Abstract
Introduction: Yishun Health’s Teleheath and Integrated Network (THINK) Centre is a nurse-led telehealth service for the continuity of patient care beyond hospital to community. It is an integral part of Yishun Health’s “First Gate” capability of a broad framework on client engagement, patient activation and supported self-management.
Target Population: It aims to be a central healthcare information and support hub for residents and caregivers of Yishun Health in the northern region of Singapore.
Partners and Interventions: Its key interventional strategies include 1) Care coordination and case management based on patient’s personalised care plan; 2) Connecting and empowering patient in self-management and enhancing health behaviour; 3) Support anticipatory care and managed escalations via a 24/7 tele-triage helpline.
A framework for transboundary care and escalation protocols was developed by THINK Centre to guide patients to access appropriate hospital, primary care, and home-based health services seamlessly. Using the framework, THINK Centre plays an integrating role in assisting hospital specialists and patients in co-creating and implementing post-discharge care plans at home. It engages specialist care teams to articulate clear self-care and escalation protocols for their target patient groups. Upon patients’ discharge, it connects and empowers patients and their caregivers at home through telephone to personalise their care and escalation plans according to the resource at their homes and communities. With the agreed achievable plans, education and support, patients and their caregivers gain confidence in self-management and care escalation, thereby reducing inappropriate healthcare utilisation.
Results: Care and escalation protocols were developed and successfully implemented for patients from general medical, geriatric, renal and ambulatory surgical units. From October 2020 to February 2023, 4480 patients were eligible, of which 2008 (45%) completed THINK intervention. Continuous quality improvement improved its reach from 30% of eligible patients to 68% over the 30-month period. Completed THINK patients had lower readmission at 30 days (9% vs 17%) and 180 days (25% vs 34%) than matched controls. Using the Anderson-Gill model, for every 100 completed THINK patients 7.5 admissions were avoided after 180 days. Inbound telephone triage accuracy was 89.7% for all disposition categories and 95.4% for emergency. Telephone triage nurse having community experience is a predictor of accurate triage (OR 18.4).
Learning Points: Close specialist-THINK Centre-patient partnership enabled integrated and personalised hospital-to-home care, thereby effectively reducing hospital readmissions. Starting small with well-defined groups identified by the specialists improved the adoption of service by clinical teams. Patient awareness and participation in co-creating and implementing care plans is critical for improving reach and effectiveness of the service. Proficiency in assessment of patients’ needs and resources in the community is an important skillset for telecare nurses.
Next Steps: Resource will be prioritised to scale up support for more specialty tracks. Leadership directions and initial implementation success increased hospital specialists’ confidence and commitment in extending their care beyond the hospital boundaries for more patient groups via THINK Centre. To improve productivity and sustainability, adoption of technology and development of accurate patient stratification tool to better identify patient suitable for telephonic interventions is needed.