Evaluating the Outcomes of a Hospital-to-Community Model of Integrated Care for Dementia

Abstract

<b><i>Introduction:</i></b> Living with dementia is challenging for persons with dementia (PWDs) and their families. Although multi-component intervention, underscored by the ethos of person-centred care, has been shown to maintain quality of life (QOL) in PWDs and caregivers, a lack of service integration can hinder effectiveness. <b><i>Methods:</i></b> CARITAS, an integrated care initiative provided through a hospital-community care partnership, endeavours to provide person-centred dementia care through ambulatory clinic consults, case management, patient and caregiver engagement, and support. We evaluated CARITAS’ clinical outcomes and cost-effectiveness with a naturalistic cross-sectional within-subject design. We assessed patients’ function, QOL, and behavioural problems post-intervention. We estimated CARITAS’ cost-effectiveness from a patient’s perspective, benchmarking it against other dementia treatments and Singapore’s Gross Domestic Product (GDP) per capita. <b><i>Results:</i></b> CARITAS care significantly improved health utility (<i>p</i> < 0.001), reduced caregiver burden (<i>p</i> < 0.001), and improved PWDs’ behavioural problems (<i>p</i> < 0.001) related to “memory” (<i>p</i> < 0.001), “disruption” (<i>p</i> = 0.017), and “depression” (<i>p</i> < 0.001). CARITAS’ benefits (<i>d</i><sub>RMBPC</sub> = 0.357, <i>d</i><sub>EQ5D index</sub> = 0.328, <i>d</i><sub>ZBI</sub> = 0.361) were comparable to those of other pharmacological and non-pharmacological interventions for dementia. CARITAS costs SG$133,056.69 per quality-adjusted life years gain, yielding an incremental cost-effectiveness ratio of 1.31 and 1.49 against the cost of donepezil in patients with mild Alz­heimer’s disease and Singapore’s GDP per capita in 2019, respectively, falling within the cost-effectiveness threshold of 1.0–3.0. <b><i>Discussion:</i></b> CARITAS integrated dementia care is a cost-effective intervention that showed promising outcomes for PWDs and their caregivers.

Integrated dementia care: A qualitative evidence synthesis of the experiences of people living with dementia, informal carers and healthcare professionals

“…Given previous studies describing integrated care as needing to be person-centred and the 'patient's perspective is at the heart of any discussion about integrated care' (Lloyd & Wait, 2005), exploratory studies with a focus on patient experience should be considered to develop a deeper understanding of what integrated dementia care means to those accessing services. Further, whilst quantitative studies exploring the impact of integrated dementia care interventions have shown some positive results, for example: improvements in memory; quality of life; mental health of the person living with dementia; and reduced carer 'burden' (Ha et al, 2020;Zwingmann et al, 2018), future studies using a mixed-methods approach may provide a more robust understanding of why some interventions work well and others do not.…”

Identifying Key Themes of Care Coordination for Patients with Chronic Conditions in Singapore: A Scoping Review

“…A handful of programmes described a focus on lowering hospital resource utilisation by supporting patients during care transitions (36%) [28,31,39,42,43,45,46,50,55,56], and facilitating referrals from the specialist outpatient clinics (SOCs) to primary care providers (PCPs) (18%) [28,39,40,51,54]. The remaining 13 articles (46%) aimed to optimise the management of specific chronic diseases [29,[31][32][33][34][35]37,45,46,49,50,52,53]. Importantly, heightened emphasis on reducing hospital resource utilisation and facilitating care transitions to lower levels of care aligns with the local vision of shifting care Beyond Hospital to Community.…”

“…Congruent to shifting care Beyond Hospital to Community, most of the initiatives reviewed provide care off-site, i.e., via phone calls or at patients' homes. Half of the articles reviewed depicted off-site care delivery [30,32,36,38,[41][42][43][44]47,48,[51][52][53]55], nine in the hospital setting [29,31,39,40,45,46,49,50,54] and three in primary care settings [34,35,37]. Only Ang et al and Ha et al, reported care delivery occurring in both hospital and primary care settings under the same respective programme [28,33].…”

“…Crucially, activities such as process optimisation and care innovation allow care coordination to be delivered cost-effectively and longitudinally while working within the constraints of limited programme funding [39,44,45,52,54]. Besides improving internal processes, collaborations with appropriate care partners across the care interfaces enhance accessibility to care for patients residing in the community requiring a range of services and can contain the cost of healthcare delivery [31,32,35,37,39]. This enables a shift beyond quality to value.…”

“…Therefore, the strength of partnership and trust between providers in the community and hospital specialists impact the uptake of care coordination initiatives and alignment of outcomes for both providers and patients [41,47]. Moreover, leveraging partnerships between private and community stakeholders, streamlining referral processes and adopting collaborative care models encompassing mutually agreed upon right-siting workstreams empowers the shift of care Beyond Hospital to Community [32,33,37,39,44,46,51,54,55].…”