NHG Health BRIDGE: Right-Siting Chronic Disease Care from Hospital to Primary Care Through the Rainbow Model for Integrated Care

Background: Launched in 2023, Healthier SG¹ allows Singapore residents to enrol with primary care providers (PCPs) at polyclinics or GP clinics, who develop individualised health plans for preventive care and chronic disease management. NHG Health is a regional health manager for 1.5 million residents in Singapore's Central North region. Between April 2024 and March 2025, over 100,000 patients were discharged from the Specialist Outpatient Clinics (SOCs) of its three acute hospitals.

 

While these patients should ideally follow up with their enrolled PCP², existing patterns indicate that systemic factors result in discharge to alternative PCPs. Enhanced discharge pathways are thus necessary to improve care continuity and outcomes.

 

Objective: /Aim: This paper applies Valentijn’s Rainbow Model for Integrated Care (RMIC) framework³ to examine how NHG Health’s BRIDGE programme (BRIDGE) operationalises integrated care principles in tertiary-to-primary transitions. RMIC encompasses dual focus on person-focused and population-based care across comprehensive macro, meso, and micro dimensions³.

 

Approach: BRIDGE coordinates patients’ care transitions from SOCs, emergency departments, and inpatient care across three acute hospitals to PCPs. This analysis reviews SOC transitions within BRIDGE, which features systematic discharge through clinical tracks with practice guidelines for capability building. Key components include right-siting officers (RSOs), virtual professional consultation, and drug subsidies designed to balance patient costs with sustainable financing.

 

Key Findings/Implications: BRIDGE's principles to ensure seamless patient transitions between NHG Health's acute hospitals and PCPs demonstrate strong organisational systems and normative integration

RSOs coordinate care transitions across 52 clinical tracks, counsel patients on discharge, and provide PCPs with comprehensive patient care management plans (including required medications). When needed, RSOs facilitate specialist-GP communication for collaborative review. This dual mechanism achieves functional and professional integration, resolving traditional discharge communication gaps that fragment care. Further improvement requires enhanced normative integration to strengthen stronger organisational commitment and increase specialists’ awareness of patients’ PCP enrolment status.

 

Person-centred care integration shows mixed implementation. While multidisciplinary assessments incorporate patient preferences and social circumstances into discharge decisions, patient participation in right-siting varies across clinical tracks, with some patients having limited awareness of their enrolment status or its significance in their care continuity.

 

Clinical integration demonstrates robust implementation through harmonised practice guidelines and standardised re-escalation pathways ensuring seamless care continuity. However, functional integration faces challenges from information system interoperability issues between NHG Health's electronic medical records and diverse GP clinic management systems, despite National Electronic Health Record availability, requiring manual coordination by RSOs.

 

Conclusion: BRIDGE represents a significant partnership initiative strengthening primary care delivery and optimising patient care pathways across NHG Health’s network. The programme has demonstrated high efficacy, with less than 5% patients re-escalating to SOCs within one year of discharge, suggesting strong patient and PCP relationships as patients remain their chronic care with their family doctor. The conceptual evaluation using the RMIC framework demonstrates strong alignment across multiple integration dimensions.

 

Future system enhancements, including decision support tools to guide specialists in selecting appropriate primary care discharge destinations, could further enhance both patient experience and efficiency of right-siting process.