Bringing care closer to home: How do we get there?

Singapore is facing the challenge of a rapidly ageing population. The proportion of residents aged 65 years and above will rise from 11.8% in 2015 ¹ to a projected 18.7% by 2030. ² Along with the ageing population, we expect an increase in prevalence of chronic diseases, diseases associated with aging like dementia, their associated complications and functional disabilities. As the population ages and Singaporeans live longer, we need to sufficiently provide appropriate healthcare and support that is easy to access, facilitate for quick recovery and good health outcomes whilst keeping costs affordable and sustainable. Doing more of the same cannot be the solution. We need to evolve our healthcare system from an acute, episodic hospital-based care model to one that is more person-centric in the home and community.

Recognizing this need, the Ministry of Health has formed six Regional Health Systems (RHS), each responsible for the population in a region. The aim is to integrate and build networks between public health institutions, community home care teams, day rehabilitation services, social care and private providers, especially general practitioners within each RHS. This moves away from the silo institution-centric approach to facilitate cohesive integrated management of patients across the spectrum of health and social services.

There have been various rapid responses from this call for shifting care into the community. For many healthcare establishments, there is a refocus to develop new and creative means for dealing with the frail elderly with a population focus. An example is the development of multi-disciplinary teams that include social care, community partners and having these groups practice on set protocols and care plans with a shared medical record. These are necessary first steps forward; however, once we scratch beneath the surface, there is often a lack of detailed thought holding the ideas and one wonders how radical they truly are. We will need to move beyond thinking about just shifting the hospital model into the community and begin pondering on the larger fundamental changes that need to take place in the health and social system.

Going to the hospital becomes the default for many patients because we fail to rethink how primary care, community and social care operate. To effectively shift care out of hospitals and re-provide these services in the community, a whole-systems approach is needed. Healthcare restructuring and new models of care cannot happen in isolation. In this present day of increasingly complex patient care, social and psychological needs are very much intertwined. Helping a patient remain at home is very dependent on them having a home that is fit for that purpose. To meaningfully address integration and the vulnerable ‘hand-offs’ during a patient’s transition journey into the community, reinvestment strategies in community-based services and social care partners need to occur. Community services need to be adequate and efficient to avoid jeopardizing care. There is currently a service gap as patients discharged from hospitals may still require intense care, yet such investments in community services and workforce are still lagging.

Whole-system changes need to be based on sound governance arrangements with clarity around decision-making and accountability. This means bringing together leaders from institutions, government agencies and relevant ministries, together with grassroots, voluntary welfare organizations and private sectors. Examples from Norway, ³ Denmark ⁴ and Sweden ⁵ have shown joined collaborations between health authorities and municipalities to facilitate the smooth transfer of patients from acute hospitals to community or long-term care facilities. There is emphasis for local authorities to develop preventative, early intervention and long-term conditions management services within the community that encourages a proactive rather than reactive approach. Drawing from these models, perhaps we will need to have such a formal inter-professional framework underpinned by senior executive support and dedicated program management to drive these high-level commitments into action.

Aside from system changes, there are manpower and competency challenges. As patient acuity, long-term and complex-care needs continue to rise, perhaps it is time to relook to shift from the ‘specialist’ to a more ‘generalist’ model of practice both for doctors and nurses. Treating patients closer to home also require changes to traditional working norms. This includes being able to make a comprehensive assessment in identifying needs, to handle clinical risks in making independent rapid decisions, entering patient’s homes and in the case of telehealth, working with new technology. Staff must be willing to work differently, merging hospital-based skillsets with a community-based approach. Some schemes in the UK have looked at providing attractive job propositions and highlighting new pioneering and innovative care approaches. ⁶ There should be focus on skills and cross-training rather than job grade, with structured opportunities to rotate between different teams and settings. This ensures the community teams are cross-trained and maintain their hospital-based skills and relationships.

A key component in developing new models of care is evaluating its cost effectiveness. Most programs that provide transitional care are currently funded as small pilot initiatives, often on a non-recurring basis. Because of this, fostering future growth, efficiency and effectiveness both at individual program and higher systems levels are rarely set as a primary consideration during implementation. Quality data collection, both clinical and financial, is important. There needs to be a comprehensive data collection system that links data at a person level and tracks patients across settings. Price incentives should be determined from the outset to ensure that financial gains and losses are adequately shared among hospitals, community providers and social care partners. The recent move by the Ministry of Health for a pilot bundled payment model for hip fractures sets the tone for funding models to enable integrated care for a defined population. New models of payment such as capitation can incentivize disease prevention, promote avoidance of unnecessary resource utilization and seek out best clinical care practices.

We have visions for a new model of care that has the patient’s home at its center. Such integration stretches beyond traditional institutions. As we move towards shifting care into the community, we need to keep sight of the challenges and goals before developing new models, as a wider strategic change is needed beyond just healthcare.