Communities of Care Approach: Developing a Place-based Model of Care and Building Partnerships in the Communities in Central Singapore.

The population in Singapore is ageing, adding pressure to community care as the health and social needs of its residents increase. This has accelerated the pace at which Regional Health Systems adopt and deliver its population health strategies from early prevention, chronic disease management, crisis care to end-of-life care. To this end, the Central Health Integrated Care Network (ICN) began its journey to develop Communities of Care (CoCs) with other health and social care partners to meet the needs of residents in the Central Zone of Singapore. This paper describes the processes and steps taken by Central Health ICN to build partnerships with other agencies and organisations to build place-based models of care in the local neighbourhoods. The faciliating factors and the barriers faced in the implementation of CoCs were described to allow sharing of such learnings on large scale change. Strategies in overcoming some of the challenges were also presented to demonstrate the iterative processes required in building integrated place-based models of care to meet the needs of the residents in different communities.

Using the Johns Hopkins ACG Case-Mix System for population segmentation in a hospital-based adult patient population in Singapore.

OBJECTIVE: Population health management involves risk characterisation and patient segmentation. Almost all population segmentation tools require comprehensive health information spanning the full care continuum. We assessed the utility of applying the ACG System as a population risk segmentation tool using only hospital data. DESIGN: Retrospective cohort study. SETTING: Tertiary hospital in central Singapore. PARTICIPANTS: 100 000 randomly selected adult patients from 1 January to 31 December 2017. INTERVENTION: Hospital encounters, diagnoses codes and medications prescribed to the participants were used as input data to the ACG System. PRIMARY AND SECONDARY OUTCOME MEASURES: Hospital costs, admission episodes and mortality of these patients in the subsequent year (2018) were used to assess the utility of ACG System outputs such as resource utilisation bands (RUBs) in stratifying patients and identifying high hospital care users. RESULTS: Patients placed in higher RUBs had higher prospective (2018) healthcare costs, and were more likely to have healthcare costs in the top five percentile, to have three or more hospital admissions, and to die in the subsequent year. A combination of RUBs and ACG System generated rank probability of high healthcare costs, age and gender that had good discriminatory ability for all three outcomes, with area under the receiver-operator characteristic curve (AUC) values of 0.827, 0.889 and 0.876, respectively. Application of machine learning methods improved AUCs marginally by about 0.02 in predicting the top five percentile of healthcare costs and death in the subsequent year. CONCLUSION: A population stratification and risk prediction tool can be used to appropriately segment populations in a hospital patient population even with incomplete clinical data.

Integrated palliative homecare in advanced dementia: reduced healthcare utilisation and costs.

OBJECTIVES: To determine the economic benefit of an integrated home-based palliative care programme for advanced dementia (Programme Dignity), evaluation is required. This study aimed to estimate Programme Dignity's average monthly cost from a provider's perspective; and compare healthcare utilisation and costs of programme patients with controls, accounting for enrolment duration. METHODS: This was a retrospective cohort study. Home-dwelling patients with advanced dementia (stage 7 on the functional assessment staging in Alzheimer's disease) with a history of pneumonia, albumin <35 g/L or tube-feeding and known to be deceased were analysed (Programme Dignity=184, controls=139). One-year programme operational costs were apportioned on a per patient-month basis. Cumulative healthcare utilisation and costs were examined at 1, 3 and 6 months look-back from death. Between-group comparisons used Poisson, zero-inflated Poisson regressions and generalised linear models. RESULTS: The average monthly programme cost was SGD$1311 (SGD-Pounds exchange rate: 0.481) per patient. Fully enrolled programme patients were less likely to visit the emergency department (incidence rate ratios (IRRs): 1 month=0.56; 3 months=0.19; 6 months=0.10; all p<0.001), be admitted to hospital (IRRs: 1 month=0.60; 3 months=0.19; 6 months=0.15; all p<0.001), had a lower cumulative length of stay (IRRs: 1 month=0.78; 3 months=0.49; 6 months=0.24; all p<0.001) and incurred lesser healthcare utilisation costs (ß-coefficients: 1 month=0.70; 3 months=0.40; 6 months=0.43; all p<0.01) at all time-points examined. CONCLUSION: Programme Dignity for advanced dementia reduces healthcare utilisation and costs. If scalable, it may benefit more patients wishing to remain at home at the end-of-life, allowing for a potentially sustainable care model to cope with rapid population ageing. It contributes to the evidence base of advanced dementia palliative care and informs healthcare policy making. Future studies should estimate informal caregiving costs for comprehensive economic evaluation.

Association of Deprescribing With Reduction in Mortality and Hospitalization: A Pragmatic Stepped-Wedge Cluster-Randomized Controlled Trial.

OBJECTIVES: Deprescribing has gained awareness recently, but the clinical benefits observed from randomized trials are limited. The aim of this study was to examine the effectiveness of a pharmacist-led 5-step team-care deprescribing intervention in nursing homes to reduce falls (fall risks and fall rates). Secondary aims include reducing mortality, number of hospitalized residents, pill burden, medication cost, and assessing the deprescribing acceptance rate. DESIGN: Pragmatic multicenter stepped-wedge cluster randomized controlled trial. SETTING AND PARTICIPANTS: Residents across 4 nursing homes in Singapore were included if they were aged 65 years and above, and taking 5 or more medications. METHODS: The intervention involved a 5-step deprescribing intervention, which involved a multidisciplinary team-care medication review with pharmacists, physicians, and nurses (in which pharmacists discussed with other team members the feasibility of deprescribing and implementation using the Beers and STOPP criteria) or to an active waitlist control for the first 3 months. RESULTS: Two hundred ninety-five residents from 4 nursing homes participated in the study from February 2017 to March 2018. At 6 months, the deprescribing intervention did not reduce falls. Subgroup analysis showed that intervention reduced fall risk scores within the deprescribing-naïve group by 0.18 (P = .04). Intervention was associated with a reduction in mortality [hazard ratio (HR) 0.16, 95% confidence interval 0.07, 0.41; P < .001] and number of hospitalized residents (HR 0.16, 95% CI 0.10, 0.26; P < .001). Pre-post analysis witnessed a reduction in pill burden at the end of the study, and a conservative daily cost saving estimate of US$11.42 (SG$15.65) for the study population. Approximately three-quarters of deprescribing interventions initiated by the pharmacists were accepted by the physicians. CONCLUSIONS AND IMPLICATIONS: Multidisciplinary medication review-directed deprescribing was associated with reductions in mortality and number of hospitalized residents in nursing homes and should be considered for all nursing home residents.

Epidemiological, Clinical, and Phylogenetic Characteristics of the First SARS-CoV-2 Transmission in a Nursing Home of Singapore: A Prospective Observational Investigation.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission has resulted in a significant burden among nursing home facilities globally. This prospective observational cohort study aims to define the potential sources of introduction and characteristics of SARS-CoV-2 transmission of the first nursing home facility in Singapore. An epidemiological serial point-prevalence survey of SARS-CoV-2 was conducted among 108 residents and 56 healthcare staff (HCS). In the current study, 14 (13%) residents and two (3.6%) HCS were diagnosed with coronavirus disease 2019 (COVID-19), with a case fatality rate (CFR) of 28.6% (4/14) among the residents. The median age of the infected residents was 86.5 [interquartile range (IQR) 78.5-88] and 85.7% were women. Five residents were symptomatic (35.7%) and the others were asymptomatic (64.3%). A higher proportion of residents who succumbed to COVID-19 had hypertension than those who recovered. The SARS-CoV-2 whole-genome sequencing showed lineage B.6 which is rare globally but common regionally during the early phase of the pandemic. Household transmission is a potential source of introduction into the nursing home, with at least six epidemiologically linked secondary cases. Male residents were less implicated due to the staff segregation plan by block. Among residents, a higher proportion of the non-survivors were asymptomatic and had hypertension compared with survivors.

Advanced dementia: an integrated homecare programme.

OBJECTIVES: We established an integrated palliative homecare programme for advanced dementia. This study explores patients' symptoms and quality-of-life and their association with enteral feeding, evaluates the impact of the programme on these parameters and examines familial caregiver burden. METHODS: This is a prospective cohort study. Patients at Functional Assessment Stage 7, with an albumin level <35 g/L, pneumonia or enteral feeding were recruited. At baseline and regular intervals, the multidisciplinary homecare team used the Pain Assessment in Advanced Dementia, Mini Nutritional Assessment and Neuropsychiatric Inventory Questionnaire (NPI-Q) to identify patients' symptoms, and the Quality of Life in Late-Stage Dementia (QUALID) tool to assess quality-of-life as primary outcomes, stratified by feeding status. The Zarit Burden Interview (ZBI) investigated caregiver burden, stratified by living arrangement and availability of stay-in help. Mann-Whitney U and χ2 tests compared continuous and categorical variables respectively between groups while Wilcoxon signed-rank test compared assessment scores at baseline and on review. RESULTS: At baseline, 49.2% of the 254 patients had pain, 92.5% were malnourished and 85.0% experienced neuropsychiatric challenges. Patients on enteral feeding had lower NPI-Q score (median=3; IQR 1-6) than orally fed patients ((median=4; IQR 2-7), p=0.004) and higher QUALID score (median=25; IQR 21-30 vs median=21; IQR 17-25 for orally fed patients), p<0.0001, indicating a better quality-of-life for orally fed patients. Both symptoms and quality-of-life improved significantly for the 53 patients reviewed at the fifth month. Median ZBI score for caregivers was 26 (IQR 15-36). Having stay-in help reduced it from 39.5 (IQR 25-49) to 25 (IQR 15-35), p=0.001. CONCLUSION: An integrated multidisciplinary palliative homecare team with geriatric training that is accessible all-hours addressed the needs of home-dwelling patients with advanced dementia, improved their quality-of-life and supported families to care for them at home.

Nursing home team-care deprescribing study: a stepped-wedge randomised controlled trial protocol.

INTRODUCTION: An ageing population has become an urgent concern for Asia in recent times. In nursing homes, polypharmacy has also become a compounding issue. Deprescribing practice is an evidence-based strategy to provide a better outcome in this group of patients; however, its implementation in nursing homes is often challenging, and prospective outcome data on deprescribing practice in the elderly is lacking. Our study assesses the implementation of team-care deprescribing to understand the benefits of this practice in geriatric setting and to explore the factors affecting deprescribing practice. METHODS AND ANALYSIS: This multicentre prospective study consists of a prestudy interview questionnaire, and a preintervention and postintervention study to be conducted in the nursing home setting on residents at least 65 years old and on five or more medications. We will employ a cluster randomised stepped-wedge interventional design, based on a five-step (reviewing, checking, discussion, communication and documentation) team-care deprescribing practice coupled with the use of a deprescribing guide (consisting of Beers and STOPP criteria, as well as drug interaction checking), to assess the health and pharmacoeconomic outcome in nursing homes' practice. Primary outcome measures of the intervention will consist of fall risks using a fall risk assessment tool. Other outcomes assessed include fall rates, pill burden including number of pills per day, number of doses per day and number of medications prescribed. Cost-related measures will include the use of cost-benefit analysis, which is calculated from the medication cost savings from deprescribing. For the prestudy interview questionnaire, findings will be analysed qualitatively using thematic analysis. ETHICS AND DISSEMINATION: This study is approved by the Domain Specific Review Board of National Healthcare Group, Singapore (2016/00422) and Monash University Human Research Ethics Committee (2016-1430-7791). The study findings shall be disseminated in international conferences and peer-reviewed publications. The study is registered with ClinicalTrials.gov (NCT02863341), Pre-results.

Economic impact analysis of an end-of-life programme for nursing home residents.

BACKGROUND: Due to limited end-of-life discussions and the absence of palliative care, hospitalisations are frequent at the end of life among nursing home residents in Singapore, resulting in high health-care costs. AIM: Our objective was to evaluate the economic impact of Project Care at the End-of-Life for Residents in homes for the Elderly (CARE) programme on nursing home residents compared to usual end-of-life care. DESIGN AND SETTINGS/PARTICIPANTS: Project CARE was introduced in seven nursing homes to provide advance care planning and palliative care for residents identified to be at risk of dying within 1 year. The cases consisted of nursing home residents enrolled in the Project CARE programme for at least 3 months. A historical group of nursing home residents not in any end-of-life care programme was chosen as the matched controls. Cost differences between the two groups were analysed over the last 3 months and final month of life. RESULTS: The final sample comprised 48 Project CARE cases and 197 controls. Compared to the controls, the cases were older with more comorbidities and higher nursing needs. After risk adjustment, Project CARE cases demonstrated per-resident cost savings of SGD$7129 (confidence interval: SGD$4544-SGD$9714) over the last 3 months of life and SGD$3703 (confidence interval: SGD$1848-SGD$5557) over the last month of life (US$1 = SGD$1.3). CONCLUSION: This study demonstrated substantial savings associated with an end-of-life programme. With a significant proportion of the population in Singapore requiring nursing home care in the near future, these results could assist policymakers and health-care providers in decision-making on allocation of health-care resources.

Validation of the care transition measure in multi-ethnic South-East Asia in Singapore.

BACKGROUND: The 15-item Care Transition Measure (CTM-15) is a measure for assessing the quality of care during transition from the patients' perspective. The purpose of this study was to test the psychometric properties of the CTM-15 and CTM-3 (a 3-item version of the CTM-15) in Singapore, a multi-ethnic urban state in South-east Asia. METHODS: A consecutive sample of patients was recruited from two tertiary hospitals. The subjects or their proxies were interviewed 3 weeks after discharge from hospital to home in English or Chinese using the CTM-15 questionnaire. Information about patients' visit to emergency department (ED), non-elective rehospitalisation for the condition of index hospitalisation, and care experience after discharge was also collected from respondents. Psychometric properties of CTM-15 and CTM-3 based on the five-point response scale (i.e. strongly disagree, disagree, neutral, agree, and strongly agree) and the three-point response scale (i.e. [strongly] agree, neutral, and [strongly] disagree) were tested for English and Chinese versions separately. Internal consistency reliability was assessed using Cronbach's alpha and construct validity was tested with T-test or Pearson's correlation by examining hypothesised association of CTM scores with ED visit, rehospitalisation, and experience with care after discharge. Exploratory factor analysis was performed to examine latent dimensions of CTM-15. RESULTS: A total of 414 (proxy: 96.1%) and 165 (proxy: 84.8%) subjects completed the interviews in English and Chinese, respectively. Cronbach's alpha values of the different CTM-15 versions ranged from 0.81 to 0.87. In contrast, Cronbach's alpha values of the CTM-3 ranged from 0.42 to 0.63. Both CTM-15 and CTM-3 were correlated with care experience after discharge regardless of survey language or response scale (Pearson's correlation coefficient: 0.36 to 0.46). Among the English-speaking respondents, the CTM-15 and CTM-3 scores based on both the three- and five-point response scales discriminated well between patients with and without ED visits or rehospitalisation for their index condition. Among Chinese-speaking respondents, no difference in CTM scores was observed between patients with and without ED visits or patients with and without rehospitalisation. The English and Chinese versions of the CTM-15 items demonstrated a similar 4-factor structure representing general care plan, medication, agreement on care plan, and specific care instructions. CONCLUSIONS: The care transition measure is a valid and reliable measure for quality of care transition in Singapore. Moreover, the care transition measure can be administered to proxies using a simpler response scale. The discriminatory power of the Chinese version of this instrument needs to be further tested in future studies.

Prevalence of pain in nursing home residents with different cognitive and communicative abilities.

OBJECTIVES: To determine the prevalence of pain and its impact among nursing homes residents with different cognitive and communication abilities. DESIGN: Cross-sectional study. SETTING: Three nursing homes in Singapore. PARTICIPANTS: Residents aged 65 years and above, without a recent change in their cognitive status. MEASUREMENTS: Self-reports were obtained whenever possible. Pain severity was measured with the Pain Assessment in Advanced Dementia scale (categorized version) among the uncommunicative. Residents were also assessed with the short-form version of the Geriatric Depression Scale, the Cornell Scale for Depression in Dementia, the state portion of the Spielberger State-Trait Anxiety Inventory, and the Human Activities Profile. RESULTS: Pain prevalence did not differ between the communicative resident with normal cognition (48.7%), mildly impaired cognition (46.5%), or severely impaired cognition (42.9%). However, the latter 2 groups reported more acute pain than those with normal cognition (7.9% to 14.1% vs. 2.5%). Those with impaired cognition reported constant pain more often, reported fewer total sites of pain, and had more frequent and more severe pain. Regardless of cognitive status, 73.3% to 100% of residents had significant scores on depression or anxiety measures when they reported pain-related mood disturbance. Pain-related reduction in activity was associated with a lower Human Activities Profile score. Sixteen of 36 uncommunicative residents had pain on the Pain Assessment in Advanced Dementia and at least 12 of them had significant mood disturbance. CONCLUSIONS: Cognitive status does not affect pain prevalence; however, it affects the chronicity and characteristics of reported pain. Self-report of pain-related mood involvement is associated with significant mood scores.

The use of a self-reported pain measure, a nurse-reported pain measure and the PAINAD in nursing home residents with moderate and severe dementia: a validation study.

OBJECTIVES: To assess the construct validity of three measures of pain and to determine a categorical version of the Pain Assessment in Advanced Dementia (PAINAD) scale. DESIGN: Validation study determining the concurrent validity of a self-reported pain score (SRPS), a nurse-reported pain score (NRPS) and the PAINAD; the divergent validity of the three pain measures with the Abbreviated Mental Test (AMT) and the Cornell Scale for Depression in Dementia (CSDD). SETTING AND SUBJECTS: eighty-eight nursing home residents with moderate and severe dementia. METHODS: Residents were asked to rate the severity of their pain in the previous week on a verbal descriptor scale (VDS). Nurses rated the resident's pain on a VDS, scored the PAINAD scale and the CSDD scale. Research assistants administered the AMT. RESULTS: The PAINAD correlated with the NRPS (Kendall's tau [tau] = 0.842); both scales correlated poorly with the SRPS (tau = 0.304 for both correlations). The PAINAD was significantly different for each level of the NRPS. On the SRPS, the PAINAD for the group with moderate+ pain was significantly different from the groups with mild pain and no pain. There was a difference between the SRPS and the NRPS when residents were depressed, but no difference when they were not. Our categorical version of the PAINAD showed good agreement with the NRPS. CONCLUSION: The NRPS and the PAINAD measure pain differently from the SRPS, especially in the presence of depression. Our categorical version of the PAINAD shows good agreement with the NRPS.

The challenge of providing holistic care in a viral epidemic: opportunities for palliative care.

OBJECTIVE: To determine, using the perspective of a hospital-based palliative care service (PCS), the spiritual and psychosocial impact of a novel and potentially fatal viral epidemic on patients, their families and health care workers. DESIGN: Qualitative study using semi-structured interviews. The data were analysed using the constant comparative method and were validated using respondent validation. PARTICIPANTS: Eight palliative care workers. SETTING: Tan Tock Seng Hospital (TTSH), the hospital designated to manage all cases of Severe Acute Respiratory Syndrome (SARS) in Singapore. RESULTS: Disease containment resulted in isolation, where isolation meant the disruption of connectedness. This disruption of connectedness took place at multiple levels: in the patient himself, between the patient and the family, within the family, between the patient and the health care worker, between the patient and society, and between health care workers. As the nature of the disease was uncertain, prognostication was inaccurate. This created difficulties in helping patients and their families prepare for death. The fear of facing the unknown led to safety-seeking behaviours, which could be overcome by repeated exposure to the feared situation. The process of bereavement was disturbed, as traditional death rituals could not be performed by the family. Informants perceived themselves to be suffering as they suffered the same anxieties, fears and grief as the patient. CONCLUSIONS: Dealing with a novel viral epidemic creates spiritual and psychosocial issues similar to those encountered in a palliative care practice. Palliative care workers would do well to be aware of such issues and act proactively when such epidemics arise.