SingHealth Regional Health System

Transcription

1 SingHealth Regional Health System Study Visit to Sweden Oct Nov

2 SingHealth SingHealth PRIMARY CARE Pop: 350,000 ACUTE/SECONDARY TERTIARY/QUATERNARY Pop: 745,000 Pop: 270,000 INTERMEDIATE/LONG TERM Total in the East: 1.36 Million 35% of Total Resident 2

3 3 SingHealth SingHealth Community Partners Voluntary Welfare Organisations Expanded Community Partners Community Development Councils (CDC) & Grassroots Organisations Other Community Hospitals & Nursing Home National Agencies

4 Beyond Programmes to Holistic Person-Based Care Focusing on the needs of the population Moving from provider-centric (setting) to person-centric (care themes)

5 Preparing our Healthcare System for Person-Based Communities Of Care Community Health Hospital Care Community Care Hospital To Home Outpatient to Community Community Health Screening Falls and Frailty Screening Primary Care Network Polyclinics Community Hospital Nursing Home End Of Life Care Mental Health Promotion Community Health Post FMC/CHC Geriatric Service Hub Health Management Unit (Biomedical) Care Line (Psychosocial) Community Nursing Community Networks for Seniors

6 segmentation health and disease prevention Continuing Community Care Synergising and Scaling Services Community Health Screening Objectives Increase accessibility of health screening and preventive health services to residents in the Eastern RHS through closer collaboration with grassroots and social agencies Early detection of chronic disease conditions or risk factors for early intervention to prevent or delay onset of chronic diseases KEY FOCUS AREAS To improve follow up rate for individuals who have been referred to GP for abnormal results (at least 65%) Strengthening health screening intervention and follow-up at CHPs (~85%) or Pre-DICTED Programme* Outcome Increased awareness of health conditions and predisposing biopsychosocial risk factors Increase adoption of healthy lifestyles Healthy diets and regular exercise 3 Transition to Enhanced Screen For Life (SFL) in FY17 *Pre-Diabetes Interventions and Continued Tracking to Easeout Diabetes (Pre-DICTED) programme Prevent or delay onset of chronic diseases

7 Communities of Care segmentation health and disease prevention Continuing Community Care Synergising and Scaling Services Hospital to Home (H2H) Objectives Provide holistic patient-centric care to support patients safe and timely transit from hospital to home Reduce necessary hospital utilisation Target frail patients with complex care needs, high healthcare utilisation, and/or have risk of future readmission that are preventable through H2H Intervention SOUTHEAST NORTHEAST Punggol EAST Sengkang Bukit Merah Aljunied Tiong Bahru Telok Blangah Marine Parade East Coast Chinatown Katong Tampines Pasir Ris Organise care delivery along Communities of Care Zones Geographical Team-Based Approach Ensure sustainability by working within MOH Programme funding for care integration Align care delivery model to encompass the biomedical, nursing, functional and psychosocial components FY18 9,288 Three-Year Projection FY19 10,083 FY20 10,424 Community Case Management (e.g. PNs & CCAs) Community Nursing Neighbours for Active Living Southeast: 5,020 5,310 5,460 East: 4,000 4,100 4,200 Northeast: Health Management Unit Care Line

8 segmentation health and disease prevention Continuing Community Care Synergising and Scaling Services End of Life Programmes Enhancing Advance Care Planning (ACP), Geriatric Care and End Of Life (EOL) care in the Eastern Region Objectives Establish a Palliative Care Model and Ecosystem to provide holistic and integrated EOL care Promote ACP awareness in the community Support Nursing Home to perform ACP and develop capability with NHs to provide geriatric and EOL care Developmental Milestones (FY18 FY20) Palliative Care Advance Care Planning Pending MOH Funding beyond FY17 Enhancing ACP, Geriatric Care and EOL care with NHs Develop and align core elements and protocols (FY18) Develop education/ training and competency framework for nurses and medical social workers (FY18) Establish financial model to build up capability of community partners (FY20) Administer and coordinate ACP at Cluster level (FY18) Develop shared resources and streamline advocacy and training programmes (FY18) Develop partnership with nursing homes and hospice care providers to establish shared ACP workflow (FY20) Deepen engagement and training with existing 5 NH partners in the east (FY19) Develop and implement EOL care delivery model for suitable residents Engage all NHs in the east, and support at least 50% of NH beds in the east (FY20) Engage NHs in SE from FY20

9 Communities of Care segmentation health and disease prevention Continuing Community Care Synergising and Scaling Services SingHealth Community Nursing SingHealth Eastern Region Roles of Community Nurses Preventive Care Health promotion & protection Disease prevention Building healthy & empowered community Individual Care Objectives Continuing quality care in community and ageing in place Right siting & Integration of care First Contact Care Perform assessment & triage Meet immediate care needs Refer or escalate as required Transitional Care Re-enablement approach Support hospital to home (H2H) Physicians Community Nursing Community Coordinators Allied Health Professionals Chronic, Aged & End of Life Care Simple Support & empower self management Chronic disease management Facilitate emergent care plan Complex Integrated case management Key staff assigned to navigate Coordinate and care manage

10 Communities of Care segmentation SingHealth Community Nursing Geographical Team-Based Nursing Geographical Team-Based Approach Deeper understanding of the population needs in the respective zones Skill-mix to cater to different levels of needs and care Greater accessibility Ease of collaboration and building capability for health & social care personnel Increase efficiency in resource allocation Tiong Bahru Chinatown health and disease prevention SOUTHEAST Bukit Merah Three-Year Pilot* Workload & Manpower Targets Telok Blangah Katong NORTHEAST Punggol Sengkang Continuing Community Care Marine Parade Tampines Aljunied Synergising and Scaling Services EAST East Coast Pasir Ris Workload (Pending MOH Funding) East Southeast Manpower (Cumulative) Community Nurses Care Coordinator Associates Year 1 Year 2 Year 3 2,720 5,140 8,160 3,500 4,150 5, E: 16; SE: 28 E: 25; SE: 31 E: 37; SE: E: 5; SE: 11 E: 10; SE: 13 E: 16; SE: 15 *3 years pilot funded by MOH will be implemented by the east and southeast region

11 Integrating Technology with Care Health Management Unit The HMU team provides proactive personalized chronic disease education and support with patients on their medical conditions through the telephone Careline A phone support service provided by a care team to help residents connect with the right healthcare services, coordinate medical appoints and reminder as well as encourage them to participate in community activities Telehealth Working with IHiS and MOH to implement telehealth platform video conferencing, vital-sign monitoring and telerehabilitation My Health Kiosk First self-help kiosk in the community for health tracking Match-A-Nurse Like Uber and Grab-Taxi, Match-A-Nurse mobile app makes it easy for offduty nurses to meet the care requests of SGH and KKH patients who live near them, to perform specific tasks for a fee 11

12 Person-Centred Care

13 Person-Centred Care Philosophy Esther Network Outcomes A unifying care philosophy for care providers to provide personcentred care Person-centred improvements that can be scaled and shared A common framework adopted nationally for high impact personcentred care Objectives Mainstream person-centred initiatives with high impact at national level Scale up Esther projects with potential for transferability at SingHealth regional level Expand & strengthen partnerships with community and MOH Developmental Milestones Co-construct strategic plan with community partners and Esthers Engagement with stakeholders to further the impact of Esther improvement work (FY18 to FY20) Establish the platforms and sponsors to own improvement initiatives in the eight domain areas identified by Esthers Run Esther Cafes in the community & SQ members (Target: 40 to 50 participants by FY18, 40 SQ members by FY18) Two-days workshop for Group Service Quality by FY18 Ongoing Capacity Building and Improvement Work (FY18 FY20) Continue training of 50 Esther coaches & trainers for capacity building Collaborate with HSR to interview community partners (Target: 15 to 20 community partners by FY18) Dovetail with the development of Community Network for Seniors (FY18 FY20)

14 How do we know we are successful? Evaluating RHS outcomes using Quadruple Aim Health Experience of Care Cost Per Capita Better Health for the Sustainable Cost Through Improvements Better Care for the Individuals Improved Provider Satisfaction Work life of Health Care Providers Reference: Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Annals of Family Medicine. 2014;12(6):

15 Thank You 15