Abstract
Background: A&E frequent attenders (FAs) are high utilisers of the healthcare system. In 2018, the top 60 A&E FAs made 1,279 visits to Khoo Teck Puat Hospital in the north of Singapore. This averaged 21.3 visits per individual, costing an estimated gross amount of S$508,000. Majority (77%) of these visits were of low acuity and did not result in hospital admission; 63% of these visits were respiratory related and 15% pain related.
Besides FAs, there is another distinct group of patients who are Alcohol-Related FAs (ARFAs). Since 2020, 37 ARFAs are engaged in a community-based intervention programme. Together, they made a total of 609 visits within one year prior to intervention. Of which, 32% are alcohol related.
Method & Implementation: A multidisciplinary case management team was formed to support these individuals. Case workers (community nurse and medical social workers), supported by the A&E doctors, engage FAs and ARFAs to address their medical and psychosocial issues within the community. They make home and community visits, provide psychosocial support and link up to community resources by collaborating with health and social care partners. Instead of the traditional clinic-based abstinence approach, the team applied Assertive Community Treatment (ACT) to ARFAs, focusing on harm reduction and proactive engagement. The team is also well supported by the National Addictions Management Service (NAMS) at the Institute of Mental Health.
The objectives of this community-based intervention for the A&E FAs and ARFAs are to reduce A&E visits and hospital admissions, and to optimise resources within the healthcare system.
Results: Between 2019 and 2022, 47 FAs have been enrolled and received at least 6 months of intervention. By comparing their pre- and post- hospital utilisations, a total of 705 A&E visits and 314 bed-days were avoided.
A total of 37 ARFAs have been intervened from 2020 to 2022. By comparing pre- and post- 1 year's utilisation, the A&E visits, ambulance calls and bed-days have declined by 14%, 9% and 18% respectively. On average, there is a reduction of 12.0 units of alcohol intake per individual (from 72.4 to 60.4 units). Two-thirds of enrolled ARFAs have a reduction of more than 25% A&E utilisation. There is also a significant improvement of their functional score i.e. Christo Inventory for Substance-misuse Services score, from 10.1 to 8.5 points per individual.
Other indirect benefits that are unquantifiable include improvements in the quality of life of these patients and their families as well as their contributions to society.
Learnings & Next Steps: Our study demonstrates that complex A&E FAs and ARFAs can be managed comprehensively by multidisciplinary teams and partners in the community. This programme effectively reduced inappropriate A&E visits, and achieved inpatient bed day avoidance.
Active screening and recruitment of potential patients is still underway. This community-based intervention is being expanded to other hospitals in Singapore.