SmoothTransitions: Enhancing Nursing Home Referrals
Care Continuum
Care Process & Redesign
National Healthcare Innovation and Productivity Medals
Agency for Integrated Care - Intermediate and Long Term Care
10 October 2025
The project aims to reduce the Length of Stay (LOS) for patients discharged to Nursing Homes (NHs) by approximately 20% and. The interventions improved the NH referral process, reduced LOS, and achieved cost savings, demonstrating the effectiveness of the.
Year Submitted: 2025
Published Date: 10 October 2025
Tags: Care Continuum, Workflow Redesign, Cost Saving, Time Saving, Intermediate and Long Term Care ＆ Community Care, Nursing Home Care, Quality Improvement, Productivity, Access To Care, Referral Rate, Care Process ＆ Redesign
About this Content
Aims
The project aims to reduce the Length of Stay (LOS) for patients discharged to Nursing Homes (NHs) by approximately 20% and to reduce the number of times a referral case is returned to SACH for clarifications or rework.
Background
The process of referring SACH patients to Nursing Homes involves multiple stakeholders with varying practices, leading to long turnaround times, impacting hospital bed occupancy and patient access to care.
Methods
A multidisciplinary team used lean methodologies including Gap Analysis, Value Stream Mapping, and DOWNTIME (8 Wastes) to identify issues and develop solutions. Interventions were piloted and then implemented hospital-wide.
Results
Post-implementation, patients' LOS at the 50th percentile reduced by 24% and at the 95th percentile by 30%. Average bed days saved per patient are 9 days, leading to cost avoidance of S$238K per annum.
Conclusion
The interventions improved the NH referral process, reduced LOS, and achieved cost savings, demonstrating the effectiveness of the implemented changes.
Lessons Learnt
Collaboration among the multidisciplinary team expanded the role of the MSW. Efforts to reduce rework would be more effective with AIC's participation in workshops.
Keywords
referral process, nursing home, patient care, workflow, cost-effective
Innovators' Details
Innovators' Details
Healthcare Cluster(s) | Agency for Integrated Care - Intermediate and Long Term Care |
Organization(s) Involved | St. Andrew’s Community Hospital |
Platform(s) | National Healthcare Innovation and Productivity Medals |
Healthcare Professional Group(s) | Allied Health, Healthcare Administration |
Applicable Specialty or Discipline | Rehabilitation Therapy, Healthcare Administrators |
Project Lead(s) | Ngiam Minyi Felicia |
Project Member(s) | Fatima Singaporewalla |
Connect with this contributor!
Eric Wie - eric_wie@sach.org.sg
Project Attachment
209_SACH_NHIP_2025_SmoothTransitions_Enhancing_Nursing-Home_Referrals.pdf