The Community Healthcare Compass: Implementing a Community “Step-up” Model for Direct Access to Appropriate Healthcare Services

Background: Unnecessary hospital admissions are a global concern as they lower patient outcomes, strain limited healthcare resources, and increase financial burdens on health systems.

This project aimed to address this issue by implementing the National University Health System (NUHS) Community Care Team’s (CCT) “Step-up” model, which enables early detection and management of deterioration in the community, and supports appropriate care placement to reduce unnecessary admissions.

 

Approach: The model targets two patient groups:

1. Post-discharge patients referred to CCT from the hospital for transitional care management
2. Patients identified by community partners with health and social care needs

The model involves the following steps:

1. Early identification of at-risk residents by CCT Nurses or community partners
2. Prompt assessment by CCT Nurses
3. Timely case escalation to APNs or Clinicians
4. Rapid case review and decision-making
5. Direct referrals to appropriate services based on patient’s condition for admission (if required)
6. a) Community Hospital: for rehabilitation and subacute care
7. b) Acute Medical Unit in the Hospital: for acute medical conditions
8. c) Mobile Inpatient Care at Home (NUHS@Home): for acute medical conditions that can be managed in home care settings
9. d) Palliative Home Care Services: for palliative care
10. Stepped-down care with community and primary care collaboration

 

Through managing patients in the community or admitting them directly to appropriate services, unnecessary admissions can be avoided. This integrated model enables timely intervention, meets both medical and social needs, optimizes resources, and strengthens community-based support.

 

 

 

Results: Since its implementation in November 2024, the “Step-up” model has managed 175 case escalations to APNs/Clinicians, including 5 cases that were referred from community partners. Of the escalated cases, 48 patients averted ED admission through direct admission to a healthcare facility.

 

Implications: Key strengths of this model include:

1. Strong practical orientation: Move beyond theory to provide concrete pathways for early intervention and care right-siting.
2. Demonstrated impact: Reduce ED congestion and improve access to appropriate care settings.
3. Interdisciplinary approach: Involve community partners and healthcare professionals in the care process.
4. Clear structure: Well-defined admission streams and processes ensuring efficient care delivery.

The “Step-up” model is a replicable framework for building community-based healthcare systems that prioritize timely, appropriate care over hospital-centric approaches. It highlights the importance of collaboration between healthcare systems and community partners in delivering integrated, person-cantered care that is anchored in the community to drive sustainable change.

Lessons: and strategies from this project can empower healthcare professionals to implement similar community-anchored models in their own settings