Impact of a patient-centered medical home demonstration on quality of life and patient activation for older adults with complex needs in Singapore

Abstract

Background The first Patient-Centered Medical Home (PCMH) demonstration in Singapore was launched in November 2016, which aimed to deliver integrated and patient-centered care for patients with bio-psycho-social needs. Implementation was guided by principles of comprehensiveness, coordinated care, shared decision-making, accessible services, and quality and safety. We aimed to investigate the impact of implementing the PCMH in primary care on quality of life (QoL) and patient activation. Methods The study design was a prospective single-arm pre-post study. We applied the 5-level EuroQol 5-dimension (EQ-5D-5L) and Visual Analog Scale (EQ VAS) instruments to assess health-related QoL. The CASP-19 tool was utilised to examine the degree that needs satisfaction was fulfilled in the domains of Control, Autonomy, Self-realisation, and Pleasure. The 13-item Patient Activation Measure (PAM-13) was used to evaluate knowledge, skills and confidence in management of conditions and ability to self-care. Multivariable linear regression models with random intercepts were applied to examine the impact of the PCMH intervention on outcome measures at 3 months and 6 months post-enrolment, compared to baseline. Results We analysed 165 study participants enrolled into the PCMH from November 2017 to April 2020, with mean age 77 years (SD: 9.9). Within-group pre-post (6 months) EQ-5D-5L Index (β= -0.01, p-value = 0.35) and EQ VAS score (β=-0.03, p-value = 0.99) had no change. Compared to baseline, there were improvements in CASP-19 total score at 3 months (β = 1.34, p-value = 0.05) and 6 months post-enrolment (β = 1.15, p-value = 0.08) that were marginally out of statistical significance. There was also a significant impact of the PCMH on the CASP-19 Pleasure domain (β = 0.62, p = 0.03) at 6 months post-enrolment, compared to baseline. We found improved patient activation from a 15.2 % reduction in the proportion of participants in lower PAM levels, and a 23.4 and 16.7 % rise in proportion for higher PAM levels 3 and 4, respectively, from 3 months to 6 months post-enrolment. Conclusions Preliminary demonstration of the PCMH model shows evidence of improved needs satisfaction and patient activation, with potential to have a greater impact after a longer intervention duration.

Cost analysis of a Patient-Centred Medical Home for community-dwelling older adults with complex needs in Singapore

“…A few knowledge gaps on the integrated PCMH model still exist. While integrated PCMH models have been shown to improve patient outcomes, 5,6 the impact on overall costs and the relative burden on various stakeholders (patients, healthcare providers and society at large) remain less well-understood. Existing literature has focused on costs to the healthcare system and providers, rather than costs from a patient-centric perspective.…”

“…12 The integrated PCMH care model in this study is part of a community-wide initiative (Community for Successful Ageing) on an integrated care system of comprehensive programmes and services promoting the well-being and health of older adults in Singapore. 6,13,14 Our integrated PCMH model differs from current advanced primary care models in Singapore that centres on a multidisciplinary team to deliver chronic disease management, 15 or Family Medicine Clinics that provide a "one-stop platform" for individualised chronic condition prevention and management by general practitioners. 16 The integrated PCMH model in this article targets community-dwelling older adults with complex biopsychosocial needs, assessed via social health, psychological and medical evaluations.…”

“…16 The integrated PCMH model in this article targets community-dwelling older adults with complex biopsychosocial needs, assessed via social health, psychological and medical evaluations. 6,13,14 Our model follows overarching principles on ageing in place (growing old at home), life-course approach (promoting the earlier implementation of interventions for health), socioecological model of care (health as an outcome of an individual's interaction with family, caregivers and community), and population health management. 6,13,14 Our study aimed to address gaps in the literature on the evaluation of costs associated with the implementation of an integrated PCMH model for community-dwelling older adults with complex needs.…”

“…6,13,14 Our model follows overarching principles on ageing in place (growing old at home), life-course approach (promoting the earlier implementation of interventions for health), socioecological model of care (health as an outcome of an individual's interaction with family, caregivers and community), and population health management. 6,13,14 Our study aimed to address gaps in the literature on the evaluation of costs associated with the implementation of an integrated PCMH model for community-dwelling older adults with complex needs. Our study examined costs not only from the health system perspective, but also from the perspectives of patients and the wider society.…”

Early Implementation of a Patient-Centered Medical Home in Singapore: A Qualitative Study Using Theory on Diffusion of Innovations

“…It was part of a larger research project that aimed to evaluate the impacts of the PCMH intervention on patient experience, quality of life, patient activation, healthcare utilization, and costs. Findings on the patient-reported outcomes have been published elsewhere [ 24 ]. This study adds to the larger research by providing an understanding of the implementation, through three research questions: What were the change strategies employed for implementing a new PCMH care model in Singapore?…”