Complex Care Coordination
Care Continuum
Care Process & Redesign
National Healthcare Group Quality Improvement
National Healthcare Group
31 December 2021
Transform care provision from fragmented care to patient-centred care for better patient outcomes. Positive outcomes across outpatient and emergency settings demonstrate the value of patient-centred, coordinated care.
Year Submitted: 2021
Published Date: 31 December 2021
Tags: Care Continuum, Care Process ＆ Redesign, Chronic Care, Primary Care, Quality Improvement, Productivity, Lean Methodology, Workflow Redesign, Clinical Practice Improvement
About this Content
Aims
Transform care provision from fragmented care to patient-centred care for better patient outcomes.
Background
Patients with chronic conditions face fragmented care across specialties. Improved care coordination ensures seamless care experiences.
Methods
Developed a regression model and algorithm to identify complex care patients and assign Primary Coordinating Doctors (PCDs).
Results
SOC visits reduced by 9–29%, ED attendances dropped by 14–33%, and ED admissions reduced by 15–52% in the first year post-enrolment.
Conclusion
Positive outcomes across outpatient and emergency settings demonstrate the value of patient-centred, coordinated care.
Lessons Learnt
Collaboration, shared vision, and automation are critical for streamlining complex care coordination processes.
Additional Information
NHG Team Recognition (Bronze). Improved clinical outcomes, reduced outpatient and ED visits, and cost savings achieved.
Keywords
Care Coordination, Complex Care, Quality Improvement, Patient-Centred Care
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | National Healthcare Group |
Organization(s) Involved | Tan Tock Seng Hospital |
Platform(s) | National Healthcare Group Quality Improvement |
Healthcare Professional Group(s) | Ancillary Care, Healthcare Administration, Medical, Pharmacy, Nursing |
Applicable Specialty or Discipline | General Medicine, Respiratory Therapy, Allergy ＆ Immunology, Oncology, Geriatric Medicine, Urology, Pharmacology, Intensive Care Medicine, Healthcare Administrators |
Project Lead(s) | Thong Yu Hor Bernard |
Project Member(s) | Mark Chan Peng Chew |
Connect with this contributor!
Adj A/Prof Thong Yu Hor Bernard - bernard_thong@ttsh.com.sg
Project Attachment
C419_TTSH_NHG_Team_Recognition_Complex_Care_Coordination.pdf