Service utilisation patterns prior to nursing home admission among older adults in Singapore: A retrospective cohort study

Background: In Singapore, where national policies prioritise family support and community-based services, admission to subsidised nursing home (NH) care is pursued only after other support options have been exhausted. Understanding healthcare and community service utilisation patterns before NH admission can reveal opportunities for early intervention and enhancement of community care pathways, enabling older adults to be cared for in the community for as long as possible. This study uses de-identified data to examine the utilisation of acute and home- and centre-based services (HCBS) among older adults before NH admission.

 

Approach: We conducted a retrospective observational cohort study of Singapore residents aged 60 and above admitted to NHs between 1 January and 31 December 2024. Service utilisation patterns over the two years preceding NH admissions were analysed, focusing on: (a) inpatient care and specialist outpatient clinic (SOC) visits at public hospitals, and (b) HCBS. Home care services included home medical, home nursing, home therapy, and home personal care; centre-based services included centre-based nursing, community rehabilitation, day care, and dementia day care.

 

Results: A total of approximately 3,700 older adults were newly admitted to NHs in 2024. Approximately 94.4% had at least one inpatient stay over the 24 months before NH admission. Among those hospitalised (n=3,506), 39.7% had inpatient stays in both the 1st-to-12th and 13th-to-24th month periods prior to NH admission, while 57.8% had inpatient stays only in the 1st-to-12th month period. SOC visits were also common, with 80.1% having at least one visit in the 24 months before NH admission.

 

Among those with SOC visits (n=2,976), 71.7% had visits in both time periods, while 18.3% had visits only within the 1st-to-12th month period. The use of HCBS was less common, 36.2% had ever utilised HCBS in the 24 months before NH admission. Among this group (n=1,345), 61.4% utilised services in both the 1st-to-12th and 13th-to-24th month periods prior to NH admission, while 29.1% utilised services only in the 1st-to-12th month period. The three most frequently utilised services were home personal care, home nursing, and community rehabilitation. Nearly half (45.1%) of HCBS users utilised more than one type of service. Among non-HCBS users (n=2,369), 25.7% were referred to services but declined them, with “not keen or refused service” being the most common reason.

 

Implications: This study shows that most NH admits in Singapore are preceded by utilisation of hospital-based inpatient care. Most older adults also have not used HCBS before NH admission. These results highlight missed opportunities for HCBS to delay or prevent NH admissions. To mitigate this, Singapore will implement the Integrated Community Care Provider model which is designed to promote timely identification of care needs across care settings and facilitate HCBS coordination and delivery, thereby encouraging utilisation.

 

As care needs become more complex with age, older adults often require a range of services to effectively manage their health and functional issues. Our findings underscore the need for an integrated strategy to address the challenges faced by many countries striving to balance institutional and community care for ageing populations.