Impact of a patient-centered medical home demonstration on quality of life and patient activation for older adults with complex needs in Singapore

An Integrated Patient-Centred Medical Home (PCMH) Care Model Reduces Prospective Healthcare Utilisation for Community-Dwelling Older Adults with Complex Needs: A Matched Observational Study in Singapore

The global ageing population is associated with increased health service use. The PCMH care model integrates primary care and home-based care management to deliver comprehensive and personalised healthcare to community-dwelling older adults with bio-psycho-social needs. We examined if an integrated PCMH reduced healthcare utilisation burden of older persons in Singapore. We compared the healthcare utilisation between the intervention group and coarsened exact matched controls for a follow-up of 15 months. Baseline matching covariates included socio-demographics, health status, and past healthcare use. We accounted for COVID-19 social distancing effects on health-seeking behaviour. The intervention group consisted of 165 older adults with complex needs. We analysed national administrative healthcare utilisation data from 2017 to 2020. We applied multivariable zero-inflated regression modelling and presented findings stratified by high (CCI ≥ 5) and low disease burden (CCI < 5). Compared to controls, there were significant reductions in emergency department (β = -0.85; 95%CI = -1.55 to -0.14) and primary care visits (β = -1.70; 95%CI = -2.17 to -1.22) and a decrease in specialist outpatient visits (β = -0.29; 95%CI = -0.64 to 0.07) in the 3-month period immediately after one-year enrolment. The number of acute hospitalisations remained stable. Compared to controls, the intervention group with high and low comorbidity burden had significant decreases in primary care use, while only those with lower comorbidity burden had significant reductions in utilisation of other service types. An integrated PCMH appears beneficial in reducing healthcare utilisation for older persons with complex needs after 1 year in the programme. Future research can explore longer-term utilisation and scalability of the care model.

Derivation, and establishment of the validity and reliability, of the CASP-11-SG quality of life scale among community-dwelling older adults

PURPOSE

The number and proportion of older adults, aged ≥ 60 years, in Singapore is rapidly increasing. A valid and reliable quality of life (QoL) measure will enable assessment of their situation and help evaluate social and clinical interventions, potentially improving care. This study aims to evaluate the validity and reliability of the control, autonomy, self-realization, and pleasure (CASP)-12v.3 QoL scale and establish a scale suitable for use among older adults in Singapore.

METHODS

Data from 3526 community-dwelling older adults from a national survey was used. Measurement properties of the CASP-12v.3 scale were evaluated. Confirmatory factor analysis (CFA; testing single- and two-factor models with residual covariances for negatively worded items and a bifactor model) was performed in half of the sample and exploratory factor analysis (EFA) was performed in the other half. The results led to revised CFA models and the CASP-11-SG scale. The CASP-11-SG scale's measurement properties, convergent, and known-groups validity, and measurement equivalence/invariance (ME/I) across English and Chinese languages were evaluated.

RESULTS

Item 3 'I feel free to plan for the future' of the CASP-12v.3 scale had low correlation with other items of the control/autonomy subscale, low item-total correlation and high item-scale correlation. While CFA and EFA supported the two-factor model, removing item 3 improved model fit. The resulting CASP-11-SG scale (Cronbach's alpha: 0.81) demonstrated convergent and known-groups validity and partial ME/I across English and Chinese languages.

CONCLUSION

The CASP-11-SG scale, with satisfactory psychometric properties, can be used for assessing QoL among older adults in Singapore.

Cost analysis of a Patient-Centred Medical Home for community-dwelling older adults with complex needs in Singapore

INTRODUCTION

The Patient-Centred Medical Home (PCMH) demonstration in Singapore, launched in November 2016, aimed to deliver integrated and patient-centred care for patients with biopsychosocial needs. Implementation was based on principles of comprehensiveness, coordinated care and shared decision-making.

METHOD

We conducted a prospective single-arm pre-post study design, which aimed to perform cost analysis of PCMH from the perspectives of patients, healthcare providers and society. We assessed short-to-intermediate-term health-related costs by analysing data on resource use and unit costs of resources.

RESULTS

We analysed 165 participants enrolled in PCMH from November 2017 to April 2020, with mean age of 77 years. Compared to the 3-month period before enrolment, mean total direct and indirect participant costs and total health system costs increased, but these were not statistically significant. There was a significant decrease in mean cost for primary care (government primary care and private general practice) in the first 3-month and second 3-month periods after enrolment, accompanied by a significant decrease in service utilisation and mean costs for PCMH services in the second 3-month period post-enrolment. This suggested a shift in resource costs from primary care to community-based care provided by PCMH, which had added benefits of both clinic-based primary care and home-based care management. Findings were consistent with a lower longer-term cost trajectory for PCMH after the initial onboarding period. Indirect caregiving costs remained stable.

CONCLUSION

The PCMH care model was associated with reduced costs to the health system and patients for usual primary care, and did not significantly change societal costs.

Health outcomes and implementation barriers and facilitators of comprehensive geriatric assessment in community settings: a systematic integrative review [PROSPERO registration no.: CRD42021229953]

BACKGROUND

Comprehensive geriatric assessment (CGA) addresses the bio-psycho-social needs of older adults through multidimensional assessments and management. Synthesising evidence on quantitative health outcomes and implementation barriers and facilitators would inform practice and policy on CGA for community-dwelling older adults.

METHODS

We systematically searched four medical and social sciences electronic databases for quantitative, qualitative, and mixed methods studies published from 1 January 2000 to 31 October 2020. Due to heterogeneity of articles, we narratively reviewed the synthesis of evidence on health outcomes and implementation barriers and facilitators.

RESULTS

We screened 14,151 titles and abstracts and 203 full text articles, and included 43 selected articles. Study designs included controlled intervention studies (n = 31), pre-post studies without controls (n = 4), case-control (n = 1), qualitative methods (n = 3), and mixed methods (n = 4). A majority of articles studied populations aged ≥75 years (n = 18, 42%). CGAs were most frequently conducted in the home (n = 25, 58%) and primary care settings (n = 8, 19%). CGAs were conducted by nurses in most studies (n = 22, 51%). There was evidence of improved functional status (5 of 19 RCTs, 2 of 3 pre-post), frailty and fall outcomes (3 of 6 RCTs, 1 of 1 pre-post), mental health outcomes (3 of 6 RCTs, 2 of 2 pre-post), self-rated health (1 of 6 RCTs, 1 of 1 pre-post), and quality of life (4 of 17 RCTs, 3 of 3 pre-post). Barriers to implementation of CGAs involved a lack of partnership alignment and feedback, poor acceptance of preventive work, and challenges faced by providers in operationalising and optimising CGAs. The perceived benefits of CGA that served to facilitate its implementation included the use of highly skilled staff to provide holistic assessments and patient education, and the resultant improvements in care coordination and convenience to the patients, particularly where home-based assessments and management were performed.

CONCLUSION

There is mixed evidence on the quantitative health outcomes of CGA on community-dwelling older adults. While there is perceived positive value from CGA when carried out by highly skilled staff, barriers such as bringing providers into a partnership, greater acceptance of preventive care, and operational issues could impede its implementation.

A Patient-Centred Medical Home Care Model for Community-Dwelling Older Adults in Singapore: A Mixed-Method Study on Patient's Care Experience

Patient-Centred Medical Home (PCMH) is a strategy to enhance patient-centredness to improve care experience. We aimed to understand patient experience of an integrated PCMH model for complex community-dwelling older adults in Singapore. We used a mixed-method design with a prospective single-group pre-post quantitative component and a concurrent qualitative component. Participants were administered the validated Consumer Assessment of Health Providers and Systems Clinician & Group Survey (CG-CAHPS) at baseline (N = 184) and 6-month (N = 166) post-enrolment. We conducted focus group discussions (FGDs) on a purposive sample of 24 participants. Both methods suggest better care experience in PCMH relative to usual care. There were improvements in the CG-CAHPS measures on patient–provider communication, care coordination, office staff interactions, support for patients in caring for their own health, and provider rating in PCMH relative to usual care. In the FGDs, participants reported benefits of consolidated appointments and positive experience in sustained patient–provider relationship, shared-decision making, and family/caregiver engagement in PCMH. Participants may not fully comprehend the concept of integrated care, hindering both the effective communication of the intended care model and perceived benefits such as the provision of multidisciplinary team-based care.

Diagnosing Frailty in Primary Care Practice

Frailty is a complex age-related clinical condition with increased vulnerability to negative health outcomes that manifest as a multidimensional syndrome and hence, a challenge to identify at-risk populations. We aim to summarize the implementation of strategies to diagnose fragility in family practice using current evidence. We searched the PubMed and Google Scholar databases for relevant articles, using the Medical Subject Headings (MeSH) terms "Frailty," "Frailty Scales," and "Primary Health Care." All original research articles on the elderly population (65 years of age or older) published in English and the last five years were included. Frailty diagnosis has resulted in positive outcomes in the overall literature. Recent hospital admission may indicate a health problem that can end up in a negative outcome and has been often described as associated with frailty. It was also shown to affect the intensive care units' mortality, in-hospital mortality, and long-term mortality. However, multiple screening instruments have been developed and validated to improve feasibility in clinical practice. The frequent lack of agreement between frailty instruments has slowed the broad implementation of these tools. The impacts of frailty warrant an upstream, proactive, holistic, interprofessional primary care approach to its identification, assessment, and management. It is a preventable disorder; identifying elderly patients at risk in primary care can help shape appropriate care processes tailored to their needs. This literature review aims to demonstrate the importance and strategies in identifying frailty in primary care settings and assess its impact on several outcomes. 

Perceived stress, quality of life, and coping skills among patients with schizophrenia in symptomatic remission

Background

Schizophrenia is one of the worst diseases with its ubiquitous challenges due to its unique psychopathology and life events. Patients with schizophrenia use various coping strategies to overcome distress. The aim of the study was to evaluate the association between perceived stress, quality of life, and coping skills in patients with schizophrenia in remission. A total of 48 consecutive patients of schizophrenia, in remission, attending outpatient department of psychiatry at Academic hospital, South India, who satisfied the inclusion and exclusion criteria were recruited for the present study. The participants were assessed on Positive and Negative Symptoms Scale, Ways of Coping Checklist – Revised and Perceived Stress Scale and WHO Quality of Life. Results were analyzed using appropriate statistical package software v 16.0.

Result

Highest medial was found in self-controlling and positive reappraisal coping skills. Distancing is associated with high physical domain of quality of life whereas patients with good social support score more in social and physical domain of quality of life.

Conclusion

Patients with history of schizophrenia even though in remission dwell a stressful life. They often need different kind of social support or cognitive aids. In that view, studying their stress level, ability to cope with it, and quality of life will help us to manage them in better way.

Early Implementation of a Patient-Centered Medical Home in Singapore: A Qualitative Study Using Theory on Diffusion of Innovations

Patient-Centered Medical Home (PCMH) has been found to improve care for complex needs patients in some countries but has not yet been widely adopted in Singapore. This study explored the ground-up implementation of a PCMH in Singapore by describing change strategies and unpacking initial experience and perception. In-depth interviews were conducted for twenty-two key informants from three groups: the implementers, their implementation partners, and other providers. “Diffusion of innovations” emerged as an overarching theory to contextualize PCMH in its early implementation. Three core “innovations” differentiated the PCMH from usual primary care: (i) team-based and integrated care; (ii) empanelment; and (iii) shared care with other general practitioners. Change strategies employed to implement these innovations included repurposing pre-existing resources, building a partnership to create supporting infrastructure and pathways in the delivery system, and doing targeted outreach to introduce the PCMH. Initial experience and perception were characterized by processes to “adopt” and “assimilate” the innovations, which were identified as challenging due to less predictable, self-organizing behaviors by multiple players. To work with the inherent complexity and novelty of the innovations, time, leadership, standardized methods, direct communication, and awareness-building efforts are needed. This study was retrospectively registered (Protocol ID: NCT04594967).