A disconnect between how we care for patients in the hospital and the amount of support they require when they return home grew my interest in health services research, especially in the areas of population health, innovative integrated care delivery models and data analytics.
As Director for PHICO, I lead a team to oversee the care integration initiatives at the SGH. By forging synergistic partnerships with community service providers, we co-create an empowered community where holistic care is delivered so that every resident can live and age well. Our team also developed the ESTHER Network Singapore, which promotes person-centred care. We consider the unique needs our patients and their caregivers while co-creating a model of care.
An innovative approach to healthcare delivery
One of the innovative care delivery models to help patients is ‘Hospital at Home (SGH@Home)’. SGH@Home aims to provide short term, acute hospital level of alternative care for patients who are able to recover safely at home. This creates virtual bed capacity. Since October 2021, we deployed SGH@Home for our patients with complex conditions who were COVID-19 positive, and recovering at home. By utilising several innovative applications, we were able to monitor our patients’ vital signs and symptoms, ensuring timely feedback to the care team. Our doctors and nurses were also able to triage patients with abnormal readings more effectively by monitoring a dashboard. This model has reduced the workload of our nurses by 50 per cent.
Providing continuity of care for patients
SGH and OCH implemented a Green Lane initiative for a selected group of patients who underwent total knee replacement or total hip replacement, had hip fractures, stroke or colorectal cancer. For example, patients who have undergone knee replacement will require care at the community hospital. Before their surgery, they are identified and counselled for their care journey which will be at OCH. After surgery, these patients are either transferred on the same day or the next day to OCH seamlessly in a protocolised care path driven manner.
Our SGH specialists have also extended care continuity into OCH. Through this collaboration, OCH has seen the lowest readmission rate back to SGH among all the community hospitals. The total length of stay for patients who suffered severe stroke has also reduced from 48 days to 32.6 days....
Sustaining quality healthcare
Adapting the Ministry of Health’s ‘3 Beyonds’, my version reads Beyond health to well-being, Beyond patients to experts and Beyond community to hospital.
Beyond health to well-being involves a holistic approach to provide support that focuses on the whole person. Our efforts in improving healthcare have to be integrated with the activities surrounding that person in the community. Tapping on existing resources and programmes, we can leverage the many touch points that the person participates in the community to translate health messages and generate a positive outlook towards health for him or her.
Beyond patients to experts means seeing our patients as a resource to learn from instead of someone requiring care and help from us. When we put our patients at the heart of all we do, we will know how to provide better care and service to them.
Beyond community to hospital requires transformation in the community and how we deliver care as a healthcare system. We need to involve the hospitals, national specialty centres, polyclinics, community hospitals nationwide to leverage the cutting-edge technologies and medicine to deliver the best care for patients.
Driven by the passion to improve lives for our patients, there are many good mentors including Professor Julian Thumboo who have inspired and taught me how to be a better leader not just for our patients, but also in terms of the implementation of policies. I was recently awarded the National Medical Research Council HPHSR (Health Promotion, Preventive Health, Population Health and Health Services Research) Clinician Scientist Award, being the first family medicine physician in Singapore to win this award. I am immensely grateful to have received significant support from the management, my team and fellow colleagues.