The impact of community nursing program on healthcare utilization: A program evaluation.

BACKGROUND: The role of nurses has evolved to meet the dynamic needs of an aging population. Community nursing has been established in Singapore with the aim to anchor population health and provide sustainable healthcare services beyond the hospital to the community. Community nurses provide health services to residents at the Community Nurse Posts (CNP) situated within the heartland residential estates. OBJECTIVE: To investigate the effect on healthcare utilization six months pre and post first community nurse visit in older adults, and if the effect is modified by the presence of two or more community nurse visits or absence of a polyclinic chronic disease diagnosis. DESIGN: A single-group pretest-posttest study SETTING(S): Fifty-one SingHealth CNPs at the southeast and east regions of Singapore PARTICIPANTS: Community-dwelling older adults aged ≥ 60 years, seen at any of the SingHealth CNPs between 1 April and 30 November 2019. METHODS: The number of emergency department (ED) visits, unplanned inpatient admissions, length of inpatient stay, specialist outpatient clinic (SOC) and polyclinic visits at SingHealth institutions six months from the first community nurse visit were compared to six months prior. Negative binomial generalized estimating equations were used to model healthcare utilization events, adjusting for baseline age, gender, and race. RESULTS: 1,600 community-dwelling participants were included, of whom 1,561 (median age of 71 years) survived the post-test period. There was a population-average 23% lower rate of ED visits (incidence rate ratio 0.77, 95% confidence interval 0.68 to 0.87, p<0.001) and 15% lower rate of unplanned inpatient admissions (0.85, 0.75 to 0.96, p=0.011). A trend towards a lower rate of inpatient length of stay and a higher rate of SOC and polyclinic visits was also observed. The reduction in acute care utilization may have been greater among adults with two or more community nurse visits. Participants with no recent polyclinic chronic disease diagnosis had a greater increase in SOC visits. CONCLUSIONS: Community nursing services are associated with reduced acute care utilization, especially for older adults with two or more community nurse visits. The trend of a higher rate of SOC visits could be attributed to the community nurses' referrals for undiagnosed/ new conditions and/or treatment of suboptimal health issues. There is a potential role for community nursing towards a sustainable healthcare system.

Factors Influencing the Uptake of Seasonal Influenza Vaccination among Community-Dwelling Older Adults during COVID-19: A Mixed Methods Study.

Background: Despite making the influenza vaccine accessible and affordable, vaccination rates remained low among community-dwelling older adults. Therefore, this study aimed to explore the factors influencing vaccine uptake and the impact of COVID-19 on vaccine uptake among community-dwelling older adults in Singapore. Methods: A mixed methods study involving a survey and semi-structured interviews were conducted between September 2020 and July 2021. Community-dwelling older adults aged ≥ 65 years were recruited from 27 Community Nurse Posts. Data on participants' demographics, health condition(s), vaccination status, attitudes towards influenza infections and vaccinations, willingness to pay, intention for future vaccination and source of information were collected via the survey. Semi-structured interviews were conducted to understand vaccination experiences, key enablers and barriers, and the impact of COVID-19 on vaccine uptake. All interviews were analysed using Braun and Clarke's thematic analysis. Quantitative data were analysed using descriptive statistics, chi-square tests and multinomial logistic regressions. Results: A total of 235 participants completed the survey. Living arrangement was a statistically significant contributing factor for influenza vaccine uptake (ꭓ2= -0.139; p = 0.03). Participants who lived alone were 2.5 times more likely to be vaccinated than those living with others (OR = 2.504, 95% CI: 1.294-4.842, p = 0.006). Avoidance of getting infected (82.5%), avoidance of transmission to others (84.7%), and advice from healthcare professionals to receive vaccination (83.4%) were key enablers, while concerns about possible side effects (41.2%), the effectiveness of the vaccine (42.6%), and not having enough information (48.1%) were barriers. Twenty participants were interviewed. The findings were congruent with the survey results. Five themes were identified as follows: (1) Perceived importance of influenza vaccination, (2) Sphere of influence, (3) Healthcare schemes and medical subsidies, (4) Psychological impediments, and (5) Inconsistent emphases at various touch points. Conclusions: Greater public health efforts are needed to reach out to the larger population of older adults of different living arrangements and those concerned about the possible side effects and effectiveness of the influenza vaccine. Healthcare professionals need to provide more information to address these concerns, especially during COVID-19, to encourage vaccine uptake.