Abstract
Background: Yishun Health (YH) is a regional hospital system caring for 300,000 people in the north of Singapore that has embarked on a multi-year, whole regional health system transformation to improve outcomes. This is based on the Unified Care Model (UCM) and its subsidiary Lifelong Care Model (LCM). Governance of this futuristic lifelong care system was defined by a Needs-Based Population Segmentation Model using the UCM Performance Framework. These provided our stakeholders the opportunity for every northern resident to have a unified ‘One Care Plan’ (OCP) by an accountable primary coordinating clinician operationalized within communities strengthened using asset-based community development principles.
In 2017, YH set up an Integrated Medical Clinic (IMC) in our Geriatric Clinic for elderly patients with an OCP run by geriatricians as the Primary Coordinating Doctor (PCD) to pilot selected lifelong care system concepts and design principles. Although encouraged by early results, attempts to spread IMC to primary care shared care partners and other specialties between 2019-2022 met with significant challenges and failed to scale. LCM deployment and scaling up is now being re-attempted in 2023 through a new IMC/PCD 2.0 using implementation science methods.
Methods: HSTP is our design, systems, and complexity-thinking enabled implementation science methodology to design, prioritize and test health system transformation and care integration actions, anchored on an iterative 3-step process involving storytelling, model building and pathfinding that together tackle the scale of complex adaptive systems. The team engaged numerous stakeholders from different medical departments, nursing, allied and operations, as well as with our major primary care shared care partner in iterative storytelling using the Needs-Based Population Segmentation Model, the LCM, as well as the lifelong care performance dashboards to iterate the LCM into various process-level operational models exemplifying the futuristic LCM. Focus was placed on activities that achieved higher agreement and/or higher certainty amongst the stakeholders.
Results: Pilots or collaborative projects initiated to exemplify and evolve towards the LCM included:
(i)Implement lifelong care Patient Registry based on Needs-Based Population Segmentation Model and operational enrolment.
(ii)Procedural appointment of PCDs in Cardiology, Renal, Diabetes (Endocrine), Geriatric Medicine, General Medicine and Family Medicine departments with assignment of registry patients to PCDs based on a clinical algorithm.
(iii)Expanding IMC/PCD 2.0 through work-flow redesign with Clinical HODs, PCDs, allied health and nursing stakeholders, including testing of Personalized Care & Support Planning processes by Geriatric and Diabetes departments, and Unified Needs Assessment process by Family Medicine departments
(iv)Development of primary care & specialist-clinic shared care processes to coordinate OCP processes between sites of care
Discussion / Conclusion: YH has targeted to impact 10,000 residents using the UCM/LCM in 3 years. Pilots or collaborative projects initiated using the HSTP process provided YH with an iterative shared model building and learning journey for stakeholders to develop and test components of the futuristic system. Use of UCM/LCM and HSTP engages stakeholders in more systemically driven implementation science processes to iterate and integrate care for different population segments; accelerating health system transformation towards people-centered and value driven care.