Enhancing Seamless and Integrated Care Transitions between Acute and Community Hospitals in Singapore through Co-designed Care Pathways

Both Singapore General Hospital (SGH) and Outram Community Hospital (OCH) are the largest acute and community hospitals in Singapore respectively, and account for a total bed complement of more than 2,100 hospital beds. OCH, is co-located with SGH to deliver a seamless continuum of care, offering integrated care pathways for patients requiring sub-acute care and rehabilitation before reintegrating into the community. This initiative, in alignment with Singapore Ministry of Health’s directives for care integration and right-siting healthcare services, seeks to enhance patient flows, eliminate administrative barriers, streamline processes, and facilitate seamless community reintegration. Nonetheless, persistent challenges remain, including a prolonged waitlist for OCH transfer from SGH and tight bed capacity in SGH. Patient engagement played a pivotal role in our pursuit of enhanced integrated care. Through purposeful engagement sessions, we have successfully identified groups of patients expressing a desire for and with benefit from earlier initiation of rehabilitation in community hospital. Comprehensive reevaluations of multi-step process involved in transferring patients from acute to community hospital and their subsequent discharge planning were conducted. To expedite patient transfers from acute hospitals to community hospitals (AH-CH), we engaged in a collaborative endeavor to co-design green lanes, condition-specific care pathways and fast-track protocols in close coordination with acute hospitals and relevant stakeholders. Regular analysis of outcome and process measures enabled continuous process improvements. Notable green-lanes established include total knee replacement (TKR), total hip replacement, hip fractures, spinal fusion, breast cancer mastectomy, cataract surgery and colorectal surgery. Similarly, fast-track protocols were developed with National Heart Centre Singapore for post-coronary artery bypass grafting patients and those requiring urgent catheterization lab activation. Our partnership with National Neuroscience Institute has allowed us to streamline transfers for stroke patients, enhancing their neuro-recovery journey. Beyond hospitals, we worked closely with community rehabilitation centers to expedite the transition of TKR patients after discharge. Our objectives are assessed through bed-days saved as the primary outcome measure, average wait time (days) and average length of stay (days) as process measure. In addition, we evaluate other key metrics including, readmission and U-turn rate, to ensure a balanced assessment. A comprehensive analysis of data from the top 13 Diagnosis-related groups (DRGs) for FY2022 reflects significant achievements. A total of 1244 acute hospital days and 1292 community hospital days were saved, resulting in a cumulative reduction of 2536 bed days equivalent to 69 AH-CH bundled admissions when compared to FY17 & 18 baseline. These accomplishments are accompanied by a1.18-day reduction in of average wait times, a 0.56% reduction in U-turn rate and a 1.37% reduction in 30-day readmission rate compared to FY2021. Throughout this transformative journey, it has become increasingly evident that collaborative co-design efforts with healthcare and community partners have been instrumental in addressing our patients’ needs effectively. In a system characterized by common cause variations, fundamental changes are necessary to realize tangible improvements. Integrated care principles continue to stand as the key to success in achieving patient-centered and cost-effective care delivery across organizations.