Abstract
BackgroundTo cope with rising demand for healthcare services in Singapore, Regional Health Systems (RHS) comprising of health and social care providers across care settings were set up to integrate service delivery. Tasked with providing care for the western region, in 2012, the National University Health System (NUHS) – RHS developed a transitional care program for elderly patients with complex healthcare needs who consumed high levels of hospital resources. Through needs assessment, development of personalized care plans and care coordination, the program aimed to: (i) improve quality of care, (ii) reduce hospital utilization, and (iii) reduce healthcare-related costs. In this study, recognizing the need for process evaluation in conjunction with outcome evaluation, we aim to evaluate the implementation fidelity of the NUHS-RHS transitional care program to explain the outcomes of the program and to inform further development of (similar) programs.MethodsGuided by the modified version of the Conceptual Framework for Implementation Fidelity (CFIF), adherence and moderating factors influencing implementation were assessed using non-participatory observations, reviews of medical records and program databases.ResultsMost (10 out of 14) components of the program were found to be implemented with low or moderate level of fidelity. The frequency or duration of the program components were observed to vary based on the needs of users, availability of care coordinators (CC) and their confidence. Variation in fidelity was influenced predominantly by: (1) complexity of the program, (2) extent of facilitation through guiding protocols, (3) facilitation of program implementation through CCs’ level of training and confidence, (4) evolving healthcare participant responsiveness, and (5) the context of suboptimal capability among community providers.ConclusionThis is the first study to assess the context-specific implementation process of a transitional care program in the context of Southeast Asia. It provides important insights to facilitate further development and scaling up of transitional care programs within the NUHS-RHS and beyond. Our findings highlight the need for greater focus on engaging both healthcare providers and users, training CCs to equip them with the relevant skills required for their jobs, and building the capability of the community providers to implement such programs.
Highlights
To cope with rising demand for healthcare services in Singapore, Regional Health Systems (RHS) comprising of health and social care providers across care settings were set up to integrate service delivery
For the assessment of moderating factors influencing program implementation, 25 healthcare providers including care coordinators (CC), managers, and physicians involved in the implementation of the program and 45 healthcare users enrolled in the transitional care program were interviewed
In assessing the implementation fidelity of the National University Health System (NUHS)-RHS transitional program, we found detailed protocols coupled with CCs’ level of confidence and familiarity in specific program components to contribute to high implementation fidelity
Summary
To cope with rising demand for healthcare services in Singapore, Regional Health Systems (RHS) comprising of health and social care providers across care settings were set up to integrate service delivery. Tasked with providing care for the western region, in 2012, the National University Health System (NUHS) – RHS developed a transitional care program for elderly patients with complex healthcare needs who consumed high levels of hospital resources. Healthcare services in Singapore have been provided largely in silos, with little coordination across different parts of the system [3]. Such fragmentation resulted in over-utilization, including excess hospitalization and service duplication, leading to suboptimal system efficiency, medical errors, increased costs, and low patient satisfaction [4, 5]. Even after the addition of new hospitals, Singapore’s healthcare system continues to struggle with high bed occupancy rates and long waiting times at acute hospitals [6], indicating a need to improve integration across care settings
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