The One Care Plan Application:  Enabling collaborative care in the community in Singapore

Background: Singapore faces challenges arising from a rapidly ageing population and an increasing prevalence of chronic diseases. The imperative is to strengthen connections between acute hospitals and primary, intermediate, long-term, and home care sectors, ensuring the provision of appropriate and accessible care in the community. Currently, services across the social-health continuum are provided by multiple providers. Limited visibility of patient information shared across the patient’s multidisciplinary team leads to challenges in tracking patient journeys and gathering of information. This results in duplicate or redundant services and overall poor coordination of care across providers. We hope to address this issue by taking a design thinking approach to create the One Care Plan (OCP) application. OCP aims to facilitate the sharing and aggregation of patient information among care providers, streamlining collaboration and delivering patient-centred care to the elderly with complex health and social needs in the community. We envision that this will enhance information sharing, care coordination, and overall patient experience. Methods: Design and co-creation sessions involving representatives from Singapore General Hospital (SGH) and three community service providers were conducted to map current processes, identify pain points, and explore opportunities for improvement. Features were prioritised based on impact and technical complexity to develop a minimum viable product in collaboration with Synapxe, the public healthtech agency of Singapore. The selected features were also mapped to the activities and impact we hope to enable and achieve. The application was launched in October 2023, initially piloted in the SGH Empowered Communities of Care program. Results: Surveys conducted at launch revealed a disparity in the flow of patient health information among public healthcare institutions (PHI) and community service providers (CSP). 92% of PHI users were able to view hospital discharge summaries (“always”/”very often”) while only 36% of CSP users reported being able to. 40% of PHI users were able to access assessments from other service providers, compared to just 12% of CSP users. Overall, at least 55% of both PHI and CSP users reported lack of awareness of their patient’s care plans and issues from other providers (“rarely”/”never”). Feedback gathered through ongoing user engagement and application monitoring will inform continuous improvement, while user experience and product effectiveness will be evaluated through continued surveys, providing insights into the crucial features required for effective integration of care in the community. Conclusion: The OCP application underscores the significance of a technological enabler for care integration in communities with diverse professional groups and institutions. The continued curation of features post-launch aims to uncover the key functionalities essential for users delivering clinical and social services in the community. This initiative contributes to the ongoing dialogue on technology's role in enhancing collaborative care, particularly in the context of Singapore's ageing population and evolving healthcare landscape. Through our pilot, we have also found that beyond a technological enabler, ground processes are also key to enabling shared care. Hence, for successful implementation of care integration, the implementation team needs to partner programme teams to streamline and establish effective processes on the ground.