Abstract
Background:Organizing care into integrated practice units (IPUs) around conditions and patient segments has been proposed to increase value. We organized transitional care into an IPU (THC-IPU) for a patient segment of functionally dependent patients with limited community ambulation.Methods:1,166 eligible patients were approached for enrolment into THC-IPU. THC-IPU patients received a comprehensive assessment within two weeks of discharge; medication reconciliation; education using standardized action plans and a dedicated nurse case manager for up to 90 days after discharge. Patients who rejected enrolment into THC-IPU received usual post-discharge care planned by their attending hospital physician, and formed the control group. The primary outcome was the proportion of patients with at least one unscheduled readmission within 30 days after discharge.Results:We found a statistically significant reduction in 30-day readmissions and emergency department visits in patients on THC-IPU care compared to usual care, even after adjusting for confounders.Conclusion:Delivering transitional care to patients with functional dependence in the form of home visits and organized into an IPU reduced acute hospital utilization in this patient segment. Extending the program into the pre-hospital discharge phase to include discharge planning can have incremental effectiveness in reducing avoidable hospital readmissions.
Highlights
Singapore’s population is one of the most rapidly ageing in Asia and an estimated one million or 20% of the country’s population will be 65 years or older by 2030 [1]
We aim to evaluate the effectiveness of a Transitional Home Care program that applied the integrated practice units (IPUs) concept (THC-IPU) in reducing 30-day readmission for patients with functional dependence admitted to the Singapore General Hospital (SGH)
Patients are required to co-pay for the program depending on their means test level. 31st May 2016 was selected as the closing date for this program evaluation as Ministry of Health (MOH) had decided to transit to a new model of transitional care and healthcare funding termed as “Hospital to Home” with effect from 1st April 2017
Summary
Singapore’s population is one of the most rapidly ageing in Asia and an estimated one million or 20% of the country’s population will be 65 years or older by 2030 [1]. Almost a quarter of semi-ambulant and non-ambulant Singapore elderly stay alone or with their elderly spouse [2] These patients face many challenges after discharge from hospital that increases their risk for unscheduled readmissions. We organized transitional care into an IPU (THC-IPU) for a patient segment of functionally dependent patients with limited community ambulation. Patients who rejected enrolment into THC-IPU received usual post-discharge care planned by their attending hospital physician, and formed the control group. Results: We found a statistically significant reduction in 30-day readmissions and emergency department visits in patients on THC-IPU care compared to usual care, even after adjusting for confounders. Conclusion: Delivering transitional care to patients with functional dependence in the form of home visits and organized into an IPU reduced acute hospital utilization in this patient segment. Extending the program into the pre-hospital discharge phase to include discharge planning can have incremental effectiveness in reducing avoidable hospital readmissions
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