Abstract
Background: The community nurses and wellbeing coordinators at Community Health Posts (CHPs), SingHealth Regional Health System of Singapore are dedicated to enhancing population health through engagement, enablement, and empowerment of residents. Patient Activation Measure (PAM) was used to assess residents’ knowledge, skills, and confidence towards self-health management for targeted, individualised coaching interventions.
Approach: Participants were enrolled between January 2023 and January 2024 at 37 CHPs across SingHealth Southeast precincts. PAM-10 survey questionnaire was administered to assess patient activation levels at baseline and post interventions. PAM scores were summed and transformed into a 0-100 scale that was converted to four levels of activation, from low (1) to high (4).
Targeted interventions included health coaching, chronic disease management and case management. Evaluation was performed on the effectiveness of CHP services on patient activation and unplanned hospitalization.
Results: A total of 79 residents were enrolled. 20 residents (25.3%) were lost to follow up. The mean age of the residents (n=59) was 72.2 years (SD=9.45), and their average follow-up duration was 138 days (SD=58.88). There was a significant increase in the mean PAM scores (57.43 vs.75.74, d=1.28, 95% CI:0.89, 1.68, p<0.001). The unplanned all cause readmission was reduced significantly at 30D (12 vs. 3, p<0.001), 60D (18 vs. 11, p=0.04), 90D (20 vs. 13, p=0.05) and 180D post interventions (30 vs. 19, p=0.02).
Implications: PAM-guided interventions at CHPs demonstrated the effectiveness in improving patient activation levels and reducing unplanned readmissions. These findings underscore the value of tailored interventions for person-centred care through active patient engagement and activation.