Abstract
Background: Yishun Health (YH) is a regional hospital system in the north of Singapore under the National Healthcare Group. In 2019, YH launched the Medical Home (MH) service, a Hospital-at-Home (HAH) service, aimed at delivering multi-disciplinary integrated acute medical care in patients' homes. Subsequently, the “Expand Acute Care Beyond Hospital” initiative was adopted as one of the four Strategic Priorities of YH to accelerate development of HAH integrated care services. This study evaluates the patient outcomes and cost-effectiveness of the MH integrated care service compared to traditional inpatient care.
Methods: This mixed-method quasi-experimental study compared 125 patients under the MH service with 125 patients receiving usual hospital care (control group). Data were collected from July 2021 to May 2023. Patient clinical, functional and experience outcomes were measured from index admission until 90-day post discharge. Health services utilized and costs during the same period were extracted from electronic medical records. Costs were adjusted to 2024 using the Singapore consumer price index and reported in Singapore dollars (SGD). Multiple linear regressions estimated incremental differences in cost, quality-adjusted life-year (QALY), and net monetary benefit (NMB) between the two groups, adjusting for age, gender, education level, Charlson Comorbidity Index (CCI), Clinical Frailty Score (CFS), and Patient Acuity Category Scale (PACS). One GDP per capita in Singapore (SGD113,779) was used as a proxy for the willingness-to-pay (WTP) threshold.
Results: MH patients had comparable clinical outcomes such as 90-day readmission rate (35% v.s. 36%, p>0.999), mortality (8.0% v.s. 5.6%, p=0.617) and length of stray (5.7 v.s. 6.8, p=0.053) with the control group but incurred significantly lower costs (SGD8,624 v.s. SGD12,140, p<0.001). Functional outcomes measured by Modified Barthel Index (MBI) and EQ5D were also comparable between both groups. Caregivers in the MH group reported lower stress levels and higher satisfaction, particularly in involvement and empowerment in patient care. The ICER (SGD1,578,000/QALY) and positive incremental NMB of 2,860 (95% CI: 2,125, 3,596) for index admission suggests the MH group is cost-effective compared to the control group.
Conclusion: The MH integrated care service demonstrated comparable clinical and functional outcomes to traditional inpatient care up to 90-day post-discharge, with significant cost savings and higher patient and caregiver satisfaction. The MH integrated care service is identified as a preferred strategy for maintaining outcomes and reducing costs, suggesting it could serve as a sustainable alternative to traditional acute care models. Future studies should examine the broader impact of mainstreaming the hospital-at-home model on healthcare delivery, patient outcomes, and cost savings at the health system level.