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Developing an Integrated Community of Care in Singapore

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. Identifier: NCT02678273
Recruitment Status : Unknown
Verified November 2016 by Singapore General Hospital.
Recruitment status was:  Recruiting
First Posted : February 9, 2016
Last Update Posted : November 8, 2016
Information provided by (Responsible Party):
Singapore General Hospital

Brief Summary:
The investigators will provide an integrated community of care to a socioeconomically disadvantaged population. This included an extended cycle of care from tertiary care to primary care and linkages with social care agencies in the community.

Condition or disease Intervention/treatment Phase
Socioeconomically Disadvantaged Other: Intervention group Not Applicable

Detailed Description:
Socioeconomically disadvantaged patients are at higher risk of unplanned readmissions, ill health from higher chronic disease burden and utilize more healthcare resources. In Singapore, people at the lowest strata of socioeconomic status have an 8 times higher risk of inpatient utilization and twice the risk of having multiple chronic diseases, while utilizing less primary care compared to the general population. The reasons for poorer health outcomes are many, including lack of social support, and a subsidy system that encourages acute hospital utilization instead of primary care utilization. A community-based intervention program that extends into the rubric of these communities is required to address the social determinants of poor health, and break the intractable cycle of low socioeconomic status and poor health. The investigators will develop an integrated community of care comprising of integrated practice units (IPUs) such as the Integrated Clinical Care Service, Transitional Home Care from Singapore General Hospital, Care Closer to Home Program from the Agency of Integrated Care, Chinatown Point Family Medicine Clinic and Ageing gracefully at home from the grassroots to systematically deliver primary, transitional and social care to a socioeconomically disadvantaged population at the Chin Swee and Banda residential estate. A community-based integrated care team will support and connect the various IPUs in the form of a community virtual ward. Residents enrolled into the intervention program will be followed up prospectively for one year. The effectiveness of an integrated community of care in improving health outcomes will be evaluated and the investigators hypothesize that the program will be cost-effective in improving the health status of socioeconomically disadvantaged populations in Singapore. The results of the study will be informative to policy makers to deliver value based healthcare and acts as a blueprint for other regional health systems to deliver care to similar populations.

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Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 600 participants
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)
Primary Purpose: Health Services Research
Official Title: Developing an Integrated Community of Care for a Socioeconomically Disadvantaged Population in Singapore
Study Start Date : November 2016
Estimated Primary Completion Date : November 2018
Estimated Study Completion Date : November 2018

Resource links provided by the National Library of Medicine

Arm Intervention/treatment
Experimental: Intervention group
Other: Intervention group

The Family Medicine Clinic will be the patient centred medical home to manage their complex care needs. A common electronic record will be created for information sharing between care partners. The Integrated Clinical Care Service will provide inpatient care for admitted residents, with emphasis on comprehensive discharge planning and hand-over of care. Patients at high risk of destabilization will receive an early review in outpatient clinic. Home or bed bound residents will be managed by SGH Home Care. The Care Closer to Home comprises a case manager and nursing aides to put in place health, personal and social services e.g. medication management, home help services. The Senior Activity Centre will encourage the elderly to remain integrated in society through community outreach programmes and social recreational activities. A community virtual ward will connect these care providers and weekly meetings to discuss care plans for the frail and sick residents


No Intervention: Control group
Standard care when patient is in the hospital. At discharge, patients may be referred to community services as deemed necessary by the hospital team. This is not restricted.

Primary Outcome Measures :
  1. Healthcare utilization (hospital admissions, emergency department visits, outpatient specialist clinics visits, primary care clinic visits) [ Time Frame: One year ]
    via electronic health records

Secondary Outcome Measures :
  1. Glycated haemoglobin [ Time Frame: One year ]
    Chronic disease indicator

  2. Lipid profile [ Time Frame: One year ]
    Chronic disease indicator

  3. Blood Pressure [ Time Frame: One year ]
    Chronic disease indicator

  4. EQ-5D [ Time Frame: Six months ]
    Health related Quality of Life

Information from the National Library of Medicine

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Ages Eligible for Study:   60 Years to 100 Years   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   Yes

Inclusion Criteria:

  1. Residents > 60 years old
  2. Staying in 1 or 2 room rental flats in the Block 51 and 52 Chin Swee and Block 5 Banda Street residential estate
  3. Have at least 1 episode of the following:

    1. SGH Specialist outpatient clinic attendance
    2. SGH A&E attendance
    3. SGH Inpatient stay

Exclusion Criteria:

  1. Patient declines service
  2. Patient has aggressive / abusive behaviour

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT02678273

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Contact: Kheng Hock Lee, MMed

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Singapore General Hospital Recruiting
Singapore, Singapore, 486838
Contact: Lian Leng Low, MMed    91051097   
Sponsors and Collaborators
Singapore General Hospital
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Principal Investigator: Kheng Hock Lee, MMed Singapore General Hospital
Publications automatically indexed to this study by Identifier (NCT Number):
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Responsible Party: Singapore General Hospital Identifier: NCT02678273    
Other Study ID Numbers: SGH_OIC_ICOC Version 1.0
First Posted: February 9, 2016    Key Record Dates
Last Update Posted: November 8, 2016
Last Verified: November 2016
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Undecided
Keywords provided by Singapore General Hospital: