Introduction: In the World Report on Ageing and Health, the World Health Organisation (WHO) described the type of health care needed for ageing populations as “integrated health care for older people”. As multi-morbidity becomes the norm, care provision becomes increasingly complex. Our current care models are often fragmented with poor coordination between providers and settings. In particular, the frail elderly often have difficulty accessing hospital-based medical services and typically incur the greatest medical costs.
The aim of this study was to map out existing home-based primary medical care services in Singapore and compare them to essential features of home-based care highlighted in international publications, in order to establish gaps in the care continuum and target new programmes in this space.
Methods: A review of international publications about home-based medical care was undertaken to identify key features of delivering holistic, team-based care to a patient’s home. Thereafter, a combination of web search and communications with service providers were undertaken to match existing services with these key features. Specific palliative care services were excluded from this study.
Results: The key features we identified were a) focus on home-bound patients, b) provision of integrated interdisciplinary care in the home with focus on managing chronic conditions and averting crises over an indefinite period, including integration with patient’s electronic health records (EHR), c) responding rapidly to acute needs and d) integration with or provision of palliative care to provide an option of dying at home.
The existing services in Singapore were found to comprise three main groups, private house call services, hospital-run transitional care services, and voluntary welfare organization supported home based primary care and nursing care services. Private house call services focused on home-bound patients, focused on acute needs including palliation but did not provide chronic longitudinal care. They were not subsidised by the public healthcare system and therefore inaccessible to majority of the population. Hospital-run transitional care services provided post-discharge acute care for patients at home, hence had excellent integration with EHR but again did not provide chronic longitudinal care after the period of transition was over. 8 home based primary medical care services were found, entirely run by voluntary welfare organisations. Of these, only one organization had integration with patient EHR, 2 offered rapid response to acute needs, and one offered palliative care services. All were fee-for-service and were amenable to government subsidies, subject to household income.
Conclusion: Of all the home-based medical services mapped out in Singapore, none of them fulfilled all key features identified in international home care publications, likely resulting in fragmented care for this group of home-bound frail elderly. Our next step would be to study patient and caregiver experiences with home care in Singapore, with an aim towards developing a comprehensive home care pilot for clinically complex individuals.