Patients gain from new focus on home care

In the article, "Bring back house calls", published in The Straits Times on Oct 17, Dr Sandeep Jauhar lamented that only less than 1 per cent of all doctor-patient encounters in the United States were house calls, resulting in doctors being ignorant of patients' home situations, and unplanned readmissions within a month in a fifth of Medicare patients, at a cost of US$17 billion (S$24 billion) a year.

The situation in Singapore is not so bleak. Dr Jauhar rightly pointed out that the main reason why house calls are rare nowadays is cost.

Based on the Singapore Medical Association's old consultation fee guidelines, (before it was deemed uncompetitive by Competition Commission of Singapore), the recommended cost of routine home visits was already eight times higher than clinic consultations. It is challenging for family physicians to do home visits as the opportunity cost of leaving their clinic unattended, and not being able to see any patients while travelling to and from a patient's home, is high. It is even harder for hospital specialists to do house calls because their opportunity cost is higher, and there is an acute shortage of them in our public hospitals.

Doctors are also not the only healthcare professionals who need to do house calls. Patients who benefit from house calls, such as frail, housebound elderly folk with multiple illnesses and medications, are complex cases and need other members of the multidisciplinary healthcare team to care for them.

For example, they may need nurses to provide wound and tube care, physiotherapists for rehabilitation to help them regain independence and retard physical decline, and occupational therapists to arrange appropriate modifications and repairs to improve patient safety and prevent falls at home.

FROM HOSPITAL TO HOME

Unlike the US, improving such integrative, transitional and home-care services is a priority for the Ministry of Health, which has been working closely with acute service hospitals and intermediate and long-term care providers in preparation for our ageing population. The national Agency for Integrated Care (AIC) has set up Aged Care Transition (Action) teams of care coordinators, and they are stationed at all five public general hospitals to arrange appropriate community services for patients and caregivers prior to discharge.

These Action teams improve patients' physical functions, safety and quality of life, and reduce unnecessary emergency room visits by 20 per cent, and avoidable readmissions by 50 per cent.

Transitional care services, such as Khoo Teck Puat Hospital's Ageing-in-Place Programme, help recently discharged patients with complex conditions transition smoothly from hospital to home through comprehensive assessment and complication prevention by a team of doctors, nurses and therapists.

"Frequent fliers", patients who are unnecessarily readmitted to acute hospitals multiple times, utilise disproportionately more scarce resources, and are costly.

Besides unstable medical conditions, other addressable reasons for repeated admissions include financial difficulties, not-yet-confident caregivers, non-adherence to medications, and unsafe homes. In fact, research suggests that seven out of the 10 factors that cause readmissions are preventable through holistic post-discharge care.

Khoo Teck Puat Hospital's Community Nurse Home Visit Programme, which adopts a "high touch" approach for these frequent fliers, first builds trust with patients and caregivers at their homes, then holistically assesses their clinical, social and environmental needs, and jointly develops individualised care plans to keep them well at home.

These community nurses become the patients' point of contact for navigation and access to available assistance schemes and services. If needed, pharmacists, dietitians, physiotherapists and even doctors will conduct home visits with the community nurses.

This innovative and cost-effective programme reduced readmission rates of frequent fliers by two-thirds, and won the first prize in the 2014 United Nations Public Service Award for the category of "Improving the Delivery of Public Services".

To help patients cope at home, there is multidisciplinary long-term home care for medically stable, housebound elderly people provided by services such as the Tsao Foundation's Hua Mei Mobile Clinic, and the Care for the Elderly Foundation's CODE 4 Home Care.

To improve medication compliance, there are existing strategies such as medication delivery services, and medicines pre-packaged in convenient by-time-of-the-day blister packs.

Caregivers are increasingly recognised as important home-care partners and support is available to them in the form of Caregivers Training Grants, which offer $200 annually for training courses and planned respite services.

COMMUNICATION IS KEY

Dr Jauhar also pointed out that one factor in the breakdown in the continuity of care after hospital discharge in the US is a lack of communication with primary care physicians when following up on patients after discharge. There is also a shortage of such physicians.

In Singapore, the new National Electronic Health Records system is linked with the polyclinics, and there are plans to link GPs to the system too, so that communication between hospital teams and Singaporeans' primary care physicians will be easier and faster.

There have been forward steps in making primary care a more attractive career for newly graduated doctors, such as the recent recognition of family medicine as a specialty by the Academy of Medicine Singapore, and expanding the roles of family physicians in Singapore's acute and community hospitals, and intermediate and long-term care.

To train future doctors in home care, the National University of Singapore's Yong Loo Lin School of Medicine has been exposing medical and nursing students to home care early in their formal curriculum through the Longitudinal Patient Experience programme, where students - mentored by doctors and nurses - learn through home visits how patients cope with their health conditions after discharge.

NUS' medicine students also learn home care informally through the faculty-supported but student-led Neighbourhood Health Service, where students offer health screening to low-income families living in rental flats, and follow-up those newly diagnosed or with uncontrolled chronic conditions via three-monthly home visits under the guidance of doctors and nurses, until they seek regular care from the public healthcare system.

Although Singapore's home-care system is in a much better state than the US, there is still room for improvement. For example, more can be done to incentivise regional healthcare systems to provide transitional and home-support schemes more comprehensively, through alignment of remuneration. What is needed is a shift from a hospital bed-occupancy model to a community-based model that rewards prevention of unnecessary readmissions and quality home care.

Traditional house calls by doctors need to be replaced by a multidisciplinary approach to home care, and home-care needs need to be viewed as a spectrum of services from discharge planning to transitional, frequent flier, long-term home and caregiver care. While Singapore's home-care ecosystem is developing well, we should not rest on our laurels but continue to strive to make it better.

  • The writer is an associate professor at the Saw Swee Hock School of Public Health and Yong Loo Lin School of Medicine at the National University of Singapore.
A version of this article appeared in the print edition of The Straits Times on November 02, 2015, with the headline 'Patients gain from new focus on home care'. Print Edition | Subscribe