A campus to bring community services together to form a coherent network of care – The Queenstown experiment

• Published in: International journal of integrated care Vol. 19; no. 4; p. 551
• Main Authors: Wong, Serene, Chiang, Grace, Meng Khoo, See
• Format: Journal Article
• Language: English
• Published: Ubiquity Press 08.08.2019
• Subjects: community services; community strategy; integrated care; integrated network of care
• ISSN: 1568-4156; 1568-4156
• DOI: 10.5334/ijic.s3551

In Singapore, a broad range of healthcare services are provided by multiple healthcare providers, government agencies and volunteer welfare organizations to support the care of patients in the community after their discharge from the hospital. These services, though comprehensive, operate in silos and are often reactive and piecemeal resulting in a chaotic support system which is difficult for patients to navigate.   This in turn leads to care that is fragmented and incoherent. It is conceivable that the solution is not to create more services but to strengthen the complex relationships between these services to construct a seamless, complementary and integrated network of care which is able to support the patient in the community with the simplicity of a single touchpoint. We describe here our strategy to use a campus, built for the community, as a catalyst for integration of health and social care beyond the confines of the hospital. Methods: In June 2018, Alexandra Hospital became the first Integrated General Hospital in Singapore; the mission - to become a health-empowering campus which delivers holistic care across the care continuum. As part of our strategy, we first started by mapping existing services in the community to sketch a landscape of the support services. A comprehensive and coherent network of care, together with an implementation framework, was then constructed based on our understanding of the needs of the community. Next, we shared this framework, exchanged ideas and refined our strategy through multiple engagement sessions with key stakeholders of Queenstown, including community leaders, primary care physicians and social service providers. The key areas in the framework include forming a Community Strategy Workgroup, developing satellite hubs, setting up home-based care teams, designing training programmes to enhance community partner capabilities to meet care demands with a focus on end-of-life care in the community and nursing homes, promoting shared care with primary care and the use of telehealth. Concurrently, care managers, community case workers, community nurses and the patients’ primary physicians come together to form the One Care Team, which serves as the single touchpoint to help patients navigate this network of care. Results: The strengths of this model are manifold. Firstly, the identification of the care team ensures ownership of the patient’s care and a handover between providers. Secondly, by establishing a close working relationship with our community partners, we have taken a collaborative approach to managing the health and social needs of the patients holistically. Thirdly, this common platform allows a review of the patient’s care goals, ensuring a consistent care plan across care settings. Conclusion and lessons: A strategy based on strengthening relationships between hospital and community partners to create a complementary and comprehensive community of care, which is delivered with the simplicity of One Care Team, can help achieve health and social integration in an otherwise fragmented system. Future plans: This plan is in its pilot stage. We will continue to collect data, monitor patient outcomes and refine our strategy to improve its applicability across the country.