RESUMO
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 (ß= -0.01, p-value = 0.35) and EQ VAS score (ß=-0.03, p-value = 0.99) had no change. Compared to baseline, there were improvements in CASP-19 total score at 3 months (ß = 1.34, p-value = 0.05) and 6 months post-enrolment (ß = 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 (ß = 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.
Assuntos
Participação do Paciente , Qualidade de Vida , Idoso , Humanos , Assistência Centrada no Paciente , Estudos Prospectivos , Singapura/epidemiologiaRESUMO
BACKGROUND: There is increasing interest in examining the life space mobility and activity participation of older adults in the community using sensor technology. Objective data from these technologies may overcome the limitations of self-reported surveys especially in older adults with age-associated cognitive impairment. This paper describes the development and validation of a prototype hybrid mobility tracker for assessing life space mobility and out-of-home activities amongst 33 community-ambulant older adults in Singapore. METHODS: A hybrid mobility tracker was developed by combining a passive Global Positioning System logger, tri-axial accelerometer and radio-frequency identification. Objective measures of life space, derived from 1 week of tracking data using Geographic Information Systems, were the maximum Euclidean distance from home (Max Euclid) and the area of the minimum convex polygon surrounding all GPS waypoints (MCP area). Out-of-home activities were quantified by visually identifying the total number of activity nodes, or places where participants spent ≥5 min, from mobility tracks. Self-reported measure of life space in 4 weeks was obtained using the University of Alabama at Birmingham Study of Life Space Assessment (UAB-LSA) questionnaire. Self-reported out-of-home activities were recorded daily in a travel diary for 1 week. Bivariate correlations were used to examine convergent validity between objective and subjective measures of life space and out-of-home activities. RESULTS: The mean age of participants was 69.2 ± 7.1 years. The mean UAB-LSA total score was 79.1 ± 17.4. The median (range) Max Euclid was 2.44 km (0.26-7.50) per day, and the median (range) MCP area was 3.31 km2 (0.03-34.23) per day. The UAB-LSA total score had good correlation with Max Euclid (r = 0.51, p = 0.002), and moderate correlation with MCP area (r = 0.46, p = 0.007). The median (range) total number of activity nodes measured by tracker of 20 (8-47) per week had a good correlation with the total activity count recorded in the travel diaries of 15 (6-40) per week (r = 0.52, p = 0.002). CONCLUSIONS: The tracking system developed to understand out-of-home travel was feasible and reliable. Comparisons with the UAB-LSA and travel diaries showed that it provided reliable and valid spatiotemporal data to assess the life space mobility and activity participation of older adults.
Assuntos
Atividades Cotidianas , Avaliação Geriátrica , Idoso , Humanos , Limitação da Mobilidade , Autorrelato , Singapura/epidemiologia , Inquéritos e QuestionáriosRESUMO
Background: Singapore's health care system is strained by the health care needs of a rapidly aging population. The unprecedented collaboration between a public hospital and a private family practice to set up the Family Medicine Clinic (FMC) to co-manage patients with chronic disease is an example of efforts to shift care to the community. Objective: To explore patients' initial experience of shared chronic disease care in a private family practice setting. Methods: In this exploratory case study, we surveyed 330 patients with stable chronic diseases and interviewed 10 complex care patients and their caregivers. Results: Most patients were willing to transfer their care from the hospital to a FMC and satisfied with the care received. Patients reported enhanced access at FMC and appreciated the improvement in care continuity and care coordination across settings. Patients with complex care needs felt engaged with their case manager even though they did not understand case management. Despite the favourable assessment of FMC, patients sought care from other health care providers and a third of patients would leave if the subsidy for their care at FMC was removed. Families and caregivers felt that their needs could be better addressed and that FMC could play a role. Conclusions: To ensure that patients' initial positive experience translates to a long-term relationship with FMC, providers should move beyond providing improved access to care. It is necessary to help patients understand the comparative advantage of community-based care and its contribution to long-term health outcomes. Providers should also elicit patients' desires and expectations when designing future models of care. At a policy level, higher cost of private primary care should be addressed.
Assuntos
Doença Crônica/terapia , Centros Comunitários de Saúde , Continuidade da Assistência ao Paciente/organização & administração , Medicina de Família e Comunidade , Hospitais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos de Casos Organizacionais , Atenção Primária à Saúde , Parcerias Público-Privadas , Singapura , Inquéritos e QuestionáriosRESUMO
The global ageing population is associated with increased health service use. The PCMH care model integrates primary care and home-based care management to deliver comprehensive and personalised healthcare to community-dwelling older adults with bio-psycho-social needs. We examined if an integrated PCMH reduced healthcare utilisation burden of older persons in Singapore. We compared the healthcare utilisation between the intervention group and coarsened exact matched controls for a follow-up of 15 months. Baseline matching covariates included socio-demographics, health status, and past healthcare use. We accounted for COVID-19 social distancing effects on health-seeking behaviour. The intervention group consisted of 165 older adults with complex needs. We analysed national administrative healthcare utilisation data from 2017 to 2020. We applied multivariable zero-inflated regression modelling and presented findings stratified by high (CCI ≥ 5) and low disease burden (CCI < 5). Compared to controls, there were significant reductions in emergency department (ß = -0.85; 95%CI = -1.55 to -0.14) and primary care visits (ß = -1.70; 95%CI = -2.17 to -1.22) and a decrease in specialist outpatient visits (ß = -0.29; 95%CI = -0.64 to 0.07) in the 3-month period immediately after one-year enrolment. The number of acute hospitalisations remained stable. Compared to controls, the intervention group with high and low comorbidity burden had significant decreases in primary care use, while only those with lower comorbidity burden had significant reductions in utilisation of other service types. An integrated PCMH appears beneficial in reducing healthcare utilisation for older persons with complex needs after 1 year in the programme. Future research can explore longer-term utilisation and scalability of the care model.
Assuntos
Atenção à Saúde , Vida Independente , Humanos , Idoso , Idoso de 80 Anos ou mais , Estudos Prospectivos , Singapura/epidemiologia , Aceitação pelo Paciente de Cuidados de Saúde , Hospitalização , Assistência Centrada no PacienteRESUMO
INTRODUCTION: Falls are an important public health issue with consequences that include injuries, quality of life reduction and high healthcare costs. Studies show that falls prevention strategies are effective in reducing falls rate among community-dwelling older adults. However, the evaluation for effectiveness was usually done in a controlled setting with homogeneous population, and thus may not be generalisable to a wider population. This study aims to evaluate the impact of community falls prevention programmes with group-based strength and balance exercises, on falls risk and health outcomes for older adults with falls risk in Singapore. METHODS AND ANALYSIS: This is a pragmatic closed cohort stepped-wedge cluster randomised trial design study, which involves sequential crossover of clusters from the waitlist control condition to the intervention condition, with the sequence of crossover randomly determined. The intervention will be sequentially rolled out to 12 clusters (a minimum of 5 participants/cluster), over 6 time periods with 8-week intervals in Central and North regions of Singapore. The primary analysis will be conducted under the intention-to-treat principle. A general linear mixed model or generalised estimating equation analysis appropriate for a multilevel longitudinal study incorporating an appropriate error distribution and link function will be used. Markov model will be developed to estimate the incremental cost per quality-adjusted life years and incremental cost per fall prevented from the implementation of falls prevention strategies from a societal perspective. Conditional on there being clinically relevant differences in short-term outcomes, we will implement simulation modelling to project the long-term divergence in trajectories for outcomes and costs using the Markov model. ETHICS AND DISSEMINATION: Ethics approval has been obtained. Results will be disseminated in publications and other relevant platforms. TRIAL REGISTRATION NUMBER: NCT04788251.
Assuntos
Terapia por Exercício , Qualidade de Vida , Humanos , Idoso , Estudos Longitudinais , Singapura , Terapia por Exercício/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Multicêntricos como AssuntoRESUMO
Within the hair follicle (HF) niche, dermal papilla (DP) cells are well known for the hair induction capacity; however, DP cell signaling also regulates HF pigmentation. Here we describe how Sox2 in the DP is a key regulator of melanocyte signaling. To study the largely unknown regulatory role the DP has on hair pigmentation, we characterize leptin receptor (Lepr) expression in the skin and as a genetic tool to target the DP. Sox2 ablation in the DP results in a phenotypic switch from eumelanin to pheomelanin. Mechanistically, we describe a temporal upregulation of Agouti and downregulation of Corin, directly by Sox2 in the DP. We also show that bone morphogenic protein (BMP) signaling regulation by Sox2 is responsible for downregulating MC1R, Dct, and Tyr in melanocytes of Sox2 cKO mice. Thus, we demonstrate that Sox2 in the DP regulates not only the choice of hair pigment but also the overall HF pigment production.
Assuntos
Folículo Piloso , Cabelo , Animais , Folículo Piloso/metabolismo , Camundongos , Pigmentação , Transdução de Sinais/fisiologia , Pele/metabolismoRESUMO
Patient-Centred Medical Home (PCMH) is a strategy to enhance patient-centredness to improve care experience. We aimed to understand patient experience of an integrated PCMH model for complex community-dwelling older adults in Singapore. We used a mixed-method design with a prospective single-group pre-post quantitative component and a concurrent qualitative component. Participants were administered the validated Consumer Assessment of Health Providers and Systems Clinician & Group Survey (CG-CAHPS) at baseline (N = 184) and 6-month (N = 166) post-enrolment. We conducted focus group discussions (FGDs) on a purposive sample of 24 participants. Both methods suggest better care experience in PCMH relative to usual care. There were improvements in the CG-CAHPS measures on patient-provider communication, care coordination, office staff interactions, support for patients in caring for their own health, and provider rating in PCMH relative to usual care. In the FGDs, participants reported benefits of consolidated appointments and positive experience in sustained patient-provider relationship, shared-decision making, and family/caregiver engagement in PCMH. Participants may not fully comprehend the concept of integrated care, hindering both the effective communication of the intended care model and perceived benefits such as the provision of multidisciplinary team-based care.
Assuntos
Vida Independente , Satisfação do Paciente , Idoso , Humanos , Assistência Centrada no Paciente/métodos , Estudos Prospectivos , SingapuraRESUMO
Patient-Centered Medical Home (PCMH) has been found to improve care for complex needs patients in some countries but has not yet been widely adopted in Singapore. This study explored the ground-up implementation of a PCMH in Singapore by describing change strategies and unpacking initial experience and perception. In-depth interviews were conducted for twenty-two key informants from three groups: the implementers, their implementation partners, and other providers. "Diffusion of innovations" emerged as an overarching theory to contextualize PCMH in its early implementation. Three core "innovations" differentiated the PCMH from usual primary care: (i) team-based and integrated care; (ii) empanelment; and (iii) shared care with other general practitioners. Change strategies employed to implement these innovations included repurposing pre-existing resources, building a partnership to create supporting infrastructure and pathways in the delivery system, and doing targeted outreach to introduce the PCMH. Initial experience and perception were characterized by processes to "adopt" and "assimilate" the innovations, which were identified as challenging due to less predictable, self-organizing behaviors by multiple players. To work with the inherent complexity and novelty of the innovations, time, leadership, standardized methods, direct communication, and awareness-building efforts are needed. This study was retrospectively registered (Protocol ID: NCT04594967).