

Developmental Milestones (FY18 – FY20) Palliative Care

•Develop and align core elements and protocols (FY18)

•Develop education/ training and competency framework for nurses and medical social workers (FY18)

•Establish financial model to build up capability of community partners (FY20)

Advance Care Planning

•Administer and coordinate ACP at Cluster level (FY18)

•Develop shared resources and streamline advocacy and training programmes (FY18)

•Develop partnership with nursing homes and hospice care providers to establish shared ACP workflow (FY20)

Enhancing ACP, Geriatric Care and EOL care with NHs

•Deepen engagement and training with existing 5 NH partners in the east (FY19)

•Develop and implement EOL care delivery model for suitable residents

•Engage all NHs in the east, and support at least 50% of NH beds in the east (FY20)

•Engage NHs in SE from FY20

Pending MOH Funding beyond FY17

Population segmentation

Population health and disease

prevention

Continuing Community Care

Synergising and Scaling Services

SingHealth Eastern Region

Individual Care

Communities of Care

Preventive Care

First Contact Care

Transitional Care

Chronic, Aged & End of Life Care

• Health promotion & protection • Disease prevention

• Perform assessment & triage • Meet immediate care needs • Refer or escalate as required

Simple • Support & empower self management • Chronic disease management • Facilitate emergent care plan

• Re-enablement approach • Support hospital to home (H2H)

Complex • Integrated case management • Key staff assigned to navigate • Coordinate and care manage

Roles of Community Nurses

SingHealth Community Nursing

Continuing quality care in community

and ageing in place

Right siting &

Integration of care

Building healthy &

empowered community

Community Nursing

Community Coordinators Physicians Allied Health

Professionals

Objectives

SingHealth Community Nursing Geographical Team-Based Nursing

Population segmentation

Population health and disease

prevention

Continuing Community Care

Synergising and Scaling Services

Geographical Team-Based Approach • Deeper understanding of the population

needs in the respective zones • Skill-mix to cater to different levels of

needs and care • Greater accessibility • Ease of collaboration and building

capability for health & social care personnel

• Increase efficiency in resource allocation

Communities of Care

*3 years pilot funded by MOH will be implemented by the east and southeast region

Bukit Merah

Telok Blangah Tiong Bahru

Chinatown Katong

Aljunied

East Coast Marine Parade

Tampines Pasir Ris

Punggol

Sengkang SOUTHEAST

NORTHEAST

EAST

Three-Year Pilot* – Workload & Manpower Targets

Year 1 Year 2 Year 3

Community Nurses

Care Coordinator Associates

Manpower (Cumulative) 44 56 72

16 23 31.0

Workload (Pending MOH Funding) East Southeast

2,720 5,140 8,160 3,500 4,150 5,105

E: 5; SE: 11 E: 10; SE: 13 E: 16; SE: 15

E: 16; SE: 28 E: 25; SE: 31 E: 37; SE: 35

Integrating Technology with Care

A phone support service provided by a care team to help residents connect with the right healthcare services, coordinate medical appoints and reminder as well as encourage them to participate in community activities

Careline

The HMU team provides proactive personalized chronic disease education and support with patients on their medical conditions through the telephone

Health Management Unit

Working with IHiS and MOH to implement telehealth platform – video conferencing, vital-sign monitoring and tele-rehabilitation

Telehealth

Like Uber and Grab-Taxi, Match-A-Nurse mobile app makes it easy for off-duty nurses to meet the care requests of SGH and KKH patients who live near them, to perform specific tasks for a fee

Match-A-Nurse

First self-help kiosk in the community for health tracking

My Health Kiosk

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Person-Centred Care

Expand & strengthen partnerships with community and MOH

Scale up “Esther” projects with potential for transferability at

SingHealth regional level

Mainstream person-centred initiatives with high impact at national level

A unifying care philosophy for care providers to provide person-

centred care

Person-centred improvements that can be scaled and shared

A common framework adopted nationally for high impact person-

centred care

Person-Centred Care Philosophy “Esther” Network

Objectives Outcomes

Developmental Milestones • Co-construct strategic plan with community partners and “Esthers”

• Engagement with stakeholders to further the impact of “Esther” improvement work (FY18 to FY20) • Establish the platforms and sponsors to own improvement initiatives in the eight domain areas identified

by “Esthers” • Run “Esther” Cafes in the community & SQ members (Target: 40 to 50 participants by FY18, 40 SQ

members by FY18) • Two-days workshop for Group Service Quality by FY18

• Ongoing Capacity Building and Improvement Work (FY18 – FY20) • Continue training of 50 “Esther” coaches & trainers for capacity building • Collaborate with HSR to interview community partners (Target: 15 to 20 community partners by

FY18) • Dovetail with the development of Community Network for Seniors (FY18 – FY20)

Evaluating RHS outcomes using Quadruple Aim

Work life of Health Care Providers

Experience of Care Population Health

Cost Per Capita

How do we know we are successful?

Reference: Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Annals of Family Medicine. 2014;12(6):573-576.

Better Health for the

Population

Better Care for the

Individuals

Sustainable Cost Through

Improvements

Improved Provider

Satisfaction

Thank You

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