Singapore is facing a dilemma: while it is set to witness a rapidly ageing population – By 2030, 25% of its population will be aged 65 and above, compared to 14% now – its limited land space means building new healthcare facilities is not a sustainable solution to meeting future demand for medical care.
A rethink of the country’s healthcare system and model is hence in order. In 2017, the Ministry of Health (MOH) identified “Beyond Hospital to Community” as one of the three major shifts that will guide national healthcare policy. This particular thrust aims to shift care for suitable patients into the community, thus relieving pressure on hospital capacity.
In this vein, the MOH Office for Healthcare Transformation (MOHT), an entity set up to address fundamental and longer-term healthcare issues in Singapore, is currently evaluating the feasibility of a programme to provide care for patients, who would otherwise have been hospitalised, in the comfort and safety of their homes. This is achieved through combining the expertise of hospital-based doctors, community nurses and allied health professionals and utilisation of digital tools such as remote monitoring devices.
Pilot trials at public hospitals
“Acute care has been operating on the notion that a centralised model for hospital care delivery was the “best” and “most productive” way. However, a deep dive into the literature and evidence from overseas systems convinced us that alternative ideas might be worth a closer look,” said Mr Lai Yi Feng, Senior Manager and Project Lead at MOHT.
MOHT has so far partnered with Khoo Teck Puat Hospital and NUHS on pilot trials of this model. More than 70 patients have been enrolled with the ongoing pilot at NUHS (named NUHS@Home), which sees about three patients cared for at home at any one time.
Dr Stephanie Ko, Associate Consultant, Division of Advanced Internal Medicine, Department of Medicine at the National University Hospital (NUH), explained that NUHS had decided to be on board the programme after recognising how care for patients at home rather than in hospitals could benefit patients. “We saw that providing medical care at home had the potential to be more patient-centred and reduce the possibility of hospital-acquired infections, while lowering cost and increasing bed capacity,” said Dr Ko.
Patients can be assured that the type of treatments they receive, such as intravenous antibiotics and drips, will be on par with that in hospitals, with five consultants from NUH’s Division of Advanced Internal Medicine and Alexandra Hospital’s Department of Medicine taking turns to provide care. “The programme is designed in such a way that patients are monitored a number of times a day. If deterioration is observed or further escalation is needed, patients can be transferred back to hospital when necessary,” said Ms Tay Yee Kian, Assistant Director of Nursing, Advanced Practice Nurse, Regional Health System Office, NUHS.
Receptiveness to the concept
Such a shift in care delivery requires a significant mindset change from both medical professionals and patients. Ms Tay noted that although this concept is quite prevalent abroad, it is not so well established in Singapore. However, feedback from pilot participants has been generally positive.
“Patients tend to feel more comfortable at home in a familiar environment surrounded by their families, they walk around more and sleep better,” said Dr Ko. “For the hospital, seeing how patients interact with their regular environment allows us to deliver more patient-centred care, as compared to seeing them in a ward setting. We are also able to build better rapport with patients and their families, as the dynamic changes from one where patients are identified by their hospital bed to one whereby they invite us as a guest into their home.”
While there were initially concerns about whether Singaporeans would be receptive, the pilot has shown that there are many patients and families who prefer to be cared for at home if possible. Another plus is potentially lower hospital bills; NUH’s preliminary data suggests that the costs of medical care at home is around 20% more affordable than that incurred if patients were in the hospital.
Identifying suitable patient profiles
The trials have helped to identify the patient profiles who may benefit most from such care. One such group is patients with advanced dementia who are already quite dependent on caregivers and prefer to avoid recurrent hospital admissions.
Ms Tay recounted that an 84-year-old dementia patient was enrolled in NUHS@Home, as his family was concerned that the unfamiliar hospital environment would exacerbate his behaviour and cause him to be more delirious. The NUHS team then treated his infection and supported his recovery with intravenous antibiotics at home, to prevent further delirium and functional decline. Another elderly patient was enrolled as he refused to be admitted to hospital. The NUHS team did daily rounds to his home to check and monitor his condition, and also administer intravenous diuretics for his heart condition. The families of both patients were appreciative of the option to be treated at home rather than in the hospital ward.
Dr Ko noted that this may particularly benefit elderly patients who are still mobile. She added, “Generally, they tend to rest in bed most of the day in the hospital and therefore tend to decondition, but when we treat them at home they tend to keep more active, so we see this happening less.”
The driving factors and challenges
With the COVID-19 pandemic exposing the risk of shortage in healthcare capacity during a crisis, the idea of treating suitable patients at home rather than the hospital has gained momentum worldwide. Such a model can quickly ramp up hospital capacity and bridge manpower shortages with teleconsultations, as well as keep patients safe from hospital-acquired infections – while ensuring quality care.
“If anything, COVID-19 showed that care does not always have to be delivered in hospitals. We are capable of delivering good care in the homes of patients, with clinical outcomes equivalent to that of inpatient care,” said Ms Tay.
While pilots have shown potential thus far, further work and studies would be required before rolling this out on a wider scale in Singapore. Both Dr Ko and Ms Tay highlighted that increased awareness and buy-in amongst patients, providers and policymakers would be crucial. In addition, the pricing of such care would need to be deliberated. “Considering that such community-based care programmes are fundamentally targeted to substitute inpatient care (rather than improve ambulatory or community services), and cost less than inpatient care, robust payment mechanisms should ensure the such care is at least cost-neutral, if not lower cost to patients rather than inpatient care,” said Mr Lai.
The NUHS pilot, which will be concluded in September 2021, will provide valuable findings for evaluation of this care model. Moving forward, NUHS hopes to offer this option to more patients, in particular those who can avoid admission, said Dr Ko. For MOHT, a pilot trial at another public hospital is on the cards for later this year. The agency will also be engaging policy owners and stakeholders on evaluating the model more realistically against usual care, especially in the financing and long-term sustainability aspects, said Mr Lai.
While the programme is still at the exploratory trial stage in Singapore, each pilot trial will provide a better idea of how this concept can be implemented in the local context. Ultimately, such efforts to evaluate and adopt innovative ideas will be crucial in transforming Singapore’s healthcare model, into one that would best serve the evolving long-term health needs of Singaporeans.