General medicine at the frontline of acute care delivery: Comparison with family medicine hospitalist model implementation in Singapore

Abstract

Introduction This mixed methods study seeks to assess the clinical outcomes and qualitative insights associated with the pragmatic implementation of a general medicine (GM) physician-led inpatient care model, first at Alexandra Hospital (AH) and then at Sengkang General Hospital (SKH), and to compare them with findings reported in an earlier implementation of the family medicine (FM) hospitalist model in Singapore. Methods Anonymous quantitative demographic and clinical data including length of stay, 30-day readmission rate, inpatient mortality rate and gross cost of hospitalisation bills were extracted from the hospital information system. Comparative analyses with the FM hospitalist model and usual care were made. Secondary qualitative data that were gathered focused on increased understanding of the proposed model, its perceived challenges and future opportunities for its implementation. Results The adapted GM care model implemented first at AH and then at SKH seemed to suggest that such a model run by physicians from various backgrounds was capable of producing similarly superior outcomes when compared with the FM hospitalist model piloted in 2011, which was juxtaposed with usual care. With regard to qualitative insights, three findings were reported: (a) perception of and mindset in relation to generalists, which illustrates the barriers to implementing GM; (b) education and training of generalists, which underlines the current lack of adequate supply of GM specialists; and (c) operational issues of care model implementation, which highlights the current mismatches between the prevailing healthcare philosophy and the requirements for successful implementation of the GM care model. Conclusion The success of a GM care model hinges on how it is operationalised. With clear protocols, definitions, and a high level of protocol compliance by healthcare team members, the intended outcomes show promise for replication at other interested sites.

Performance management of generalist care for hospitalised multimorbid patients—a scoping review for value-based care

“…For example, the sub-groups of patients that are selected for integrated generalist care programs in various hospitals may have similar levels of less critical generalist needs, and the process of care and patient outcome measures could potentially be benchmarked. Examples of these programs would be the Integrated General Hospital at Alexandra Hospital ( 3 ) and Integrated General Medicine at Singapore General Hospital in Singapore ( 7 ).…”

“…One such implementation of generalist inpatient care is the Integrated General Hospital care model which was launched in 2018 ( 6 ). Following that, another acute hospital implemented a specialist-led General Medicine care model, reported in a 2021 publication ( 3 , 7 ). Value-based care is also beginning to take root in the Singapore healthcare system.…”

Community hospitals of the future—challenges and opportunities

“…However, there is a paucity of research regarding the barriers and facilitators for the implementation of integrated care models in CHs, as most research efforts have explored and evaluated such care models in the AH setting ( 13 , 20 ). To guide the envisioned delivery of such a model of care in CHs—termed Community Hospitals of the Future (CHoF), this study aims to explore the challenges that CHs face, to uncover future opportunities for CHs that would guide the conceptualization of CHoF, and to shift CHs to meet the needs of an aging population and rising multimorbidity.…”

“…It also highlighted that generalist clinicians are well placed to provide for complex care needs that span across multiple conditions, and specialist care can be provided as needed through multidisciplinary teams (13,16,17). While a generalist-led, integrated approach has shown to be effective in reducing hospital usage in patients with chronic diseases, cost savings from appropriate resourcing of care are rarely realized as integrated models of care are usually concentrated within the acute hospital setting with higher hospitalization costs (13,(17)(18)(19)(20). Community hospitals, on the other hand, have services to cater for subacute medical needs and are considered lower resourced with a lower average daily bill, positioning themselves as a prime candidate for integrated hospital care (21,22).…”