Abstract
Background: Yishun Health(YH) introduced the Integrated Medical Clinic(IMC) to address fragmented care for complex patients as part of care transformation using the Unified Care Model(UCM), guided by YH Health System Transformation Playbook(HSTP). Patients were segmented according to their bio-psycho-social needs, and eligible residents were invited to enroll in the IMC service during a subsequent visit to a Specialist Outpatient Clinic(SOC). Enrolled patients were assigned a Primary Coordinating Doctor(PCD) responsible for integrating all care services under a one-care-plan and accountable for their health outcomes.
This paper evaluates the effectiveness of the IMC service for patients assigned to Geriatric PCDs, as geriatric patients are generally older with multiple Chronic Illnesses(CI) that might require multi-disciplinary care, suggesting that IMC could improve their health outcomes and experience.
Methods: A quasi-experimental study was conducted to compare the effectiveness of IMC services for enrolled patients against a control group of unenrolled patients. Outcomes data were analysed against patients’ bio-psycho-social needs by sub-segments, i.e., with medical issues only, with medical & mental health issues, with medical & social issues, with medical & psychosocial issues.
Patients’ annual total healthcare cost and utilization(Emergency Department(ED) and SOC visits, Emergency Admissions and Emergency Bed Days) from 1-year pre-enrolment to 1-year post-enrolment were analyzed and compared between IMC patients and controls.
Additionally, Patient-Reported Outcomes Measures(PROMs) that includes Instrumental Activities of Daily Living(IADL), depression symptoms, patient engagement and Health-Related Quality of Life(HRQOL) were assessed for IMC patients at each visit.
Results: Between 2022 and 2024, 320 patients were enrolled into IMC under Geriatric PCDs, and they were older than the control group(83 yr. against 81 yr.). Compared to pre-enrolment period, IMC patients showed increased average visits to assigned PCDs(0.7 to 1.6) across the sub-segments one-year post-enrolment. However, they also showed reductions in average annual unanticipated health services utilization, with decreases in ED visits(1.1 to 0.9), Emergency Admissions(0.8 to 0.6), Emergency Bed Days(8.1 to 5.9) and total healthcare services utilization cost(SGD$11,752 to SGD$9,644). In contrast, the control group exhibited higher frequencies and increasing trends for health services utilization during the same period.
Most IMC patients reported maintenance or improvement in PROMs(IADL 75.5%,depression symptoms 96.6%,HRQOL 82.1% and health engagement 75.9%) between their first visit and 6-months post-enrolment visit.
Our findings suggests that the care coordination and continuity provided by our integrated IMC PCDs for geriatric patients effectively reduced unanticipated health services utilization i.e., ED visits and emergency admissions. The increase in SOC visits to assigned PCDs suggest that patients were actively engaging with their PCD who were better able to integrate patient care and manage complications leading to better health outcomes.
Implications: Our evaluation suggests that effective care coordination and continuity by a PCD in an integrated IMC service can greatly improve outcomes for complex geriatric patients. Lessons from the implementation of the PCD and IMC service for geriatric patients provides useful knowledge on how we might accelerate the scaling up of these services for the rest of YH patients living with complex medical conditions and in need of better continuity and care coordination.