Do healthcare needs-based population segments predict outcomes among the elderly? Findings from a prospective cohort study in an urbanized low-income community.

BACKGROUND: A rapidly ageing population with increasing prevalence of chronic disease presents policymakers the urgent task of tailoring healthcare services to optimally meet changing needs. While healthcare needs-based segmentation is a promising approach to efficiently assessing and responding to healthcare needs at the population level, it is not clear how available schemes perform in the context of community-based surveys administered by non-medically trained personnel. The aim of this prospective cohort, community setting study is to evaluate 4 segmentation schemes in terms of practicality and predictive validity for future health outcomes and service utilization. METHODS: A cohort was identified from a cross-sectional health and social characteristics survey of Singapore public rental housing residents aged 60 years and above. Baseline survey data was used to assign individuals into segments as defined by 4 predefined population segmentation schemes developed in Singapore, Delaware, Lombardy and North-West London. From electronic data records, mortality, hospital admissions, emergency department visits, and specialist outpatient clinic visits were assessed for 180 days after baseline segment assignment and compared to segment membership for each segmentation scheme. RESULTS: Of 1324 residents contacted, 928 agreed to participate in the survey (70% response). All subjects could be assigned an exclusive segment for each segmentation scheme. Individuals in more severe segments tended to have lower quality of life as assessed by the EQ-5D Index for health utility. All population segmentation schemes were observed to exhibit an ability to differentiate different levels of mortality and healthcare utilization. CONCLUSIONS: It is practical to assign individuals to healthcare needs-based population segments through community surveys by non-medically trained personnel. The resulting segments for all 4 schemes evaluated in this way have an ability to predict health outcomes and utilization over the medium term (180 days), with significant overlap for some segments. Healthcare needs-based segmentation schemes which are designed to guide action hold particular promise for promoting efficient allocation of services to meet the needs of salient population groups. Further evaluation is needed to determine if these schemes also predict responsiveness to interventions to meet needs implied by segment membership.

Factors associated with emergency room visits and hospitalisation amongst low-income public rental flat dwellers in Singapore.

BACKGROUND: In Singapore, a densely urbanised Asian society, more than 80% of the population stays in public housing estates and the majority (90%) own their own homes. For the needy who cannot afford home ownership, public rental flats are available. Staying in a public rental flat is associated with higher hospital readmission rates and poorer access to health services. We sought to examine sociodemographic factors associated with hospital admissions and emergency room visits amongst public rental flat residents. METHODS: We surveyed all residents aged ≥60 years in a public rental housing precinct in central Singapore in 2016. Residents self-reported their number of emergency room visits, as well as hospitalisations, in the past 6 months. We obtained information on residents' sociodemographic characteristics, medical, functional and social status via standardised questionnaires. We used chi-square to identify associations between emergency room visits/hospitalisations and sociodemographic characteristics, on univariate analysis; and logistic regression for multivariate analysis. RESULTS: Of 1324 contactable residents, 928 participated in the survey, with a response rate of 70.1%. A total of 928 residents participated in our study, of which 59.5% were male (553/928) and 51.2% (476/928) were ≥ 70 years old. Around 9% (83/928) of residents had visited the emergency room in the last 6 months; while 10.5% (100/928) had been admitted to hospital in the past 6 months. On multivariable analysis, being religious (aOR = 0.43, 95%CI = 0.24-0.76) and having seen a primary care practitioner in the last 6 months (aOR = 0.46, 95%CI = 0.27-0.80) were independently associated with lower odds of emergency room visits, whereas loneliness (aOR = 1.96, 95%CI = 1.13-3.43), poorer coping (aOR = 1.72, 95%CI = 1.01-3.03) and better adherence (aOR = 2.23, 95%CI = 1.29-3.83) were independently associated with higher odds of emergency room visits. For hospitalisations, similarly poorer coping (aOR = 1.85, 95%CI = 1.12-3.07), better adherence (aOR = 1.69, 95%CI = 1.04-2.75) and poorer functional status (aOR = 1.85, 95%CI = 1.15-2.98) were all independently associated with higher odds of hospitalisations, whereas those who were religious (aOR = 0.62, 95%CI = 0.37-0.99) and those who were currently employed (aOR = 0.46, 95%CI = 0.37-0.99) had lower odds of being hospitalised. CONCLUSION: In this public rental flat population, functional status, coping and adherence, and having a religion were independently associated with emergency room visits and hospitalisation. Residents who had seen a primary care practitioner in the last 6 months had lower odds of visiting the emergency room.

A systematic review of health status, health seeking behaviour and healthcare utilisation of low socioeconomic status populations in urban Singapore.

INTRODUCTION: It is well-established that low socioeconomic status (SES) influences one's health status, morbidity and mortality. Housing type has been used as an indicator of SES and social determinant of health in some studies. In Singapore, home ownership is among the highest in the world. Citizens who have no other housing options are offered heavily subsidised rental housings. Residents staying in such rental housings are characterised by low socioeconomic status. Our aim is to review studies on the association between staying in public rental housing in Singapore and health status. METHODS: A PubMed and Scopus search was conducted in January 2017 to identify suitable articles published from 1 January 2000 to 31 January 2017. Only studies that were done on Singapore public rental housing communities were included for review. A total of 14 articles including 4 prospective studies, 8 cross-sectional studies and 2 retrospective cohort studies were obtained for the review. Topics addressed by these studies included: (1) Health status; (2) Health seeking behaviour; (3) Healthcare utilisation. RESULTS: Staying in public rental housing was found to be associated with poorer health status and outcomes. They had lower participation in health screening, preferred alternative medicine practitioners to western-trained doctors for primary care, and had increased hospital utilisation. Several studies performed qualitative interviews to explore the causes of disparity and concern about cost was one of the common cited reason. CONCLUSION: Staying in public rental housing appears to be a risk marker of poorer health and this may have important public health implications. Understanding the causes of disparity will require more qualitative studies which in turn will guide interventions and the evaluation of their effectiveness in improving health outcome of this sub-population of patients.

Anti-hypertensive medications and injurious falls in an older population of low socioeconomic status: a nested case-control study.

BACKGROUND: This study aimed to determine whether the number of anti-hypertensive medication classes or any change in anti-hypertensive medication were associated with injurious fall among the community-dwelling older population of low socioeconomic status. METHODS: Using data from electronic medical records, we performed a nested case-control study among older Singapore residents (≥60) of low socioeconomic status (N = 210). Controls (n = 162) were matched to each case (n = 48) by age and gender. Variables with p < 0.10 in univariate analysis were included in multivariate analysis. We used conditional logistic regression to assess the associations of the number of anti-hypertensive medication classes and change in anti-hypertensive medication with injurious falls. We also performed stepwise regressions as sensitivity analyses. p < 0.05 was considered statistically significant. RESULTS: The mean (±SD) age of participants was 78.1 (± 8.33) years; 127 (60.4%) were female, 189 (90.0%) were Chinese. Those on ≥2 anti-hypertensive medication classes had an increased risk of experiencing an injurious fall compared to those not on any anti-hypertensive medication (OR = 5.45; CI:1.49-19.93; p = 0.01). Among those who were taking anti-hypertensive medication, those who had a change in the medication 180-day prior to injurious fall had a significantly increased risk of experiencing an injurious fall compared to those that did not report any change in anti-hypertensive medication (OR = 3.88; CI:1.23-12.19; p = 0.02). Sensitivity analyses generated consistent findings. CONCLUSION: Both ≥2 anti-hypertensive medication classes and change in anti-hypertensive medication were associated with an increased risk of experiencing an injurious fall among the older population of low socioeconomic status. Our findings could guide prescribers to exercise caution in the initiation of anti-hypertensive medications or in making medication changes, especially among the older population of low socioeconomic status.

FAM-FACE-SG: a score for risk stratification of frequent hospital admitters.

BACKGROUND: An accurate risk stratification tool is critical in identifying patients who are at high risk of frequent hospital readmissions. While 30-day hospital readmissions have been widely studied, there is increasing interest in identifying potential high-cost users or frequent hospital admitters. In this study, we aimed to derive and validate a risk stratification tool to predict frequent hospital admitters. METHODS: We conducted a retrospective cohort study using the readily available clinical and administrative data from the electronic health records of a tertiary hospital in Singapore. The primary outcome was chosen as three or more inpatient readmissions within 12 months of index discharge. We used univariable and multivariable logistic regression models to build a frequent hospital admission risk score (FAM-FACE-SG) by incorporating demographics, indicators of socioeconomic status, prior healthcare utilization, markers of acute illness burden and markers of chronic illness burden. We further validated the risk score on a separate dataset and compared its performance with the LACE index using the receiver operating characteristic analysis. RESULTS: Our study included 25,244 patients, with 70% randomly selected patients for risk score derivation and the remaining 30% for validation. Overall, 4,322 patients (17.1%) met the outcome. The final FAM-FACE-SG score consisted of nine components: Furosemide (Intravenous 40 mg and above during index admission); Admissions in past one year; Medifund (Required financial assistance); Frequent emergency department (ED) use (≥3 ED visits in 6 month before index admission); Anti-depressants in past one year; Charlson comorbidity index; End Stage Renal Failure on Dialysis; Subsidized ward stay; and Geriatric patient or not. In the experiments, the FAM-FACE-SG score had good discriminative ability with an area under the curve (AUC) of 0.839 (95% confidence interval [CI]: 0.825-0.853) for risk prediction of frequent hospital admission. In comparison, the LACE index only achieved an AUC of 0.761 (0.745-0.777). CONCLUSIONS: The FAM-FACE-SG score shows strong potential for implementation to provide near real-time prediction of frequent admissions. It may serve as the first step to identify high risk patients to receive resource intensive interventions.

Effectiveness of a transitional home care program in reducing acute hospital utilization: a quasi-experimental study.

BACKGROUND: Improving healthcare utilization is essential as health systems around the world grapple with the escalating demands for acute hospital resources. Evidence suggests that transitional care programs are effective to improve utilization of healthcare. However, the evidence for transitional care programs that enhance the home medical care model and provide multi-disciplinary patient-centered care is not well established. We evaluated if a transitional home care program operated by the Singapore General Hospital was effective in reducing acute hospital utilization. METHODS: We performed a quasi-experimental study using a pre-post design to evaluate the effectiveness of a transitional home care program in reducing hospital admissions and emergency department attendances of medically complex patients enrolled into the program in a tertiary hospital in Singapore. Patients received a comprehensive needs assessment performed by the physician and a nurse case manager in the home setting, followed by an individualized care plan that included medical and nursing care, patient education and coordination of care with hospital specialists and community services. Primary study outcomes were emergency department attendances and hospital admissions to all hospitals. These were extracted from hospital administrative data and national health records. Wilcoxon Signed Ranks Test was used for assess differences in pre and post continuous data. RESULTS: Overall, 262 patients were enrolled into the program and 259 were analyzed. Patients had a 51.6% and 52.8% reduction in hospital admissions in the three-month and six-month post enrollment, respectively. Similarly, a 47.1% and 48.2% reduction was observed for emergency department attendances in the three and six months post enrollment, respectively. The average difference in per patient hospital bed days in the pre- and post-enrollment periods were 12.05 days and 20.03 days at the 3-month and 6-month periods, respectively. CONCLUSIONS: Patients enrolled in the transitional home care program had significantly lower acute hospital utilization through the reduction of emergency department attendances and hospital admissions. A comprehensive assessment of patients' medical and social needs in the home setting and formulation of an individualized care plan optimized post-discharge care for medically complex patients.

A historical perspective of the barriers to generalism.

BACKGROUND: As early as the late 19th century, there were calls to give greater emphasis to general practice. The momentum picked up after the Second World War. The voices calling for more generalism reached a crescendo in the late 1960s. Optimism was very high in the following two decades. Today, there is a pervasive sense of lost opportunity as generalism continues to languish behind the increasing momentum of specialisation of medicine. OBJECTIVE: This article is a view of generalism through the lens of history. It seeks to understand and draw lessons from the slow progress of generalism in the light of the forces that have shaped its development through the years. DISCUSSION: The tensions between sectors that promote generalism continue to this day. The ongoing antagonism between the plough, the town and the gown remains a dominant factor that shapes the path to generalism. Political activism seems to be an effective tool in promoting greater generalism.

Applicability of a previously validated readmission predictive index in medical patients in Singapore: a retrospective study.

BACKGROUND: Hospital readmissions are serious and costly events, and readmission rates are considered to be an indicator of quality in health care management. Several models to identify patients at risk of unplanned readmissions have been developed in Western countries, but little is known about their performance in other countries. This paper reports the possible utility of one such model developed in Canada, the LACE index, in patients in a tertiary hospital in Singapore. METHODS: We used administrative data from Singapore General Hospital for patients admitted between 1st January 2006 and 31st December 2010. Data such as demographic and clinical data including disease codes were extracted. The patient cohort was divided into two groups with a LACE index of 10 as the cutoff. Multivariate logistic regression analysis models were used to compare the outcomes between the two groups of patients with adjustment for age, sex, ethnicity, year of discharge, intensive care unit admission, and admission ward class. RESULTS: Overall, 127 550 patients were eligible for analysis. Patients with a LACE index ≥ 10 had a higher risk of 30-day unplanned readmission after index discharge (odds ratio [OR]: 4.37; 95% confidence interval [CI]: 4.18-4.57). After adjustment, the risk remained significant (OR: 4.88; 95% CI: CI 4.57-5.22). The C-statistic for the adjusted model was 0.70 (P < 0.001). Similar results were shown for 90-day unplanned readmission and emergency visits after the same adjustment. CONCLUSION: The use of the LACE index may have significant application in identifying medical patients at high risk of readmission and visits to the Emergency Department in Singapore.

Implementation of social prescribing: lessons learnt from contextualising an intervention in a community hospital in Singapore.

The need to develop holistic public health approaches that go beyond treating the biological causes of ill health, to addressing the social determinants of health, have been highlighted in the global health agenda. Social prescribing, where care professionals link individuals to community resources that tackle social needs have gained increasing traction worldwide. In Singapore, SingHealth Community Hospitals introduced social prescribing in July 2019 to manage the complex health and social needs of the aging populace. Faced with the paucity of evidence on the effectiveness of social prescribing and its implementation, implementers had to contextualise the theory of social prescribing to patients' needs and setting of practice. Using an iterative approach, the implementation team constantly reviewed and adapted practices, work processes and outcome measurement tools based on data and stakeholder feedback to address implementation challenges. As social prescribing continues to scale in Singapore and take root in the Western Pacific region, agile implementation and continued evaluation of programmes to build an evidence pool will help to guide best practices. The aim of this paper is to review the implementation of a social prescribing programme from the exploratory phase to full implementation, and draw lessons learned in the process.

Lessons learned from the hospital to home community care program in Singapore and the supporting AI multiple readmissions prediction model.

In a prior practice and policy article published in Healthcare Science, we introduced the deployed application of an artificial intelligence (AI) model to predict longer-term inpatient readmissions to guide community care interventions for patients with complex conditions in the context of Singapore's Hospital to Home (H2H) program that has been operating since 2017. In this follow on practice and policy article, we further elaborate on Singapore's H2H program and care model, and its supporting AI model for multiple readmission prediction, in the following ways: (1) by providing updates on the AI and supporting information systems, (2) by reporting on customer engagement and related service delivery outcomes including staff-related time savings and patient benefits in terms of bed days saved, (3) by sharing lessons learned with respect to (i) analytics challenges encountered due to the high degree of heterogeneity and resulting variability of the data set associated with the population of program participants, (ii) balancing competing needs for simpler and stable predictive models versus continuing to further enhance models and add yet more predictive variables, and (iii) the complications of continuing to make model changes when the AI part of the system is highly interlinked with supporting clinical information systems, (4) by highlighting how this H2H effort supported broader Covid-19 response efforts across Singapore's public healthcare system, and finally (5) by commenting on how the experiences and related capabilities acquired from running this H2H program and related community care model and supporting AI prediction model are expected to contribute to the next wave of Singapore's public healthcare efforts from 2023 onwards. For the convenience of the reader, some content that introduces the H2H program and the multiple readmissions AI prediction model that previously appeared in the prior Healthcare Science publication is repeated at the beginning of this article.

A qualitative study of challenges and enablers faced by private general practitioners providing primary care to patients with complex needs in Singapore.

BACKGROUND: Singapore faces an ageing population with increasingly complex healthcare needs, a problem which could be addressed by high quality primary care. Many patients with complex needs are not managed by private general practitioners (GPs) who form the majority of the primary care workforce. Currently, there is paucity of literature describing the needs of these private GPs in providing such care. AIM: Understand the challenges, enablers and possible solutions from the perspective of private GPs in providing primary care of patients with complex needs. METHOD: We conducted a qualitative study using an inductive approach. Private GPs were interviewed using a semi-structured question guide with convenience sampling until thematic saturation was reached. These 12 interviewees were part of a network of clinics that provide primary care for complex patients who were recently discharged from a community hospital providing post-acute care. Data was transcribed prior to a process of familiarisation, coded and analysed using thematic analysis by three independent investigators. RESULTS: Three themes emerged in the analysis. From a micro-organizational standpoint, private GPs and patients with complex needs must be willing to accept each other to have a therapeutic encounter (e.g., patients' multidimensional needs, GP clinic set-up is simple yet busy). Next, from a meso-organizational view, trust and good communication channels between the referring doctors and private GPs must exist for effective collaboration in managing complex care. Lastly, macro-organizationally, external stakeholders (e.g., policy-makers) should fund care models, which are financially viable to both patients, and private GPs (e.g., via adequate subsidies and renumeration respectively) as such complex care require many resources. CONCLUSION: Multiple factors exist which influence the ability of private GPs in Singapore to care for patients with complex needs. Addressing these factors may reduce the over dependence on high-cost hospitals for care delivery in similar healthcare systems.

Global developments in social prescribing.

Social prescribing is an approach that aims to improve health and well-being. It connects individuals to non-clinical services and supports that address social needs, such as those related to loneliness, housing instability and mental health. At the person level, social prescribing can give individuals the knowledge, skills, motivation and confidence to manage their own health and well-being. At the society level, it can facilitate greater collaboration across health, social, and community sectors to promote integrated care and move beyond the traditional biomedical model of health. While the term social prescribing was first popularised in the UK, this practice has become more prevalent and widely publicised internationally over the last decade. This paper aims to illuminate the ways social prescribing has been conceptualised and implemented across 17 countries in Europe, Asia, Australia and North America. We draw from the 'Beyond the Building Blocks' framework to describe the essential inputs for adopting social prescribing into policy and practice, related to service delivery; social determinants and household production of health; workforce; leadership and governance; financing, community organisations and societal partnerships; health technology; and information, learning and accountability. Cross-cutting lessons can inform country and regional efforts to tailor social prescribing models to best support local needs.

Could peak proteinuria determine whether patient with dengue fever develop dengue hemorrhagic/dengue shock syndrome?--a prospective cohort study.

BACKGROUND: Worldwide there is a need to develop simple effective predictors that can distinguish whether a patient will progress from dengue fever (DF) to life threatening dengue hemorrhagic (DHF) or dengue shock syndrome (DSS). We explored whether proteinuria could be used as such a marker. METHODS: We included patients admitted to hospital with suspected dengue fever. Starting at enrollment until discharge, each patient's daily spot urine protein creatinine ratio (UPCR) was measured. We classified those with confirmed dengue infection as DF or DHF (including DSS) based on WHO criteria. Peak and day of onset of proteinuria was compared between both groups. RESULTS: Compared to those with DF, patients with DHF had significantly higher median peak proteinuria levels (0.56 versus 0.08 g/day; p < 0.001). For patients with DHF, the median day of onset of proteinuria was at 6 days of defervescence, with a range of -2 to +3 days after defervescence. There were three patients with DF who did not have proteinuria during their illness; the five remaining patients with DF had a median day of onset of proteinuria of was at 6 days of defervescence with a range of 0 to +28 days. CONCLUSIONS: Peak UPCR could potentially predict DHF in patients with dengue requiring close monitoring and treatment.

Health-seeking behaviour of the elderly living alone in an urbanised low-income community in Singapore.

INTRODUCTION: Elderly persons who live alone are more likely to be socially isolated and at increased risk of adverse health outcomes, unnecessary hospital re-admissions and premature mortality. We aimed to understand the health-seeking behaviour of elderly persons living alone in public rental housing in Singapore. METHODS: In-depth interviews were conducted using a semi-structured question guide. Participants were selected using a purposive sampling approach. Interviews were conducted until theme saturation was reached. Qualitative data collected was analysed using manual thematic coding methods. RESULTS: Data analysis revealed five major themes: accessibility of healthcare services and financial assistance schemes; perceived high cost of care; self-management; self-reliance; and mismatch between perceived needs and services. CONCLUSION: Elderly persons living in one-room rental flats are a resilient and resourceful group that values self-reliance and independence. Most of the elderly who live alone develop self-coping mechanisms to meet their healthcare needs rather than seek formal medical consultation. The insightful findings from this study should be taken into consideration when models of healthcare delivery are being reviewed and designed so as to support the disadvantaged elderly living alone.

Attitudes towards the doctor-patient relationship: a prospective study in an Asian medical school.

CONTEXT: Patient-centredness is an accepted guiding principle for health system reform, patient care and medical education. Although these attitudes are strongly linked with cultural values, few studies have examined attitudes towards patient-centredness in a cross-cultural setting. OBJECTIVES: This prospective study evaluated attitudes towards patient-centredness in a cohort of Asian medical students and examined changes in these attitudes in the same students on completion of their junior clinical clerkships. METHODS: The study was conducted in a cohort of 228 medical students entering Year 3 in medical school. The Patient-Practitioner Orientation Scale (PPOS), a validated instrument which scores an individual's level of patient-centredness, was used. RESULTS: Being female and having personal experience of continuing care were significantly associated with higher scores. Students in the USA were previously reported to have similar 'caring' but higher 'sharing' scores on the same scale. At the end of the junior clinical clerkship, there were improvements in the 'caring' subscale, but no change or a reduction in 'sharing'. Students who did not have previous personal experience with continuing care experienced a greater increase in overall PPOS score. CONCLUSIONS: When compared with students in the USA, the students in our study appear to have a lower propensity to view the doctor-patient relationship as a partnership. This may be a reflection of differences in cultural norms and expectations of doctor-patient interaction in different societies. Our finding that attitudes towards patient-centredness did not decline over the course of the year, which contrasts with findings of other studies, may be attributed to various factors and warrants further study.

The hospitalist movement--a complex adaptive response to fragmentation of care in hospitals.

The increasing complexity of healthcare is accelerating the rate of specialisation in medicine, which in turn aggravates the fragmentation of care in hospitals. The hospitalist movement advocates for the return of generalist physicians to the hospital to provide general and more holistic medical care to inpatients. This can be seen as an adaptive response to care fragmentation. Starting in the mid-1990s in North America, where the impact of healthcare complexity and fragmentation has been most widely felt, the hospital movement has gained strength and spread across the continent rapidly. This paper examines the phenomenon of the hospitalist movement in the United States, Canada and Singapore. The conclusion is that variants of the hospital movement may emerge in different parts of the world as healthcare systems adapt to common global trends that drive the increasing complexity of healthcare.

Frequent hospital admissions in Singapore: clinical risk factors and impact of socioeconomic status.

INTRODUCTION: Frequent admitters to hospitals are high-cost patients who strain finite healthcare resources. However, the exact risk factors for frequent admissions, which can be used to guide risk stratification and design effective interventions locally, remain unknown. Our study aimed to identify the clinical and sociodemographic risk factors associated with frequent hospital admissions in Singapore. METHODS: An observational study was conducted using retrospective 2014 data from the administrative database at Singapore General Hospital, Singapore. Variables were identified a priori and included patient demographics, comorbidities, prior healthcare utilisation, and clinical and laboratory variables during the index admission. Multivariate logistic regression analysis was used to identify independent risk factors for frequent admissions. RESULTS: A total of 16,306 unique patients were analysed and 1,640 (10.1%) patients were classified as frequent admitters. On multivariate logistic regression, 16 variables were independently associated with frequent hospital admissions, including age, cerebrovascular disease, history of malignancy, haemoglobin, serum creatinine, serum albumin, and number of specialist outpatient clinic visits, emergency department visits, admissions preceding index admission and medications dispensed at discharge. Patients staying in public rental housing had a 30% higher risk of being a frequent admitter after adjusting for demographics and clinical conditions. CONCLUSION: Our study, the first in our knowledge to examine the clinical risk factors for frequent admissions in Singapore, validated the use of public rental housing as a sensitive indicator of area-level socioeconomic status in Singapore. These risk factors can be used to identify high-risk patients in the hospital so that they can receive interventions that reduce readmission risk.

Evaluating a novel Integrated Community of Care (ICoC) for patients from an urbanised low-income community in Singapore using the participatory action research (PAR) methodology: a study protocol.

INTRODUCTION: Poorer health outcomes and disproportionate healthcare use in socioeconomically disadvantaged patients is well established. However, there is sparse literature on effective integrated care interventions that specifically target these high-risk individuals. The Integrated Community of Care (ICoC) is a novel care model that integrates hospital-based transitional care with health and social care in the community for high-risk individuals living in socially deprived communities. This study aims to evaluate the effectiveness of the ICoC in reducing acute hospital use and investigate the implementation process and its effects on clinical outcomes using a mixed-methods participatory action research (PAR) approach. METHODS AND ANALYSIS: This is a single-centre prospective, controlled, observational study performed in the SingHealth Regional Health System. A total of 250 eligible patients from an urbanised low-income community in Singapore will be enrolled during their index hospitalisation. Our PAR model combines two research components: quantitative and qualitative, at different phases of the intervention. Outcomes of acute hospital use and health-related quality of life are compared with controls, at 30 days and 1 year. The qualitative study aims at developing a more context-specific social ecological model of health behaviour. This model will identify how influences within one's social environment: individual, interpersonal, organisational, community and policy factors affect people's experiences and behaviours during care transitions from hospital to home. Knowledge on the operational aspects of ICoC will enrich our evidence-based strategies to understand the impact of the ICoC. The blending of qualitative and quantitative mixed methods recognises the dynamic implementation processes as well as the complex and evolving needs of community stakeholders in shaping outcomes. ETHICS AND DISSEMINATION: Ethics approval was granted by the SingHealth Centralised Institutional Review Board (CIRB 2015/2277). The findings from this study will be disseminated by publications in peer-reviewed journals, scientific meetings and presentations to government policy-makers. TRIAL REGISTRATION NUMBER: NCT02678273.

Performance of the LACE index to identify elderly patients at high risk for hospital readmission in Singapore.

Unplanned readmissions may be avoided by accurate risk prediction and appropriate resources could be allocated to high risk patients. The Length of stay, Acuity of admission, Charlson comorbidity index, Emergency department visits in past six months (LACE) index was developed to predict hospital readmissions in Canada. In this study, we assessed the performance of the LACE index in a Singaporean cohort by identifying elderly patients at high risk of 30-day readmissions. We further investigated the use of additional risk factors in improving readmission prediction performance.Data were extracted from the hospital's electronic health records (EHR) for all elderly patients ≥ 65 years, with alive-discharge episodes from Singapore General Hospital in 2014. In addition to LACE, we also collected patients' data during the index admission, including demographics, medical history, laboratory results, and previous medical utilization.Among the 17,006 patients analyzed, 2051 or 12.1% of them were observed 30-day readmissions. The final predictive model was better than the LACE index in terms of discriminative ability; c-statistic of LACE index and final logistic regression model was 0.595 and 0.628, respectively.The LACE index had poor discriminative ability in identifying elderly patients at high risk of 30-day readmission, even if it was augmented with additional risk factors. Further studies should be conducted to discover additional factors that may enable more accurate and timely identification of patients at elevated risk of readmissions, so that necessary preventive actions can be taken.