A study on the effect of engagement and empowerment of community dwelling adults by Wellbeing Coordinators on their healthcare utilization

Background: SingHealth envisions a population where seniors are empowered and actively involved in their health. This involves providing person-centred care and addressing the Social Determinants of Health of residents, which are fundamental to reduce health disparities and improve health outcomes.

To achieve this vision and objective, SingHealth developed and deployed Wellbeing Coordinators (WBCs), who act as health and social care integrators to journey closely with residents in the community.

 

Approach: SingHealth WBCs are trained laypersons deployed as part of place-based community care teams to screen residents for their health and social needs, co-develop health goals with residents, help ensure their adherence to health plans and appointments, conduct health coaching, and connect them with community partners and resources based on their identified health and social needs. These residents include those who are well, at-risk, with chronic conditions, and those recently discharged from the hospital requiring care transition support back into the community. The WBCs follow up closely with residents at their homes or at one of 120 Community Health Posts across the Eastern region of Singapore.

 

A retrospective study was conducted to evaluate the impact by WBCs under Changi General Hospital’s (CGH) Neighbours For Active Living programme on healthcare utilisation of 2,794 clients enrolled from 2021 to 2023 where 90% of them are seniors aged 60 years and above. The healthcare utilization of these clients at 6-month pre-enrolment (6MPre) period was compared to that of clients in the 7th to 12th month post-enrolment (6MPost) period.

 

Results: Compared to 6MPre period, clients supported by CGH WBCs showed a significant reduction in mean ED visits in 6MPost period from 1.59 to 0.82 (p<0.01). Significant reductions in mean inpatient admissions (from 1.36 to 0.58, p<0.01) and total inpatient length of stay from 10.50 to 4.91, p<0.01) were also observed in the study population. In contrast, there was significant increase in mean visits to Specialist Outpatient Clinics (SOCs) in the study population (3.89 to 4.68, p<0.01)

 

Implications: The study highlighted the value of trained laypersons such as WBCs in supporting residents in their health journey in the community. Through educating and nudging residents to adhere to their health plans and medication, guiding them in adopting health-seeking behaviours, addressing Social Determinants of Health, and timely escalation to other healthcare professionals to provide required support in the community, WBCs can help to reduce avoidable ED visits and inpatient admissions. The increase in mean visits to SOCs could reflect the effectiveness of WBCs in ensuring that residents adhere to follow-up appointments.

 

Trained laypersons such as WBCs thus can play a key role that complements the established roles of clinicians and nurses as part of Multi-Disciplinary Teams in contributing to better health outcomes. SingHealth will continue to develop and deploy WBCs as part of our place-based community care teams to support our residents.