[AVBC 2025] Integrated Care Pathway for Stroke and Hip Fracture Rehabilitation: LOS and Care Coordination
Care Process & Redesign
Appropriate & Value-based Care Conference
SingHealth
27 November 2025
Implement an integrated care pathway for stroke and post-operative hip fracture rehabilitation at Outram Community Hospital. The implementation demonstrated significant improvements in care coordination and resource utilisation, underpinned by standardised.
Year Submitted: 2025
Published Date: 27 November 2025
Tags: Care Process ＆ Redesign, Quality Improvement, Workflow Redesign, Productivity, Cost Saving, Time Saving, Value Based Care, Length Of Stay
About this Content
Aims
Implement an integrated care pathway for stroke and post-operative hip fracture rehabilitation at Outram Community Hospital (OCH) to optimise value through reduced hospital length of stay (LOS) and enhanced care coordination.
Background
Current challenges from fragmented care pathways and misaligned objectives resulted in extended Acute Hospital-Community Hospital (AH-CH) stays, suboptimised transfers from AH to CH, and suboptimised care delivery and protocols.
Methods
The initiative implements evidence-based interventions with evaluation through quantitative measures (AH-CH LOS, rehabilitation improvement, U-turn and readmission rates) and qualitative measures (semi-structured interviews on patient and staff experience).
Results
Statistically significant bed-days savings compared to historical control, with AH LOS mean difference of 7.7 days and AH-CH LOS mean difference of 12.4 days. Key outcomes include a 33% reduction in AH-CH LOS, a decrease in 30-day readmissions from 8.2% to 4.9%, zero U-Turns within 72 hours, and increased rehabilitation efficiency from 0.8 to 1.0.
Conclusion
The implementation demonstrated significant improvements in care coordination and resource utilisation, underpinned by standardised care pathways and a strong accountability culture among the MDT, with potential to scale some components to more conditions and CHs.
Lessons Learnt
Improved LOS increased patient turnovers and workload intensity across domains, requiring higher manpower needs for weekend rehabilitation and admissions, and demonstrating CH capability to manage higher acuity patients with appropriate resourcing.
Keywords
Stroke, Hip Fracture, Rehabilitation, Care Coordination, Length of Stay
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | SingHealth |
Organization(s) Involved | SingHealth Community Hospitals |
Platform(s) | Appropriate & Value-based Care Conference |
Healthcare Professional Group(s) | Allied Health |
Applicable Specialty or Discipline | Rehabilitation Therapy |
Project Lead(s) | Loo Yu Xian |
Project Member(s) | Cheryl Tan Yan Fang |
Connect with this contributor!
Loo Yu Xian - loo.yu.xian@singhealthch.com.sg