An evaluation of a care transition process pilot in Singapore

Abstract

Background: Despite the need for centreand home-based long-term care services (CHLTCS) among patients to be discharged from acute care hospitals, the services take-up rate is about 50% in Singapore. A re-engineered acute-to-CHLTCS transition process that reduces resource duplication and that provides timely and accurate service information is evaluated on its ability to reduce patient waiting time, and increase take-up rate. Methods: Data was obtained from records of patients who were assessed to be likely to benefit from CHLTCS prior to discharge from an acute care hospital. The intervention group comprised 39 patients from six clinical specialty wards, which submitted the highest number of CHLTCS referrals among all wards over the past year, over a fiveand an eight-day period in July and August 2013. CHLTCS referral management staff were deployed alongside the hospital team to assess these patients’ care needs, provide information on alternative services and service providers, and obtain the patients and families’ commitment to a service provider before a CHLTCS referral was submitted via the national referral management system, and a service provider assigned. The comparator group comprised 209 patients from all wards in May and June 2013. These patients underwent the existing care transition process where they were assessed and referred to CHLTCS by only the hospital team. CHLTCS referral management staff assessed the merits of these submitted referrals, checked the patient and family’s preference on service providers, before assigning a service provider. Results: Prior to referral submission, 34% of the intervention group patients declined the CHLTCS referral while none from the comparator group declined. Among patients with a submitted CHLTCS referral, the intervention group’s take-up rate was higher than the comparator group’s (82% v 50%). More patients in the intervention group were referred to CHLTCS service within one day of hospital discharge (77% v 58%) and assigned to service providers on the day of referral submission (76% v 46%). World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116670– http://www.ijic.org/ Discussions: The joint deployment of the hospital and CHLTCS referral management teams reduced the duplication of and streamlined the assessment and referral submission processes between the teams. The timely provision of accurate information on alternative services and service providers allowed informed care decisions to be made by patients and families early, which, in turn, reduced unproductive efforts in referral management. Conclusion: The re-engineered care transition process increased CHLTCS take-up rate substantially, suggesting that there is potential continued need for CHLTCS in Singapore. Lessons learned: The key ingredients of success in this pilot are informed care decisions made early and shorter overall processing time from care needs assessment to service provider assignment. Limitations: The most important limitation in this study was the non-random selection of clinical specialty wards in the intervention group. Additionally, the intervention period was short, resulting in a small study sample taken from only one hospital. Suggestions for future research: Future research should involve random sampling of patients from all hospital wards, and examine the impact of this re-engineered care transition process on the hospital length of stay and re-admission rate of patients.