Enhancing Patient Wellbeing Through Integration of Social Prescribing, Transitional Care, and Place-based Care in Community Hospitals Settings

NCT07856030 | Not Yet Recruiting

• 2 other identifiers: 2026-1373SHF-SCH/26/IFC1-6/01
• Study Type: interventional
• Target: 720
• Locations: 1 country
• Sites: 2

Brief Summary

The study aims to find out whether placed-based care (PBC), helps patients receive better support when they return home after leaving the community hospital, compared with the usual care provided.

Conditions

Community Hospital Patients Discharging to the Community

Keywords

Community Hospital; Social Prescribing; Placed Based Care

Outcome Measures

Primary Outcomes (1)

• Care Transition Quality (CTM-15)

  The CTM-15 is the primary outcome measure for this study and aligns closely with the five core domains of the PBC intervention: specialist outpatient clinic (SOC) follow-up coordination, community resource linkage, medication adherence support, primary care transition planning, and caregiver and self-care capability. The CTM-15 is a validated 15-item instrument that assesses the quality-of-care transitions from the patient's perspective, capturing key domains such as medication management, understanding of the care plan, preparation for self-care, and coordination across healthcare settings.

  T1: 21 Days Post-Discharge

Study Arms (2)

SCH Place-based Care Intervention Ward

ACTIVE COMPARATOR

SingHealth Community Hospitals Place-based Care model will be utilised in the ward on top of standard of care treatment.

Other: SingHealth Community Hospitals Place-based Care

SCH Control Ward

NO INTERVENTION

Wards will have normal standard of care treatment.

Interventions

SingHealth Community Hospitals Place-based Care OTHER

Place-based Care (PBC) at SingHealth Community Hospitals represents a significant evolution of these approaches, addressing the limitations of fragmented care by integrating social prescribing with structured transitional care. Within community hospital settings, PBC encompasses five core domains: coordinated specialist outpatient follow-ups, linkage to community resources, medication adherence support, primary care transition planning, and caregiver education and self-care empowerment. This integrated model shifts the conventional discharge process from a primarily episodic and medically driven approach to a comprehensive, person-centred care pathway that incorporates both clinical and social assessment, coordinated care planning, supported transition, and structured follow-up. By embedding social prescribing within the continuum of care, PBC aims to improve both clinical outcomes and patient experience during vulnerable transition periods.

SCH Place-based Care Intervention Ward

Eligibility Criteria

• Age: 50 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Participant is (male or female) ≥ 50 years of age at Recruitment.
• Participant is expected to discharge to the community.
• Participant is able to converse in either English, Mandarin, or Malay
• Participant is able to sign the written informed consent.
• Participant is considered reliable and capable of adhering to the protocol.
• Participant is able to complete all the questionnaires.

You may not qualify if:

• Participant is planned for hospice discharge.
• Participant is planned for nursing home placement, transitional shelter or care facilities

Sponsors & Collaborators

• SingHealth Community Hospitals: lead

Study Sites (2)

Outram Community Hospital

Singapore, Singapore

Location

Sengkang Community Hospital

Singapore, Singapore

Location

Study Officials

• Kheng Hock Lee

  SingHealth Community Hospitals

  PRINCIPAL INVESTIGATOR

Central Study Contacts

A/Prof Lee Kheng Hock

CONTACT

69703201; lee.kheng.hock@singhealth.com.sg

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Associate Professor Lee Kheng Hock

Study Record Dates

• First Submitted: September 27, 2026
• First Posted: October 2, 2026
• Study Start (Estimated): November 17, 2026
• Primary Completion (Estimated): July 31, 2027
• Study Completion (Estimated): January 31, 2028
• Last Updated: October 2, 2026

Record last verified: 2026-09

Data Sharing

• IPD Sharing: Will not share

Locations

SG (2)