NOVEL APPROACHES TO IMPROVE THE HEALTH AND WELLBEING

NOVEL APPROACHES TO IMPROVE THE HEALTH AND WELL-BEING OF OLDER PERSONS : INTEGRATING CARE, AGEING-IN-PLACE 29 September, 2015 Clinical Professor Chee Yam Cheng, Senior Advisor, National Healthcare Group (NHG) & President, NHG College Dr Jason Cheah, Chief Executive Officer, Agency for Integrated Care (AIC) Dr Anchal Gupta, Assistant Manager, Agency for Integrated Care (AIC) Mr Wilson Ong, Executive, Agency for Integrated Care (AIC)

Declaration of Interest • We hereby declare that the disclosed information below is true and complete to the best of our knowledge (within the period of 36 months before and known occurring for subsequent 12 months from the date of 29 th Sept, 2015) : • We have not received remuneration from a commercial entity or other organisation to give any public talks or advice related to the subject of our presentation • We have not received any remuneration for expenses incurred to attend the conference apart from the honorarium that has been set out by BMJ • We have not received any remuneration from a commercial entity or organisation to conduct research related to the subject of our presentation

OVERVIEW OF HEALTHCARE LANDSCAPE IN SINGAPORE

Quick Facts About Singapore Population 5. 46 million Residents >65 years of age 9. 3% Life Expectancy 82. 5 years Total Fertility Rate 1. 25 %GDP spend on healthcare 4. 6% Source: Department of Statistics Singapore (2015) SINGAPORE’S HEALTHCARE LANDSCAPE Wellness Care Primary Healthcare • Preventable healthcare services in community • First contact point with patients in community, referred to medical specialists hospitals for further treatment when needed • Mainly private sector; some public sector involvement , e. g. Health Promotion Board • 80% Private- run by General Practitioners; 20% public sector run Polyclinics Secondary/Tertiary Healthcare Intermediate and Long term Care • Hospital care comprising of multidisciplinary inpatient and specialist outpatient services, and 24 -hour emergency services. • Continuing care for patients in community. E. g. community hospitals, nursing homes, day care centres, home care service, dialysis centers • 80% Public sector run acute hospitals • 70% by People sector (Charitable organisations)

Rapidly Changing Elderly Demographics 2014 2020 2030 Old (> 65) 432 K 613 K 962 K Old (> 85) 39 K 57 K 91 K Old (> 65) w/o Family Support^ ~9% ~11% ~13% No. of People with Chronic Conditions* 1. 36 M 1. 54 M 1. 80 M Elderly consume more healthcare* • • • Hospital admission rate 5 x that of persons aged 45 -54 Inpatient stay 1. 6 x that of persons aged 45 -54 Urgent need to shift away from hospital centric care *Utilisation includes both resident and non-resident admissions at public sector acute hospitals (excluding KKH) Source: Ministry of Health Singapore, National Health Survey 2010 A very different system beyond 2020 ^ Defined as having no caregivers at home * Refers to estimated number of Singapore residents aged 20 years and above with diabetes, high blood pressure or high blood cholesterol only.

SINGAPORE’S APPROACH TO SUPPORT ITS ELDERLY: AGEING-IN-PLACE “A key focus of the Ministerial Committee on Ageing (MCA) is ageingin-place. Our survey shows that our seniors prefer to age in place gracefully and with dignity, within a closely knit community. ” Minister Gan Kim Yong, Health Minister, Singapore, in 2012

Our Vision: Ageing-in-Place Ø Growing old in the home & environment that one is familiar with, with minimal change or disruption to one’s life / activities Ø Our Solution: Integrated care provision in community as a key to enable Ageing-in-Place • Easily accessible health + social care • Well coordinated and person-centered care • Affordable care • Optimal caregiver support • Community involvement in care provision

A Multi-Pronged Approach Ministry of Health (MOH) Agency for Integrated Care (AIC) Projection of national level service demand National Care Integrator for health & social care systems Healthcare Financing Coordinate patient referrals to intermediate & longterm care services Regulatory frameworks Standards and performance measurement Policy direction Capacity and capability building of the Primary Care, long-term care sector Regional Health Systems (RHS) Ministry of Health Holdings (MOHH) Platform for collaboration amongst service providers in a geographic region Common IT platform across the care continuum- National Electronic Health Records Skills transfer from acute to ILTC sector Common employment of junior doctors across care continuum Strategies and programs to address needs of regional population Direct Implementers of Care Integration Corporate manpower development Enablers- Manpower and IT platform

CARE INTEGRATION IN COMMUNITY Examples of some initiatives by AGENCY FOR INTEGRATED CARE (AIC)

Care Coordination and Case Management Initiatives Hospital’s Case Manager Hospital admission Care planning during hospital stay ACTION (Aged Care Transition) Care Coordinators are usually Nurses, Social workers, or Allied health professionals Hospital discharge Screening for high risk Goal setting and care planning; Referral to patients; Needs long-term care services assessment Community Case Managers For more complex, high risk patients; Long-term follow up of patients About 1 month post discharge Follow-up (phone calls/ home visits); Optimize self-care; Hand over to long- term care service Home visits and comprehensive case assessment; Formation of care plan Patient’s journey Follow up (phone call+ home visits); Review of care plan; Necessary referrals; Interdisciplinary team meetings

Aged Care Transition (ACTION): Outcomes • Aim: To enable seamless care transition post hospital discharge Ø As at Apr 2015, 120 care coordinators in 6 Restructured Hospitals and 5 Community Hospitals. Ø The teams recruit an average of 14, 000 patients per year. • Evaluation of the Pilot Programme (data from Jan 2009 - Jun 2011) Ø Odds of readmission within 15 and 30 days for ACTION patients: 40% and 32% lower than control group Ø Odds of Emergency Dept. attendance within 30 days: 21% lower than control group Ø Estimated cost savings S$5. 4 mil over 6 months. • Continuing Outcome Measures from the Programme (data from 2012 -2014) Ø Sustained reduction in utilisation of acute hospitals • Hospital Readmission Rate (15 D) – maintained in the range of 5 to 7%. • Emergency Re-attendance Rate (30 D) – range of 2 to 3%. *In comparison to hospital-wide double-digit readmission rates Ø Better Patient Satisfaction • Around 800 patients and caregivers were interviewed to understand satisfaction levels. • 99% of respondents rated ACTION services as “Good or above”.

Integrating Community Based Services Singapore Programme for Integrated Care for the Elderly (SPICE) • • • Based on the concept of the Program for All Inclusive Care for the Elderly (PACE) in US Offers a community based alternative to Nursing Home for frail elderly with high care needs Semi- capitated funding SPICE Centre Regional network with Primary Care and Acute Hospitals Medic al Social Worke r Therapi st Meal Deliver y Doctor Patie nt Therapy & Nursing Aides Case Manage r Patient’s Home Nursin g Patie nt Transport Nurse Home Person al Care Home Medic al Caregive r Home Assessment & Modification

Outcomes Singapore Programme for Integrated Care for the Elderly (SPICE) • Utilisation of Residential Services Ø Statistically lower rate for Nursing Home admissions for the SPICE group compared to control groups. Ø Statistically significant decrease in Community Hospital (CH) utilisation (Length of stay: average 18 days) and expenditure (Total Cost: average $4269) was observed after enrolment into SPICE; statistically significant reduction in CH utilisation for SPICE group compared to control groups Ø A statistically significant decrease in Acute Hospital utilisation (SPICE group Length of stay: median 17 days) and expenditure (SPICE group Total Cost: median $9, 890) was observed; however, difference not statistically significant when compared to control groups • Clients’ and Caregivers’ Satisfaction Ø Improvements in the SPICE participants’ perception of health and (2) decrease in caregiver stress after 12 months of care from SPICE; however difference was not statistically significant, likely due to the low number of responses received for the satisfaction surveys

CARE INTEGRATION AT REGIONAL HEALTH SYSTEM (RHS) Example from NATIONAL HEALTHCARE GROUP (NHG), a Regional Health System serving the central region of Singapore

Formation of Regional Health System (RHS) 15 Care Integration through the Regional Health System (RHS) – A patient-centric healthcare ecosystem comprising of partners from the primary, acute and community care sectors working together to deliver integrated healthcare services to improve population outcomes. Alexandra Health Jurong Health Services National Healthcare Group National University Health System Eastern Health Alliance “We have decided that we can achieve a better outcome if we reduce the size of each catchment and organize the healthcare delivery systems at the regional level…” Singapore Health Services Source: Ministry of Health, Singapore “This transformation in healthcare delivery to create a hassle-free healthcare system at the regional level, is a major strategy that we are pushing. It will make healthcare more convenient, safer, better and at the lowest possible cost…. ” Minister for Health (Aug 2004 – May 2011)

National Healthcare Group (NHG) Our Approach and Our Population Unknown (70 -80%) Outreach Approach 1. Lower Socio economic Status: Case finding for residents of rental flats 2. School kids : Partner with preventive School Health programmes 3. Working adults : Workplace Health/Partner with MOM (Ministry of Manpower) 4. General population : Community & opportunistic screening Known – Approx 320, 000 in Central Region (20 -30%) Health Status Led by Health Coordination Well / At Risk Community Chronic Illness Progression/Complication Primary Care Automated reminders at set intervals Maintain health Goal(s) Pre-Clinical Prevent onset Automated monitoring, escalation when needed Delay progression Hospital Care Co-ord by Healthcare Professional End of Life Palliative Case Management Maintain function, rationalize care (FP, SOC), pre-empt complications, avoid admission Stabilize, restore function if possible, avoid admission Minimise pain, avoid admission

(Mobile) Community Health Centre Services Offered : Diabetic Retinal Photography • Provision of ancillary support services to General Practitioners (GPs) • Wider geographical coverage and hence nearer to residents and GP Clinics • Operating on board 24 -seater Diabetic Foot Screening Nurse Counselling for Chronic Diseases

Virtual Hospital Objectives • Prevent / Reduce avoidable and unplanned admissions • Reduce avoidable attendances at emergency and outpatient clinics • Reduce length of stays in hospital • Improve patient’s / care giver’s satisfaction to care provision Components • Telephonic reviews/assessment: in-bound/ outbound calls • Home visits conducted by Health Manager • VH team’s daily case discussion on care plan • Multi-Disciplinary Rounds with the primary physician, medical social worker, disease managers • Coordination & liaison with internal & external partners (inter-departments, community health & personal care partners)

Virtual Hospital: Preliminary Outcomes Emergency Department Attendances Readmissions to Acute Hospitals

LEARNING POINTS AND NEXT STEPS

Learning Points • Start with political “buy-in” and leadership (from policy development to implementation and evaluation) • E. g. Formation of Regional Health Systems • Continually remove ‘silos’ and ‘fragmentation’ within various working bodies: § Change mental model and create new skills amongst professionals: • Collaboration; Creating “win-win” solutions and approaches § Incentivize integration via common funding streams • E. g. Integrated care pilots enabled integration between acute hospitals and community providers via a common funding stream • Start with specific patient populations and demonstrate“quick wins”; evaluate outcomes & apply to future endeavors; adapt where possible; • E. g. Virtual Hospital, ACTION (Aged Care Transition), SPICE (Singapore Programme for Integrated Care for Elderly) • Shared IT systems play a great role in enabling integration • E. g. National Electronic Health Records- extending access to Community providers and Primary care practitioners

Next Steps for Us • Improve public perception of community care services • Further align financial models to sustain care integration • Capitated models • “Pay-for-Performance” or outcome-based payments • Develop a standardized needs assessment framework to right site patients to appropriate community care service • Increase involvement of General Practitioners to deliver holistic care for elderly in community • Leverage on technology as a tool to integrate care. Examples of ongoing pilots include: • Singapore Integrated Diabetic Retinopathy Programme (Tele-Ophthalmic Service for Diabetic Retinopathy Screening) • Tele-geriatrics Programme (Tele-consultation for Nursing Home patients by Geriatrician from Acute Hospital)

THANK YOU Prof Chee Yam Cheng: yam_cheng_chee@nhg. com. sg Dr Jason Cheah: Jason. Cheah@aic. sg

Bibliography (1) • Journal References • Ada C. Mui. The Program of All-Inclusive Care for the Elderly (PACE)- An Innovative Long-Term Care • • • Model in the United States. Journal of Aging & Social Policy 2002. Volume 13, Issue 2 -3. Alwan A et al. Monitoring and surveillance of chronic non-communicable diseases: progress and capacity in high-burden countries. The Lancet, 2010, 376: 1861– 1868. Coleman EA, Boult C; American Geriatrics Society Health Care Systems Committee. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc 2003; 51: 556 -7. Coxon K. Common experiences of staff working in integrated health and social care organisations: a European perspective. Journal of Integrated Care 2005; 13(2): 13– 21. Hammar T, Rissanen P, Perälä ML. (2009) The cost-effectiveness of integrated home care and discharge practice for home care patients. Health Policy. 92(1): 10 -20. Hirth et al (2009) Program of All-Inclusive Care (PACE): Past, Present and Future; J Am Med Dir Assoc 2009; 10: 155 -160 Huey Ling Pang, Loong Mun Wong, Faezah Shaikh, Harbans Kaur Integrating aged care in Singapore—the ACTION framework” International Journal of Integrated Care. 2010 Oct-Dec; 10(Suppl): e 101. Kodner DL. All together now: a conceptual exploration of integrated care. Healthcare Quarterly (Toronto, Ont. ) 2009, 13 Spec No: 6 -15 Murray M. Process improvement and supply and demand: the elements that underlie integration. Healthc Q 2009. 13 Spec No: 37 -42. Peikes D, Chen A, Shore J, Brown R. (2009) Effects of care coordination on hospitalization, quality of care and health care expenditures among Medicare beneficiaries. JAMA; 301(6): 603– 18. Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M. Comprehensive discharge planning in the hospitalized elderly: a randomized clinical trial. Ann Intern Med 1994; 120: 999 -1006. Suter E, Oelke ND, Adair CE, Armitage GD Ten key principles for successful health systems integration. Healthc Q 2009. Oct; 13 Spec No: 16 -23. World Health Organization (WHO). (1996) Integration of health care delivery: report of a study group. Geneva, Switzerland: WHO; Technical Report series, No. 861.

Bibliography (2) • Website References • Agency for Integrated Care – www. aic. sg • International Journal for Integrated Care - www. ijic. org • Ministry of Health, Singapore- www. moh. gov. sg • National Healthcare Group- https: //corp. nhg. com. sg/RHS/Pages/RHS-for-the- Central-Region. aspx • Singapore Silver Pages- www. aic. sg/silverpages/ • Tan Tock Seng Hospital, community health programmes- https: //www. ttsh. com. sg/community-health-programmes/