RESEARCH REPORT

Tracer Study of Elderly Patients from Alexandra Hospital Raudhah Bte Razali, Arts and Social Sciences ‘20 Lim Yong Shan, Science ‘22 Joey Lee Jia Yi, Dentistry ‘22 Daniel Lam Chin Kiat, Business ‘22

Foreword

NUS Chua Thian Poh Community Leadership Centre (CTPCLC) offers a

Community Development Practicum module through which students have

the opportunity to collaborate with community organisations on research

and evaluation projects. Over the years, CTPCLC students have partnered

with a range of social purpose driven organisations (e.g. government

agencies, voluntary welfare organisations, social enterprises) on projects

that address pressing social and community issues.

In this study, Raudhah Bte Razali, Lim Yong Shan, Joey Lee Jia Yi, and

Daniel Lam Chin Kiat partnered with MOH Office of Healthcare

Transformation to study how Alexandra Hospital patients navigate their

healthcare journey post-discharge. They conducted interviews with

patients at three time points (1 week, 1 month and 2 months post-

discharge) to understand discharged patients’ experiences in managing

their health. In particular, the students focused on learning more about

their healthcare needs and challenges faced in managing their health after

being discharged from the hospital.

Findings from the study provided MOHT with deeper insights on the

experiences of these patients, which would enable them to design more

appropriate solutions to deliver patient-centred care.

Dr. Angeline Lim

Lecturer Chua Thian Poh Community Leadership Centre

Contents

01 About MOHT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 01

02 About the Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 02

03 Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 03

04 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 05

05 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 08

06 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 09

07 Partner’s Reflections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

08 Student Fellows’ Reflections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1 © 2020 National University of Singapore. All rights reserved.

ABOUT MOHT MOH Office of Healthcare Transformation (MOHT) is an agile unit with the mandate to address

fundamental and longer-term issues critical for system-level healthcare transformation to

meet Singapore’s changing demography, and health and disease patterns. MOHT works with

partners to identify pilots that support its programmes and complement ongoing work at MOH

and clusters / institutions, with each pilot taking a design-centric approach to implementation,

involving providers, healthcare professionals, patients and caregivers at all stages of the

design of solutions. MOHT adopts a value-based healthcare approach in endeavouring to

achieve better health and clinical outcomes. A longer-term and broader perspective is

essential in identifying key system-wide changes needed. These encompass shifts in the

following three directions: (1) longitudinal, holistic care across persons’ entire life course; (2)

strengthened focus on wellness and the prevention of chronic disease; and (3) empowerment

of individuals and patients for better self-management. Each collaboration will be staged with

rapid build-measure-learn cycles, anchored by enablers such as technology scanning, IT,

data analytics, finance and incentive redesign. From these collaborations, MOHT will develop

frameworks, methodologies and toolkits to enable effective solutions to be scaled across the

wider healthcare system.

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ABOUT THE PROJECT A patient’s healthcare journey continues even after he or she is discharged from the hospital.

Often, healthcare challenges only surface when patients are at home1. The effectiveness of

patients’ transition into the community thus highly influences whether they are readmitted into

the hospital, highlighting the importance of enabling patients to seamlessly transit from

hospital to community. With Singapore’s healthcare system originally built for a younger

population, it is imperative to ensure that the healthcare system accommodates the different

and complex needs of elderly patients in light of the country’s ageing population2.

In Singapore, multiple barriers to smooth transition from hospital to community still remain,

supported by a relatively high attrition rate from the healthcare system post-discharge and

hospital readmission rates. To date, MOHT has partnered Alexandra Hospital (AH) and

community care providers to discuss potential methods to make care more accessible to

patients and address the challenges that patients face in their healthcare journey. In order to

ascertain that these solutions are indeed addressing the patients’ medical, social and

functional needs, we collaborated with MOHT to understand elderly patients’ experiences

taking care of their own health and navigating through the various healthcare and community

care services after their discharge from the hospital through a longitudinal approach.

1 Kripalani, Sunil, Amy T. Jackson, Jeffrey L. Schnipper, and Eric A. Coleman. (2007). Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalists. Journal of Hospital Medicine, 2(5),314-323. 2 Choo, F. (2018, February 2). Hospital-to-Home programme has helped around 8,000 patients. The Straits Times. Retrieved from https://www.straitstimes.com/singapore/health/public-hospital-transitional-care-programme-has-helped-around-8000-patients

3 © 2020 National University of Singapore. All rights reserved.

METHOD To better understand the post-discharge journey of elderly patients, we conducted interviews

with 8 elderly patients at three time points after they were discharged from Alexandra Hospital.

Specifically, we interviewed them 1 week, 1 month and 2 months after they had been

discharged from the hospitals. Patients were asked about their medical, social and functional

needs, as well as challenges encountered in taking care of their health and navigating the

healthcare system.

Image: Team members being given an introductory tour around the wards while learning about the healthcare landscape within Alexandra Hospital.

Patients who were deemed potential research participants were first shortlisted by the nursing

team at AH. Patients were shortlisted based on three criteria: (1) age (above 60 years old), (2)

having multiple medical conditions, and (3) whether their homes are located within the zones

under the NUHS cluster. The research team then recruited participants by approaching and

speaking to these patients at AH prior to their discharge and obtained their consent to

participate in the study.

(Note: we had initially recruited 17 patients for the study. We were able to reach out to 10

participants at Time 1 (1 week post-discharge) and at Time 2 (1 month post-discharge), but

due to non-response by participants for subsequent interviews, we were left with a sample of

8 participants whom we were able to engage across all 3 time points.)

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Figure 1 below summarises the demographics of the respondents.

Figure 1: Demographics of patient respondents, categorised by age, gender, living arrangements and

cause of hospitalisation.

To analyse our interview findings, we adapted the Partners At Care Transition Measure (PACT-

M)3 to understand how patients were activated to take charge of their own health and how

they navigated through healthcare and community care services. The PACT-M was

constructed to understand the long-term experiences of elderly patients aged 65 and above

with multiple health conditions in their transition from hospital to community. We adapted the

framework’s components in conducting a thematic analysis of our interview findings. These

findings relate to patient activation and patient navigation. Patient Activation is defined as

patients’ knowledge, skill and confidence in managing their own health, while Patient

Navigation is defined as patients’ knowledge of healthcare and social services and ability to

access these services.

3 Oikonomou, E., Chatburn, E., Higham, H., Murray, J., Lawton, R., & Vincent, C. (2019). Developing a measure to assess the quality of care transitions for older people. BMC Health Services Research, 19(1), Article 505 (2019).

5 © 2020 National University of Singapore. All rights reserved.

FINDINGS Our interviews at each time point provided us with valuable insight into the various

experiences and challenges in their post-discharge journeys. We present the key themes that

emerged from interviews at each time point before providing a summary of the key findings

based on their overall post-discharge journey. These findings could be further stratified into

three main categories – social, medical and functional – to provide a more holistic overview

of patients’ needs and aspirations.

1-Week Post-Discharge

Figure 2 summarises our qualitative findings extracted from interviews with patients at 1-week

post-discharge.

Figure 2: Social, medical, and functional challenges/experiences faced by elderly patients 1 week into

their post-discharge journey.

In general, there was consensus in the experiences of patients in their transition from hospital

to home at the 1-week mark. Patients unanimously reported that they follow medication

schedules stringently, albeit a weak understanding of its use. Functional and social challenges

include limited physical mobility due to their recovering injury, as well as turning to loved ones

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for physical and emotional support. Almost half of our interviewed respondents reflected that

they relied on spirituality for comfort and relief For example, one respondent mentioned that

healing from physical illness comes with prayer and suggested that her daily routine of reading

religious scriptures enables her to cleanse her body to make her feel better from her illness.

1-Month & 2-Month Post-Discharge

Figure 3 below presents our key findings from interviews with patients’ 1-month and 2-

months into their post-discharge journey.

Figure 3: Social, medical and functional challenges/experiences faced by elderly patients 1 month and

2 months into their post-discharge journey.

Interestingly, we began to see a change in patients’ attitudes and challenges as they

transitioned into the later part of their post-discharge journey. Notably, patients reflected a

general sense of unwillingness to approach healthcare practitioners or their loved ones for

help, for fear of troubling them. Frequent follow-up appointments to their healthcare providers

also led to mental and physical fatigue. Feelings of resignation, lethargy and fear were also

reported at this stage.

7 © 2020 National University of Singapore. All rights reserved.

Summary

Figure 4 summarises a typical Alexandra Hospital patient’s post-discharge journey from

hospital to home. It shows how a patient navigates the healthcare system and their community

in their post-discharge process.

Figure 4: A typical Alexandra Hospital patient’s post-discharge journey from hospital to home.

(T1: 1 week post-discharge; T2: 1 month post-discharge; T3: 2 months post-discharge)

While some of our findings are consistent with contemporary studies regarding transitional

care, like the fact that communication is often fragmented, our study has also highlighted

issues that were not mentioned in studies done outside of Singapore. Pertinent findings from

our study are as follows (see Figure 5):

Figure 5: A summary of more pertinent findings in our study

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RECOMMENDATIONS

1. Streamlining Post-Discharge Process

To make discharge navigation easier for patients, we propose that a patient’s follow-up

appointments can be scheduled within the same day if possible. This potentially reduces the

number of times the patient and his/her caregiver has to travel to the hospital, in turn reducing

both the patient’s and caregiver’s fatigue. In addition, having a customized help sheet for

each patient based on their needs may enable patients to understand the post-discharge

process and encourage them to take charge of their own health. Navigation within the hospital

for follow-up appointments can also be made more elderly-friendly, with mother tongue

translations and colour-coded pathways which elderly patients can more easily understand.

2. Encourage Help-Seeking Behaviour

We recommend setting up guidelines on when patients should contact the hospital if they

encounter challenges with their post-discharge care. We propose having more

comprehensive rehabilitation instructions, such as informing patients what to do if they

experience pain during their rehabilitation exercises. Collectively, these recommendations

seek to provide patients with more information that can help them take charge of their health

and increase their confidence in outreaching to the relevant people in their post-discharge

journey. This could allow patients to overcome the hesitancy that they feel in seeking help

from the hospital.

3. Diversify Social Support Avenues

Leveraging on how spirituality was a common source of comfort among patients interviewed,

we suggest partnering with religious organisations in raising awareness of existing healthcare

helplines and organisations. As religious networks were identified as a trusted source of

information among patients, this recommendation could provide patients with more

information on how to navigate the community care landscape. This in turn activates patients

to take control over their own health, thereby reducing pressure on the caregiver to take

ownership of the patient’s health.

9 © 2020 National University of Singapore. All rights reserved.

CONCLUSION ‘Beyond Hospital to Community’ is one of the three paradigm shifts that will shape the future

of Singapore’s healthcare system, aimed at creating an integrated healthcare system that

streamlines patients’ ability to take care of their own health within the community. In order to

do so, there is first a need to understand patients’ experiences transitioning from the hospital

to the community. Through this study, we shed light on the lived post-discharge experiences

of the Singaporean elderly - their needs, fears, and the barriers they face.

While the study is limited in terms of its small and gender-biased sample (with 7 out of 8

respondents being female), its findings remain a true representation of the post-discharge

journey that these patients experience. Stakeholders, like the Ministry of Health, private or

public community healthcare organisations, can consider using these insights to craft more

patient-centric solutions.

Future research into the use of religious networks as touchpoints, adoption of technology and

better communication mediums, can surely help to bolster our healthcare system.

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PARTNER’S REFLECTIONS

MOH Office for Healthcare Transformation (MOHT) collaborated with Chua Thian

Poh Community Leadership Centre (CTPCLC) in a project to design solutions for

elderly patients in Queenstown who require help in accessing and navigating care

post discharge. CTPCLC students carried out 2 studies. The first involved

longitudinal research with patients over 3 months to derive an in-depth

understanding of patients’ healthcare journeys from hospital to home. The second

focused on understanding the elderly patients’ technology adoption appetite and

capacity. Both studies provided valuable information on the challenges faced by the

elderly as well as their help-seeking behaviours.

In the patient tracer journey study for example, students discover how vulnerable

patients can feel in the face of illness and how proper coordination of care, as well

as patient empowerment towards self-care, can alleviate those feelings. The study

on tech and the elderly found that even though the elderly feel that that technology

was generally useful in maintaining health, technology is not seen as a major driver

of health-seeking behaviour.

These insights inform care providers in developing solutions that are useful, relevant

and pitched appropriately to the levels of patients’ ability and willingness to accept

care. Both studies are helpful in guiding care practitioners in the drive towards

patient-centred care, providing care that is respectful of, and responsive to,

individual patient preferences, needs and values.

Liang Hwee Ting

Director

Corporate Communications, Outreach and Patient Experience

MOH Office for Healthcare Transformation

11 © 2020 National University of Singapore. All rights reserved.

STUDENT FELLOWS’ REFLECTIONS

Working on this project with MOHT and the team was an

insightful experience which broadened my perspective on the

healthcare and community care landscape. Interacting with

elderly patients on this project made me realise that every patient

has a unique experience in taking care of their own health,

enabling me to appreciate the diversity of patients’ needs and

aspirations. This valuable research journey has truly instilled in me

the importance of patient-centric care in Singapore in light of an

ageing population and has motivated me to pursue my interest in

healthcare research.

Raudhah Bte Razali

Arts and Social Sciences ‘20

Throughout this research process with CTPCLC and

MOHT, I have gained invaluable technical knowledge and soft

skills. My experience with the elderly patients instilled in me

greater compassion and spurred me to actively understand the

healthcare landscape in Singapore, particularly for the elderly,

whose experiences may not always be heard. It was a

meaningful research study of understanding how the

healthcare system in Singapore functioned, not only at the level

of hospital care, but also to post-discharge and beyond.

Lim Yong Shan

Science ‘22

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Coming from a healthcare-related background, I thought I

would have a better understanding of the situation, but I failed

to realise that the study of care encompasses so much more.

After finding out how lost patients can feel post-discharge, I

believe that we, as healthcare professionals, should be on the

lookout constantly for how to make things better for our

patients, even if our healthcare system is seen to be one of the

most robust. The conversations and relationships I have built

with our interviewees are sure to remain etched in my

memories, serving as motivation for me to become a better

clinician.

Joey Lee Jia Yi

Dentistry ‘22

The collaborative project between CTPCLC and MOHT

was an eye-opening experience that allowed me to gain

insights into the elderly healthcare landscape in Singapore.

During the interviewing process, I found the conversations with

the elderly particularly meaningful as I not only get to find out

more about their pain points about the current healthcare

system, but also get to know them on a more personal level.

As we are in the era of embracing technology, my hope is for

these mediums to create a more efficient healthcare system,

while leveraging on all the feedback received from patients.

Daniel Lam Chin Kiat

Business ‘22

About Chua Thian Poh Community Leadership Centre Located at NUS University Town, the Chua Thian Poh Community Leadership

Centre is named in recognition of Dr Chua’s generous gifts to the University. At

the Centre, we aim to nurture Singapore’s next generation of community

leaders, who will not only be intellectually engaged in social and community

issues, but will also be passionate about addressing social and community

challenges in Singapore.

Each year, we admit a select number of NUS undergraduates from different

disciplines as student fellows. Together with faculty members and

organisational partners, the student fellows learn to adopt a multi-disciplinary

approach and conduct social research such as needs assessment, asset

mapping, programme evaluation, social impact measurement and identification

of sustainable solutions.

To date, our student fellows have worked with over 100 organisational partners

serving different communities in Singapore; healthcare, family service,

disadvantaged individuals, and many more. The programme has also inspired

our student fellows and alumni to continue initiating ground-up community

projects involving a wider NUS community. We hope to inspire young

community leaders within and beyond NUS to contribute to a more caring, and

resilient society.

Chua Thian Poh Community Leadership Centre

University Town, 1 Create Way, Town Plaza, #02-05, Singapore 138602

ctpclc.nus.edu.sg ctpclc@nus.edu.sg fb.com/ctpclc