1. Transitional Care Programme Evaluation – The Singapore Experience
12th April 2013
Dr Patsy Chow
Dr Loong Mun Wong
Dr Jason Cheah
Agency for Integrated Care

2. What is Transitional Care?
“Care transitions” refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.
In its position statement in 2003, the American Geriatrics Society defined transitional care as “a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location”.
Source: Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care Systems Committee. Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society. 2003;51(4):

3. Transitional Care – Innovation Abounds
There are many innovative models of transitional care delivery; some more well established than others.
Some examples in the US
The Care Transitions Intervention®
The Transitional Care Model (TCM)
Project RED
Project BOOST
Australia
No single standard model as long as programme satisfies the legislative guidelines linked to The Aged Care Act 1997: “A form of flexible care provided to an older person at the end of an inpatient hospital episode in the form of a package of services that includes at least low intensity therapy and either nursing support or personal care”
Emphasises on transitions between acute and community care
Reference: The Australian Government. National Evaluation of the Transition Care Program. Final Evaluation Report

4. Some Classical Models
The Care Transitions Intervention® spearheaded by Dr Eric A. Coleman
Aims to empower patients/care-givers to assume greater and active role in self management as they transit across settings
4-week programme led by Transitions Coach®
The Four Pillars®
Medication self management
Dynamic patient-centric health record
Timely primary care/specialist care follow-up
Knowledge of ‘red flags’ and appropriate responses
The Transitional Care Model (TCM) by Dr Mary D. Naylor
8 -12 week programme directed by Advanced Practice Nurses
Patient assessment and development of care plan begin within 24 hours of hospital admission
Regular home visits with telephonic support (7 days a week) after discharge
First post discharge visit with the physician accompanied by the Transitional Care Nurse
Interdisciplinary approach; close collaboration with physician

5. Defining Transitional Care in Singapore
Transitional care initiatives are nascent in Singapore; most are in pilot phase.
Transitional care (TC) in our local context is defined as care and/or services to support patients’ transfer from the acute care to community setting.
Objectives
To support post discharge patients to transit from hospital to community by streamlining and coordinating care services.
To optimise patients’ outcomes following an episode of illness.
To minimise hospital utilisation by facilitating timely discharge and reducing unnecessary hospital readmissions and/or ED visits.
Key features
Time-limited
Coordinates services according to individualised care plans
Handover to community based partners for follow-up care

6. Transitional Care Initiatives in Singapore
Existing programmes can be broadly classified into two categories:
Predominantly Care Coordination
Predominantly Skilled Care Interventions
Caters to patients with complex social care needs and those at risk of functional decline
Targets at patients with higher level of acuity in terms of physical care needs
Emphasis rests on care coordination and patient/caregiver empowerment
Focuses on direct intervention or care provision (e.g. medical, nursing, functional, pharmaceutical)
Minimal provision of direct skilled care
Less emphasis on care coordination activities
FOC
Fees for service
All are hospital-led at present (3 in total)
E.g. Aged Care Transition Team
The first transitional care pilot in Singapore inspired by The Care Transitions Intervention®
The most mature programme by far
Demonstrates positive results
E.g. Post Acute Care at Home
Slightly more advanced in development compared to the other hospital-led TC programmes
TC fees
Doctor: $75 (subsidised) or $160 (full paying) Nurse: $40 (subsidised) or $85 (full paying) Therapist: $50 (subsidised) or $110 (full paying)hospital

7. Aged Care Transition (ACTION) Teams
ACTION is a government funded project started in 2008.
Aim:
To help patients make a safe and smooth transition from hospitals into their homes or community, by streamlining and coordinating care services to optimise patients’ outcomes throughout and after an episode of illness.
Scale:
81 care coordinators in 6 Restructured Hospitals (RHs), 1 Tertiary Centre & 5 Community Hospitals.
More than 28,731 patients recruited since 2008.

8. Patient Screening Criteria of ACTION
Elderly above the age of 65 yrs
Multiple co-morbidities
Polypharmacy
Impaired mobility or significant functional decline
Impaired self care skills
Poor cognitive status
Lives alone or has poor social support
Catastrophic/Chronic illness and injury with anticipated long term health care needs
Multiple admissions / ED visits over the last 6 months
Note: Provision of 80/20 rule for exceptions (e.g. young patients)

9. ACTION Process Hospital Community High-risk hospital inpatients
Admission
Discharge
About 1-3 months post discharge
Screening high-risk patients
Assessment of needs
Referral to appropriate ILTC services
Develop and implement care plan
Goal setting and evaluation of care plans
ACTION Team
Care Coordinators
Nurses, Social workers, Allied health professionals
High-risk hospital inpatients
Residential Facility e.g. community hospital
Home with supporting services
Day rehabilitation services
Home Medical & Home nursing services
Social support services
Telephone follow up, home visit and assessment
Optimize a patient’s self-care capabilities at home
Caregiver education and support
Monitoring of high risk clients
Hand-off to other services

10. Mixed-Method Evaluation Approach
Administrative data analysis

11. ACTION Clients are Elderly and Frail
Based on 2009Q1 to 2011 Q2 administrative database (N=14,025)
Patient profile is heterogeneous across sites
77% above 70 years old
38% are main carer of themselves
65% taking > 5 medications
72% have 3 or more co-morbidities
27% with history of >1 fall
Source: RHIME Administrative Data Analysis

12. Does ACTION Reduce Hospital Utilisation?
Retrospective case-control study to compare the number of readmissions and ED visits within 6 months after index hospitalisation
Cases from ACTION cohort (Feb 09 - Jul 10)
Controls were selected from MOH Casemix and Subvention Database
Inclusion criteria – at least 1 of the following
≥3 diagnoses
At least 1 of these diseases: diabetes, hypertension, hyperlipidemia, dementia, COPD, stroke and schizophrenia
≥1 hospitalisation or ED visit in past 6 months prior to index hospitalisation
Exclusion criteria
Social over-stayer / absconder
Age <65y
Non-subsidised patients
Data fields extracted from the Casemix database include
-age, gender, date of index hospital admission, primary diagnosis, length of stay, Charlson Co-Morbidity Index, no. and dates of hospitalizations and ED visits within 6 month.
Data was extracted in a de-identified form and analysed in MOH’s Microdata Lab

13. Statistical Analysis
Propensity score weighting was done to adjust for selection bias based on these covariates:
Age
Gender
Length of initial hospital stay
Charlson Co-Morbidity Index
No. of hospitalisation in the 180 days preceding index hospital admission and ED attendance
No. of ED attendance in the 180 days preceding index hospital admission
Propensity score-weighted logistic regression was done to obtain respective adjusted outcomes.
Propensity score = predicted probability that a given patient will be enrolled into ACTION program conditional on covariates.

14. Baseline Characteristics of Clients (after weighting by propensity score)
ACTION (N=4132)
Control (N=4132)
P-value
Age (years)
Mean (SD)
79.2 (7.7) -
Gender
Male
1795 (43.5%)
1797 (43.5%)
Female
2335 (56.5%)
2333 (56.5%)
Charlson Index
1.6 (1.8)
1.5 (1.8)
0.37
Length of stay (days)
11.6 (13.0)
11.1 (15.4)
0.25
Past Hospitalisation history
No. of admissions within 180 days before index hospitalisation
0.79 (1.4)
0.81 (1.4)
0.51
Patients with ≥ 1 admission within 180 days before index hospitalisation
n (%)
1731 (41.9%)
1847 (44.7%)
0.014
No. of 180-day ED attendances within 180 days before index hospitalisation
1.9 (2.0)
1.9 (3.1)
0.89
Patients with ≥ 1 attendance within 180 days before index hospitalisation
4004 (96.9%)
3781 (91.5%)
<0.001
Based on results as at 19th Jan 2012
ACTION patients
-were old (mean age 79.2y),
-had relatively long hospital stay (mean 11.6 days)
After propensity adjustment, the characteristics (demographic, length of the index hospital stay, comorbidity burden, and pre-index hospitalization admissions) of ACTION and control group are similar except the proportion of patients with prior ED visits (ACTION 96.9% vs Controls 91.5%).
Propensity score used to adjust for Age, Gender, Charlson’s index, Length of Stay, Number of admissions in 180 days prior to index admission, Number of ED attendances in 180 days prior to index admission
Source: RHIME-MOH Comparison with Comparator Group

15. Comparison Results – Readmission (Unplanned)
ACTION (N= 4132)
Control (N=4132)
P-value
Unplanned readmission after hospital discharge
Readmission within 15 days n
411
879
<0.001
Patients with ≥ 1 readmission within 15 days
n (%)
413 (10.0)
880 (21.3)
Readmission within 30 days
646
1148
Patients with ≥ 1 readmission within 30 days
644 (15.6)
1148 (27.8)
Readmission within 180 days
1564
2130
Patients with ≥ 1 readmission within 180 days
1843 (37.9)
2074 (51.6)
Solely unplanned readmissions
10.0% of ACTION clients were readmitted at least once within 15 days post discharge, 15.6% within 30 days and 37.9% within 180 days.
Comparing ACTION clients and controls
(i) The total number of unplanned readmissions for ACTION clients are significantly lower than that of the control group within 15 days, 30 days and 180 days after discharge.
(ii) A (statistically) significantly lower proportion of ACTION clients were readmitted within 15 days, 30 days and 180 days after discharge compared to the control grp.
-15-days readmission (ACTION 10.0% vs. Controls 21.3%)
-30-days readmission (ACTION 15.6% vs. Controls 27.8%)
-180-days readmission (ACTION 37.9% vs. Controls 51.6%)
Propensity score used to adjust for Age, Gender, Charlson’s index, Length of Stay, Number of admissions in 180 days prior to index admission, Number of ED attendances in 180 days prior to index admission
Source: RHIME-MOH Comparison with Comparator Group

16. Comparison Results - ED Attendance
ACTION (N= 4132)
Control (N=4132)
P-value
ED attendance after hospital discharge
ED attendance within 30 days n
992
1240
Mean (SD)
0.24 (0.62)
0.30 (0.73)
0.002
Patients with ≥ 1 ED attendance within 30 days
n (%)
797 (19.3)
950 (23.0)
<0.001
ED attendance within 180 days
3801
4545
0.92 (2.0)
1.1 (3.1)
0.052
Patients with ≥ 1 ED attendance within 180 days
1913 (46.3)
2021 (48.9)
0.027
Based on results as at 19th Jan 2012
19.3% of ACTION clients visited ED at least once within 30 days post discharge and 46.3% within 180 days.
The mean number of ED visits were however very small (0.24 within 30 days and 0.92 within 180 days)
Comparing ACTION clients and controls
(i) A (statistically) significantly lower proportion of ACTION clients visited ED within 30 days after discharge compared to the control grp.
-ED visit within 30-days (ACTION 19.3% vs. Controls 23.0%)
Propensity score used to adjust for Age, Gender, Charlson’s index, Length of Stay, Number of admissions in 180 days prior to index admission, Number of ED attendances in 180 days prior to index admission
Source: RHIME-MOH Comparison with Comparator Group

17. Adjusted Odds Ratio (95% CI)
Comparison Results
ACTION patients significantly less likely to be readmitted, and less likely to visit ED.
The odds of unplanned readmission within 15, 30 and 180 days for ACTION patients are lower than the odds for control patients.
The odds of ED attendance of ACTION clients within 30 days are lower than that of controls.
Odds ratios of hospital readmission and ED attendance - ACTION vs. Controls (after weighting by propensity score)
Outcome
Adjusted Odds Ratio (95% CI)
P-value
Readmission
within 15 days
0.5 (0.4, 0.5)
<0.001
within 30 days
0.5 (0.5, 0.6)
within 180 days
0.6 (0.6, 0.7)
ED attendance
0.81 (0.72, 0.90)
0.90 (0.82, 0.99)
0.027
Unplanned re-adm
Propensity score used to adjust for Age, Gender, Charlson’s index, Length of Stay, Number of admissions in 180 days prior to index admission, Number of ED attendances in 180 days prior to index admission
Source: RHIME-MOH Comparison with Comparator Group

18. ACTION Clients are More Likely to be Readmission-Free
Hazard ratio (95% CI) = 1.3 ( ), P<0.001
Hazard ratio of 1.3 means that an ACTION client who has not yet been readmitted by a certain time (within the 180 days time frame) has 1.3 times the chance of remaining admission-free and staying in the community at the next point in time compared to someone in the control group.
Within 180d post-discharge, 889 (21.5%) deaths in ACTION and 670 (13.6%) deaths in Control grp.
Source: RHIME-MOH Comparison with Comparator Group

19. Estimated Cost Savings
Estimating cost savings from the difference in reduced hospital days and programme implementation costs
ACTION saved 6283 bed days of unplanned admissions over 6 months
Estimated S$5.3m saved from these reduced bed days
Operational cost of ACTION programme over six months (Apr to Sep 2010) was S$1.94m (>95% the care coordinators’ salary)
Hence overall cost savings = S$3.4m over 6 months
Assumes no net additional healthcare cost used by ACTION care recipients compared to the control group**.
While we did not obtain actual expenditures in this evaluation, cost savings from public health system’s perspective could be estimated from the difference in hospital day and incremental program costs.
Beds days saved = reduced unplanned hospitalizations 6mths x average length of stay* =6283 days
Cost savings = 6283 x average cost for C-class bed per day (2009 figure) = 6283 x 842=$5.3m
*assume same LOS in index admission (propensity adjusted)
**Assumes no net additional healthcare cost by ACTION care recipients compared to the control group.
We think assumption is reasonable given that we did not consider savings from reduced ED visits for ACTION care recipients, that ACTION care recipients did not receive any residential care, were not on any other hospital programs, and were not likely to incur additional primary care and community care costs compared to a control group of similar conditions.
The only likely addition cost to ACTION care recipients and their family would be additional equipment and home modifications as well as set up cost (only CCIT as minimal capita cost set at hospital)
Notwithstanding a careful cost effectiveness analyses, our demonstration program appeared to deliver good value for money.

20. More Evaluation of ACTION
ACTION clients/ caregivers were surveyed in Feb/ Mar 2011 after discharge from service
Exclusion
Those who lodged a hospital complaint
Social overstayer
Cognitively impaired without a caregiver
Those transferred to community hospital/ inpatient in rehabilitation ward/ sub-acute ward/ sheltered home/ nursing home
1st interview: 1 week post-discharge
Health-Related QoL (EQ-5D)
2nd interview: 4-6 weeks post-discharge
Care Transitions Measure (CTM-15), Health-Related QoL (EQ-5D), satisfaction ratings
451 completed both surveys
70% of responses by caregiver proxy
Source: RHIME-IMH Survey

21. Quality of Care Transition
CTM-15 measures four domains
Information transfer
Patient and caregiver preparation
Self-management support
Empowerment to assert preferences
Total score ranges from 0 to100
Higher scores indicate better transition
Overall mean CTM-15 score of surveyed clients/ caregivers was 63.8.
Source: RHIME-IMH Survey

22. Perception in Health-Related QoL (EQ-5D)
Analysed for surveys completed by same person (n=296)
Higher proportion reported having ‘no problems’ at 4-6 weeks for all 5 dimensions (P<0.05)
5 dimensions – MOBILITY, SELF-CARE, USUAL ACTIVITIES , PAIN / DISCOMFORT and ANXIETY / DEPRESSION
I have no problem.. 
I have slight problem.. 
I have moderate problem.. 
I have severe problem.. 
I have extreme problem … 
Interview 1
Interview 2
‘Self’-rated health
(0=worst health, 100=best health)
60.4
64.1
P<0.05
Source: RHIME-IMH Survey

23. Majority were Satisfied with ACTION
70% rated ACTION service overall as good or excellent.
68% rated care and concern shown by ACTION care coordinators as good or excellent.
63% rated knowledge of care coordinators as good or excellent
Source: RHIME-IMH Survey

24. Conclusion of ACTION Analysis
The ACTION, a hospital-based transitional care program, significantly reduced acute care utilization for up to 6 months post discharge.
Improved care recipient well-being, and positive responses to quality of care transition and service satisfaction ratings
Findings confirmed the effectiveness of the Care Transition Intervention in Singapore’s public health system.

25. Post Acute Care at Home (PACH)
A tertiary hospital pilot programme that delivers transitional care to patients that requires multi disciplinary team interventions post discharge
Key objective include:
Reducing unnecessary ED attendance and readmissions and hence burden on hospital resources
Services provided are time limited with an average duration of
3 months
Encourages handover of patient management to the community whenever possible
The hospital had conducted the first phase of its evaluation to assess the effectiveness of the programme

26. Initial Results: Bed Days Saved
Based on the analysis of administrative database of PACH client cohort (Apr 11 – Dec 11),
2.9 bed-days can potentially be saved per patient, from
ED visits and readmission averted through timely response by team to urgent calls made by clients
Management of certain conditions at home (which in the absence of PACH would have led to hospital admissions), e.g.
Behavioural problems from persons with dementia staying at home
Facilitation of timely discharge from acute hospital through the provision of post discharge support
AIC and Ministry of Health will work with the hospital on the second phase of the evaluation in acquiring mortality and health service utilisation data to facilitate further analysis.
Source: PACH Administrative Data Analysis

27. Challenges of Current TC Programmes
There are currently 3 hospital-led transitional care programmes that provide multidisciplinary interventions to help patients transit from hospitals to community.
Common challenges faced by this category of TC programmes
Patients were not keen to be enrolled into such community programmes due to high out-of-pocket charges
Difficulties in recovering cost from patients and hence services were highly subsidised by hospitals
Problems in discharging patients to community partners who are not well-equipped
Limitations in performing robust evaluation by hospitals due to lack of access to comprehensive data

28. Moving Forward
Expansion of ACTION service in other segments such as specialist outpatient clinics and ED
ACTION teams will collaborate and align more closely with other local projects within respective hospitals
Revision of funding model for hospital-led TC programmes to ensure affordability and sustainability
A unified evaluation will be conducted under the oversight of AIC and Ministry of Health to assess programme outcomes in-depth.
Emergence of new hybrid models taking reference from, for instance Project BOOST and UK Virtual Ward

29. Acknowledgement
ACTION Managers, ACTION Care Coordinators, ACTION Clinical Champions and ACTION Heads of AH, CGH, NUH, KTPH, TTSH, SGH, NHC, RCCH, SLH, AMKCH, SACH and BVH
Colleagues from Health Services Research and Health Information Department, Ministry of Health
Colleagues from Research Division, Institute of Mental Health
Dr Ian Leong, PACH Programme Director, TTSH
Dr Wong LM, Chief, CID, AIC
Ms Polly Cheung, Deputy Chief, CID, AIC
Dr Wee Shiou Liang, Head (RHIME), AIC
Colleagues from Regional Integration Office, AIC
MOH and AIC Management

30. References
Coleman EA, Boult CE on behalf of the American Geriatrics Society Health Care Systems Committee. Improving the Quality of Transitional Care for Persons with Complex Care Needs. Journal of the American Geriatrics Society. 2003;51(4):
The Australian Government. National Evaluation of the Transition Care Program. Final Evaluation Report
The Care Transitions Program [Internet]. [Cited 2013 Feb 18]. Available from:
Health Workforce Solutions LLC and Robert Wood Johnson Foundation. Transitional Care Model [Internet] [cited 2013 Feb 18]. Available from:
Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomised controlled trial. Arch of Int Med. 2006;166:
Coleman EA. The care transitions intervention [Internet]. [Cited 2013 Feb 20]. Available at:
Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalised with heart failure: a randomised, controlled trial. JAGS. 2004;65:

31. Thank you