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Developing a hospital to community model of care: From experience to evidence to implementation


Kheng Hock Lee

Singapore General Hospital, SG
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Introduction: Singapore is a developed country with one of the most rapidly ageing populations in the world. Regional health systems (RHSs) anchored by major hospitals were created to improve care integration and improve care for the elderly. The region supported Singapore General Hospital (SGH) covers a population of 269,910 of which 48,620 (18%) are age 65 and above.

Short description of practice change implemented: In 2006 SGH introduced hospital-based family physicians to serve as generalist for inpatients to improve care continuity.  A cohort study showed a reduction of 1.1 days in the average length of stay.[1]  In 2008, a transitional home care program was introduced.  A quasi experimental before and after study demonstrated a reduction of 57% in hospital readmissions and 47.1% reduction in emergency room (ER) visits.[2]  In 2011, an adapted virtual ward program was introduced.  A randomized control trial (RCT) failed to show any benefits.[3]  In 2013, the care model was re-designed based on lessons learned from earlier models. An RCT showed reduction of hospital readmissions by 33% and ER visits by 40%.[4]  In 2017, this model was deployed in communities with high readmission rates identified through geospatial mapping and guided by data analytics.[5]  The model was co-designed through participatory action with local communities.[6]  In 2018, this care model was scaled up to include the RHS’ entire area of coverage.  The program now serves more than 4000 patients.

Conclusions: Care integration programs are effective when they are continuously improved using evidence from evaluations.  Implementation should be guided by participatory action and community engagement.


1- Bringing generalists into the hospital: outcomes of a family medicine hospitalist model in Singapore.  Hock Lee K, Yang Y, Soong Yang K, Chi Ong B, Seong Ng H.  J Hosp Med. 2011 Mar;6(3):115-21

2- Housing as a Social Determinant of Health in Singapore and Its Association with Readmission Risk and Increased Utilization of Hospital Services.  Low LL, Wah W, Ng MJ, Tan SY, Liu N, Lee KH.  Front Public Health. 2016 May 30;4:109.

3- Transitional care for the highest risk patients: findings of a randomised control study.  Lee KH, Low LL, Allen J, Barbier S, Ng LB, Ng MJ, Tay WY, Tan SY.  Int J Integr Care. 2015 Oct 22;15

4- Applying the Integrated Practice Unit Concept to a Modified Virtual Ward Model of Care for Patients at Highest Risk of Readmission: A Randomized Controlled Trial.  Low LL, Tan SY, Ng MJ, Tay WY, Ng LB, Balasubramaniam K, Towle RM, Lee KH.  PLoS One. 2017 Jan 3;12(1):e0168757.

5- Predicting frequent hospital admission risk in Singapore: a retrospective cohort study to investigate the impact of comorbidities, acute illness burden and social determinants of health.  Low LL, Liu N, Wang S, Thumboo J, Ong ME, Lee KH.  BMJ Open. 2016 Oct 14;6(10):e012705.

6- Evaluating a novel Integrated Community of Care (ICoC) for patients from an urbanised low-income community in Singapore using the participatory action research (PAR) methodology: a study protocol.  Low LL, Maulod A, Lee KH.  BMJ Open. 2017 Oct 8;7(10).

How to Cite: Hock Lee K. Developing a hospital to community model of care: From experience to evidence to implementation. International Journal of Integrated Care. 2019;19(4):630. DOI:
Published on 08 Aug 2019.


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