Unified Needs Assessments to Enable Systemic Healthcare Services Integration and Health System Transformation

Background: Needs assessment tools (NATs) help health systems identify and characterize resident needs and design care plans. Conventional NATs tend to be disease, specialty, profession, or institution-specific and are fragmented across these boundaries. This results in overlapping or duplicated assessments, and challenges for data sharing that result in rising healthcare costs and diminishing patient and provider experience. Developing and implementing a unified NAT across the health system can support achieving person-centered value-driven integrated care for residents. Yishun Health (YH) is a regional health system caring for 300,000 people in the north of Singapore that is embarking on whole system transformation. At the systems-level, aggregation of standardised needs data supports the use of population health management (PHM) tools (e.g. population segmentation, resource allocation, and performance management). Therefore, successful unification of needs assessments to enable these functions also requires a single standardised and person-centered NAT. Methodology: Available literature on validated NATs were screened to shortlist tools that were person-centered. Using Maslow’s hierarchy of needs, domains and categories of the tool were expanded and redefined to be locally-contextualised, align with principles of salutogenesis, consider paediatric needs and “systemic” public health needs at the resident-level, and be totally exhaustive of all determinants that enable residents to achieve complete physical, mental, and social wellbeing. A systemic design approach was then employed to develop a more person-centered needs assessment process incorporating principles of patient empowerment, individual agency, relationship- and strength-based working. Tools were designed to yield standardised data for monitoring residents through time and be aggregated into coherent population-level data for PHM. Multiple stakeholders, including clinical, informatics, and operations teams were engaged in the development and planning of pilot studies to improve the tool and enhance the assessment process. Results & Discussion: The Omaha system was examined and adapted for use in YH. Its 4 domains were renamed: ‘My Body’, ‘My Mind & Networks’, ‘My Self-Care’, and ‘My Living’. 5 new needs categories were added: ‘screening’, ‘vaccination’, ‘confidence’, ‘development’ and ‘Connection & Contribution to Public and Societal Health & Wellbeing’. The designed process of needs assessment involved 5 steps: Identification of Signs and Symptoms, Anticipatory Concerns, Needs Rating, Behaviour and Knowledge Rating, and Asset Documentation. All steps incorporated free text for detailed documentation, and multiple-choice options or Likert scales to aggregate standardised data. A self-administered version of the tool was also adapted from the MyStrengths MyHealth(TM) application. The NAT’s standardised process of data collection and ability to aggregate data facilitates integrated resident care planning and prioritization of services and resources at the population-level. For successful implementation, change management is needed to shift clinician perspectives away from siloed disease-based assessments towards a unified NAT, and digital solutions are needed achieve efficiency in assessment, swarming of data for aggregation, and enable integration of NAT across boundaries. Conclusion: Person-centered NATs are the future for value-based health systems. A unified and standardised NAT will enable YH to play its role as both a healthcare provider and regional population health manager – bringing us closer to integrated care and effective PHM.