Challenges and opportunities in pragmatic implementation of a holistic hospital care model in Singapore: A mixed-method case study

Abstract

Introduction Hospital-based practices today remain predominantly disease-oriented, focusing on individual clinical specialties with less visibility on a comprehensive picture of each patient’s health needs. To tackle the challenge of growing multimorbidity worldwide, practices without disease-specific focus have shown better integration of services. However, as we move away from the familiar disease-specific approaches of care delivery, many of us are still learning how to implement generalist care in a cost-effective manner. Methods This mixed-method case study, which centred on a specialist-led General Medicine model implemented at an acute hospital in Singapore, aimed to (1) quantitatively summarise its clinical outcomes, and (2) qualitatively describe the challenges and lessons gathered from the pragmatic implementation of the care model. Quantitative hospital data were extracted from databases and summarised. Qualitative staff-reported experiences and insights were gathered through semi-structured interviews and analysed using thematic analysis. Results Quantitative findings revealed that the generalist care model was implemented with high fidelity, where more than 75% of patients admitted were placed under General Medicine’s or General Surgery’s care. The mean length of stay was 2.6 days, and the 30-day post-discharge readmission rate was 15%. Inpatient mortality rate was found to be 2.8%, and the average gross hospitalisation bill amounted to SGD3,085.30. For qualitative findings, themes concerning feasibility and operational aspects of the implementation were grouped into categories- (1) Feasibility of ‘One Care Team’ approach, (2) Enablers required for meaningful generalist care, (3) Challenges surrounding information sharing, (4) Lack of integration with the community to facilitate care transition, and (5) Evolving roles of self-management. The findings were rich, with some being identified as barriers that could benefit from system-level de-constraining. Discussion This case study was an illustration of our pursuit for an integrated solution to rising prevalence of multimorbidity. While quantitative findings indicated that a pivot towards General Medicine might be possible, data also revealed gaps in clinical outcomes, especially in readmission rates. These findings corroborated with much of the lessons and challenges gathered from qualitative interviews, specifically surrounding the lack of receptacles in the community to facilitate care transition, training, and competency of generalists in holistic management of complex multimorbid cases, as well as inadequate infrastructure to allow information sharing between providers. Thus, a multi-pronged approach might be required to develop a new and sustainable care model for patients with multimorbidity in the long run. In the short to medium transitional period, nonetheless, the specialist-led General Medicine care model demonstrated might be a viable interim approach, especially in circumstances where trained medical generalists remained limited.

Characterization of Patients with Chronic Diseases and Complex Care Needs: A New High-Risk Emergent Population

“…Most of today's doctors are trained in a 'hi-tech' culture of care, but we probably need to recover our atavistic roots and off er 'hi-touch' medicine as well. On the other hand, the current institutional culture of hospitals must also adapt to this new reality by off ering more friendly care to these emerging populations, such as active policies to promote and maintain autonomy, assuring an optimal night's rest, a correct nutrition by adapting textures and avoiding prolonged fasting, or rationalizing and improving the timetables for administering medicines or extracting blood samples [31][32][33].…”

Barriers and Facilitators to Implementing Interventions for Reducing Avoidable Hospital Readmission: Systematic Review of Qualitative Studies

“…Updated literature search for potential qualitative studies from March 2020 to October 2021 identified 5 additional studies that were considered eligible (Supplementary file 4). A total of thirteen qualitative studies, 9,10,[23][24][25][26][27][28][29][30][31][32][33] were included. Details of literature search and study selection are presented in Figure 2.…”

“…Lai 2021, Singapore 24 To examine the challenges and lessons in implementing a holistic care model at a regional acute hospital and its community partners for reducing readmission.…”

“…Variations in individual judgement affected outcome of the readmission reduction interventions. 24 N/A Cost • Operating and maintenance costs of the supporting system pose a challenge to intervention implementation. 33 N/A Outer setting…”

Comparison of health care delivery system between Pakistan and Singapore

“…Further, the ascent in medicinal services cost is another test that requires government mention to give quality consideration at least cost. In conclusion barely any wellbeing specialists have identified that the quality of essential human services office is low in nation thusly individuals like to go to private medicinal services where cost is high[30,31]. CONCLUSION This paper underlined medicinal services conveyance arrangement of Pakistan in contrast with Singapore pursued by hierarchical structure, investigation of both the medicinal services frameworks, and proposals to improve social insurance change and its usage.…”