Developing an Integrated Community of Care in Singapore

NCT02678273 | Withdrawn

• 1 other identifier: SGH_OIC_ICOC Version 1.0
• Study Type: interventional
• Target: N/A
• Locations: 1 country
• Sites: 1

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.

Conditions

Socioeconomically Disadvantaged

Keywords

population; Singapore

Outcome Measures

Primary Outcomes (1)

• Healthcare utilization (hospital admissions, emergency department visits, outpatient specialist clinics visits, primary care clinic visits)

  via electronic health records

  One year

Secondary Outcomes (4)

• Glycated haemoglobin

  One year

• Lipid profile

  One year

• Blood Pressure

  One year

• EQ-5D

  Six months

Study Arms (2)

Intervention group

EXPERIMENTAL

Intervention

Other: Intervention group

Control group

NO INTERVENTION

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.

Interventions

Intervention group OTHER

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 .

Intervention group

Eligibility Criteria

• Age: 60 Years - 100 Years
• Sex: all
• Healthy Volunteers: Yes
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Residents \> 60 years old
• Staying in 1 or 2 room rental flats in the Block 51 and 52 Chin Swee and Block 5 Banda Street residential estate
• Have at least 1 episode of the following:
• SGH Specialist outpatient clinic attendance
• SGH A\&E attendance
• SGH Inpatient stay

You may not qualify if:

• Patient declines service
• Patient has aggressive / abusive behaviour

Sponsors & Collaborators

• Singapore General Hospital: lead

Study Sites (1)

Singapore General Hospital

Singapore, 486838, Singapore

Location

Related Publications (1)

• Low LL, Maulod A, Lee KH. Evaluating a novel Integrated Community of Care (ICoC) for patients from an urbanised low-income community in Singapore using the participatory action research (PAR) methodology: a study protocol. BMJ Open. 2017 Oct 8;7(10):e017839. doi: 10.1136/bmjopen-2017-017839.

  PMID: 28993391 DERIVED

Study Officials

• Kheng Hock Lee, MMed

  Singapore General Hospital

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: NON RANDOMIZED
• Masking: NONE
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Study Record Dates

• First Submitted: February 4, 2016
• First Posted: February 9, 2016
• Study Start: November 1, 2016
• Primary Completion: November 1, 2018
• Study Completion: November 1, 2018
• Last Updated: April 28, 2023

Record last verified: 2023-04

Locations

SG (1)