Anchor & Integrate Care in the Community (AICC)
Care Process & Redesign
Workforce Transformation
National Healthcare Innovation and Productivity Medals
National University Health System
27 January 2026
The aim is to reduce unnecessary transfers, readmissions within 30 days, and total admissions for nursing home residents to. The AICC programme reduced hospital admissions and unnecessary referrals by empowering staff with relevant skills and tools.
Year Submitted: 2025
Published Date: 27 January 2026
Tags: Workforce Transformation, Readmission Rate, Workflow Redesign, Access To Care, Care Process ＆ Redesign, Job Redesign, Upskilling
About this Content
Aims
The aim is to reduce unnecessary transfers, readmissions within 30 days, and total admissions for nursing home residents to NTFGH by implementing the AICC pilot collaboration.
Background
NTFGH observed an increase in hospital admission rates from nursing homes, with some transfers being unnecessary. This led to significant costs and bed days annually.
Methods
The AICC pilot care model involves deploying nurses in participating nursing homes as trainers and healthcare navigators to improve communication, care transitions, and develop care protocols.
Results
The number of residents with multiple ED admissions decreased over FY2021 and FY2022, indicating improvements in resident management and healthcare delivery.
Conclusion
The AICC programme reduced hospital admissions and unnecessary referrals by empowering staff with relevant skills and tools. Further evaluation is needed to quantify long-term effects.
Lessons Learnt
Management and staff buy-in were crucial for implementation. Community nurses learned to appreciate the challenges faced by NH staff, providing appropriate support.
Keywords
Collaboration, Hospital Admission, Workflow, Quality Improvement
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | National University Health System |
Organization(s) Involved | Ng Teng Fong General Hospital |
Platform(s) | National Healthcare Innovation and Productivity Medals |
Healthcare Professional Group(s) | Healthcare Administration, Nursing, Others, Community Care |
Applicable Specialty or Discipline | Healthcare Administrators, Operations, Nursing |
Project Lead(s) | Thomas Soo |
Project Member(s) | Wesley Teo |
Connect with this contributor!
Wesley Teo - wesley_teo@nuhs.edu.sg