Advancing social prescribing in Singapore: an update on progress.

In 2019, SingHealth Community Hospitals (SCH) introduced Social Prescribing (SP) program to support patients in transitioning back to the community after hospitalization, which involves personalized care plans developed by Wellbeing Coordinators (WBCs) to connect patients with relevant community resources. With the recent launch of the nation-wide 'Healthier SG' initiative, a population health strategy in Singapore aimed at enabling individuals to prevent and manage chronic diseases, it is important to provide an update on our program's recent developments. This includes creating a living asset map, updating outcome assessment tools, organizing training sessions to enhance the skills SP practitioners, and establishing the Singapore Community of Practice in Social Prescribing (SCOMP).

Implementation of social prescribing: lessons learnt from contextualising an intervention in a community hospital in Singapore.

The need to develop holistic public health approaches that go beyond treating the biological causes of ill health, to addressing the social determinants of health, have been highlighted in the global health agenda. Social prescribing, where care professionals link individuals to community resources that tackle social needs have gained increasing traction worldwide. In Singapore, SingHealth Community Hospitals introduced social prescribing in July 2019 to manage the complex health and social needs of the aging populace.

Lessons learned from the hospital to home community care program in Singapore and the supporting AI multiple readmissions prediction model.

In a prior practice and policy article published in Healthcare Science, we introduced the deployed application of an artificial intelligence (AI) model to predict longer-term inpatient readmissions to guide community care interventions for patients with complex conditions in the context of Singapore's Hospital to Home (H2H) program that has been operating since 2017. In this follow on practice and policy article, we further elaborate on Singapore's H2H program and care model, and its supporting AI model for multiple readmission prediction, in the following ways: (1) by providing updates on the AI and supporting information systems, (2) by reporting on customer engagement and related service delivery outcomes including staff-related time savings and patient benefits in terms of bed days saved, (3) by sharing lessons learned with respect to (i) analytics challenges encountered due to the high degree of heterogeneity and resulting variability of the data set associated with the population of program participants, (ii) balancing competing needs for simpler and stable predictive models versus continuing to further enhance models and add yet more predictive variables, and (iii) the complications of continuing to make model changes when the AI part of the system is highly interlinked with supporting clinical information systems, (4) by highlighting how this H2H effort supported broader Covid-19 response efforts across Singapore's public healthcare system, and finally (5) by commenting on how the experiences and related capabilities acquired from running this H2H program and related community care model and supporting AI prediction model are expected to contribute to the next wave of Singapore's public healthcare efforts from 2023 onwards. For the convenience of the reader, some content that introduces the H2H program and the multiple readmissions AI prediction model that previously appeared in the prior Healthcare Science publication is repeated at the beginning of this article.

Global developments in social prescribing.

Social prescribing is an approach that aims to improve health and well-being. It connects individuals to non-clinical services and supports that address social needs, such as those related to loneliness, housing instability and mental health. At the person level, social prescribing can give individuals the knowledge, skills, motivation and confidence to manage their own health and well-being.

A qualitative study of challenges and enablers faced by private general practitioners providing primary care to patients with complex needs in Singapore.

Background: Singapore faces an ageing population with increasingly complex healthcare needs, a problem which could be addressed by high quality primary care. Many patients with complex needs are not managed by private general practitioners (GPs) who form the majority of the primary care workforce. Currently, there is paucity of literature describing the needs of these private GPs in providing such care.

Do healthcare needs-based population segments predict outcomes among the elderly? Findings from a prospective cohort study in an urbanized low-income community.

Background: A rapidly ageing population with increasing prevalence of chronic disease presents policymakers the urgent task of tailoring healthcare services to optimally meet changing needs. While healthcare needs-based segmentation is a promising approach to efficiently assessing and responding to healthcare needs at the population level, it is not clear how available schemes perform in the context of community-based surveys administered by non-medically trained personnel. The aim of this prospective cohort, community setting study is to evaluate 4 segmentation schemes in terms of practicality and predictive validity for future health outcomes and service utilization.

Health-seeking behaviour of the elderly living alone in an urbanised low-income community in Singapore.

Introduction: Elderly persons who live alone are more likely to be socially isolated and at increased risk of adverse health outcomes, unnecessary hospital re-admissions and premature mortality. We aimed to understand the health-seeking behaviour of elderly persons living alone in public rental housing in Singapore.

Methods: In-depth interviews were conducted using a semi-structured question guide.

Factors associated with emergency room visits and hospitalisation amongst low-income public rental flat dwellers in Singapore.

Background: In Singapore, a densely urbanised Asian society, more than 80% of the population stays in public housing estates and the majority (90%) own their own homes. For the needy who cannot afford home ownership, public rental flats are available. Staying in a public rental flat is associated with higher hospital readmission rates and poorer access to health services.

Anti-hypertensive medications and injurious falls in an older population of low socioeconomic status: a nested case-control study.

Background: This study aimed to determine whether the number of anti-hypertensive medication classes or any change in anti-hypertensive medication were associated with injurious fall among the community-dwelling older population of low socioeconomic status.

Methods: Using data from electronic medical records, we performed a nested case-control study among older Singapore residents (≥60) of low socioeconomic status (N = 210). Controls (n = 162) were matched to each case (n = 48) by age and gender.

A systematic review of health status, health seeking behaviour and healthcare utilisation of low socioeconomic status populations in urban Singapore.

Introduction: It is well-established that low socioeconomic status (SES) influences one's health status, morbidity and mortality. Housing type has been used as an indicator of SES and social determinant of health in some studies. In Singapore, home ownership is among the highest in the world.

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.

Introduction: Poorer health outcomes and disproportionate healthcare use in socioeconomically disadvantaged patients is well established. However, there is sparse literature on effective integrated care interventions that specifically target these high-risk individuals. The Integrated Community of Care (ICoC) is a novel care model that integrates hospital-based transitional care with health and social care in the community for high-risk individuals living in socially deprived communities.

Transitional Home Care Program Utilizing the Integrated Practice Unit Concept (THC-IPU): Effectiveness in Improving Acute Hospital Utilization.

Background: Organizing care into integrated practice units (IPUs) around conditions and patient segments has been proposed to increase value. We organized transitional care into an IPU (THC-IPU) for a patient segment of functionally dependent patients with limited community ambulation.

Methods: 1,166 eligible patients were approached for enrolment into THC-IPU.

Performance of the LACE index to identify elderly patients at high risk for hospital readmission in Singapore.

Unplanned readmissions may be avoided by accurate risk prediction and appropriate resources could be allocated to high risk patients. The Length of stay, Acuity of admission, Charlson comorbidity index, Emergency department visits in past six months (LACE) index was developed to predict hospital readmissions in Canada. In this study, we assessed the performance of the LACE index in a Singaporean cohort by identifying elderly patients at high risk of 30-day readmissions.

FAM-FACE-SG: a score for risk stratification of frequent hospital admitters.

Background: An accurate risk stratification tool is critical in identifying patients who are at high risk of frequent hospital readmissions. While 30-day hospital readmissions have been widely studied, there is increasing interest in identifying potential high-cost users or frequent hospital admitters. In this study, we aimed to derive and validate a risk stratification tool to predict frequent hospital admitters.

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.

Background: Emerging evidence from the virtual ward care model showed that multidisciplinary case management are inadequate to reduce readmissions or death for high risk patients. There is consensus that interventions should encompass both pre-hospital discharge and post-discharge transitional care to be effective. Integrated practice units (IPU) had been proposed as an approach of restructuring the organization and work processes of multidisciplinary teams to achieve value in healthcare.

Predicting 30-Day Readmissions in an Asian Population: Building a Predictive Model by Incorporating Markers of Hospitalization Severity.

Background: To reduce readmissions, it may be cost-effective to consider risk stratification, with targeting intervention programs to patients at high risk of readmissions. In this study, we aimed to derive and validate a prediction model including several novel markers of hospitalization severity, and compare the model with the LACE index (Length of stay, Acuity of admission, Charlson comorbidity index, Emergency department visits in past 6 months), an established risk stratification tool.

Method: This was a retrospective cohort study of all patients ≥ 21 years of age, who were admitted to a tertiary hospital in Singapore from January 1, 2013 through May 31, 2015.

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.

Objectives: To evaluate the impact of comorbidities, acute illness burden and social determinants of health on predicting the risk of frequent hospital admissions.

Design: Multivariable logistic regression was used to associate the predictive variables extracted from electronic health records and frequent hospital admission risk. The model's performance of our predictive model was evaluated using a 10-fold cross-validation.

Oral Vitamin B12 Replacement for the Treatment of Pernicious Anemia.

Many patients with pernicious anemia are treated with lifelong intramuscular (IM) vitamin B12 replacement. As early as the 1950s, there were studies suggesting that oral vitamin B12 replacement may provide adequate absorption. Nevertheless, oral vitamin B12 replacement in patients with pernicious anemia remains uncommon in clinical practice.

Frequent hospital admissions in Singapore: clinical risk factors and impact of socioeconomic status.

Introduction: Frequent admitters to hospitals are high-cost patients who strain finite healthcare resources. However, the exact risk factors for frequent admissions, which can be used to guide risk stratification and design effective interventions locally, remain unknown. Our study aimed to identify the clinical and sociodemographic risk factors associated with frequent hospital admissions in Singapore.

Housing as a Social Determinant of Health in Singapore and Its Association with Readmission Risk and Increased Utilization of Hospital Services.

Background: Residence in public rental housing is an area-level measure of socioeconomic status, but its impact as a social determinant of health in Singapore has not been studied. We therefore aimed to examine the association of public rental housing with readmission risk and increased utilization of hospital services in Singapore.

Methods: We conducted a retrospective cohort study using retrospective 2014 data from Singapore General Hospital's electronic health records.

Transitional care for the highest risk patients: findings of a randomised control study.

Background: Interventions to prevent readmissions of patients at highest risk have not been rigorously evaluated. We conducted a randomised controlled trial to determine if a post-discharge transitional care programme can reduce readmissions of such patients in Singapore.

Methods: We randomised 840 patients with two or more unscheduled readmissions in the prior 90 days and Length of stay, Acuity of admission, Comorbidity of patient, Emergency department utilisation score ≥10 to the intervention programme (n = 419) or control (n = 421).

Predicting 30-Day Readmissions: Performance of the LACE Index Compared with a Regression Model among General Medicine Patients in Singapore.

The LACE index (length of stay, acuity of admission, Charlson comorbidity index, CCI, and number of emergency department visits in preceding 6 months) derived in Canada is simple and may have clinical utility in Singapore to predict readmission risk. We compared the performance of the LACE index with a derived model in identifying 30-day readmissions from a population of general medicine patients in Singapore. Additional variables include patient demographics, comorbidities, clinical and laboratory variables during the index admission, and prior healthcare utilization in the preceding year.