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Targeting an ageing population

Organization: CernerAgency for Integrated Care

Country: Singapore

Forum: Accountable care

In response to poor chronic disease control and high rates of avoidable A&E admissions and readmissions as a result of fragmented long-term care, the Singapore Ministry of Health set-up the Agency for Integrated Care (AIC) in 2008. The aim of AIC is to co-ordinate and deliver long-term care for the entire population, including the elderly.

AIC recognized that the elderly population consists of patient groups with very different needs and launched several initiatives to cater for these different groups. Among them were the Singapore Integrated Care Program for the Elderly (SPICE), a center based community medical home, and Holistic Care for Medically Advance Patients (HOME), a palliative healthcare program. To track all relevant patients, and transition them from hospital into the appropriate long-term community-care program, AIC created Aged Care Transition (ACTION) teams.

The results of these initiatives have been significant. ACTION teams have reduced a patient’s chance of being re-admitted to hospital within 30 days of discharge by over 40 percent. SPICE has halved the number of A&E visits. Patient experience has also improved with more than 50 percent of SPICE participants reporting an improved perception of their own health status after a year on the program; and of those patients who died within one year of HOME’s launching, about 70 percent died in their preferred place of death.

Going forward, AIC aims to cover other segments of the elderly population with new programs as well as launching new initiatives such as the Family Medicine Clinic and the Primary Care Network models.

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