Transforming Community Care at Scale: Outcomes of Singapore’s Community Case Management Service in a National Cohort of Older Adults

Background: To promote ageing in place and reduce avoidable hospitalisations, Singapore has implemented the Community Case Management Service (CCMS) since 2018. This programme integrates health and social care services to address the complex and diverse needs of community-dwelling clients, while also alleviating caregiver burden. Although CCMS has been implemented nationwide, there is currently no local research that systematically examines clients’ outcomes following enrolment in CCMS. This study aimed to assess changes in clients’ functional, psychosocial, and clinical outcomes, and their risks related to resource utilisation and caregiver burden.

 

Approach: We conducted a retrospective pre-post study involving 673 clients enrolled in CCMS between April 2023 and March 2024. These clients completed interRAI Home Care assessments within one month prior to CCMS utilisation, and again prior to discharge from the programme. Needs-based recommendations from the interRAI assessments were used to guide personalised care planning under CCMS. Six outcome variables from the interRAI assessments were examined: fall risk, depressive symptoms, caregiver burden risk, vulnerability risk, institutionalisation risk, and risk of emergency department visits. Changes in the distribution of these categorical interRAI outcome variables between baseline and discharge were evaluated using the Stuart-Maxwell test of marginal homogeneity to determine whether significant shifts occurred.

 

Results: The mean age of clients was 73 years, and 51% were women. At baseline, 25.0% were at risk of falls, 42.6% exhibited depressive symptoms, 63.9% had caregiver burden risk, 22.5% had vulnerability risk, 29.0% were at risk of institutionalisation, and 64.5% were at risk of emergency department (ED) visits. The interval between baseline and discharge assessments ranged from 3 to 12 months, with a median of 5 months. Significant shifts in the distribution of four of the six outcome variables were detected between baseline and discharge assessments (all p<0.05), specifically in fall risk, depressive symptoms, caregiver burden risk, and risk of ED visits. Improvements were observed across these four outcome variables. At discharge, the number of clients assessed as having no falls in the past 90 days increased by 7.3%, no depressive symptoms by 13.7%, and lowest risk of ED visits by 9.2%, while the number of caregivers assessed as having high caregiver burden risk decreased by 21.1%. No significant changes were detected in the remaining two outcome variables: vulnerability and institutionalisation risks.

 

Implications: This study provides the first large-scale quantitative analysis of outcomes among older adults enrolled in CCMS. The findings suggest that participation in CCMS is associated with improvements that support independent ageing, including lower risks of falls and utilisation of acute emergency services, enhanced mental well-being, and alleviation of caregiver burden.

 

These outcomes highlight the potential of CCMS to enhance person-centred care through timely and coordinated interventions across health and social care sectors, particularly for clients with complex needs. To ensure sustained impact and inform future enhancements of Singapore’s integrated care strategy, ongoing evaluation is essential. This includes assessing the long-term effects of CCMS and understanding client and caregiver experiences.