A rapidly ageing population means more elderly will require hospital care with constant monitoring, but inpatient care brings its own challenges.
Prolonged inpatient care can lead to hospital-acquired infections and physical deconditioning. A greater demand for beds puts pressure on the healthcare system, which results in higher costs, and bed and healthcare staff shortage.
“SGH@Home offers an opportunity to address these issues by innovating an alternative healthcare model to complement current models of care,” said Dr Michelle Tan (below), Consultant and Head, Department of Family Medicine and Continuing Care, Singapore General Hospital (SGH).
<<Just like a hospital ward round, the care team contacts patients (like this sample list shown on a large monitor) to assess their recovery and address their concerns.>>
The SGH@Home pilot service allows eligible patients to recover at home, usually after a surgical procedure. Launched in May 2022, the two-year project aims to enrol 600 patients to receive hospitalstandard acute care at home.
Patients monitor their own symptoms and vital signs, and report the results to the SGH care team at stipulated intervals via a smart device app. Their progress is monitored by phone or video consultation.
<<A nurse reviews
Mr KK Wong’s
recovery for a serious
skin infection. He was
put on intravenous
antibiotics drip at
home, allowing him
to avoid a four-day
Performing such tasks on their own, or with the help of their caregivers, “encourages an early return to independence for patients”, said Dr Low Lian Leng, Director, SingHealth Office of Regional Health, SGH Campus; Director, Population Health and Integrated Care Office (PHICO), Regional Health System (RHS)-Community Integration, SGH; and SGH@Home project co-lead.
Unlike discharged inpatients who often experience a sharp change in their care situation — Dr Low describes this as “a cliff effect” — virtual ward patients face a more gradual transition from acute care to recovery outside the hospital.
At the same time, said Dr Tan, who is also the SGH@Home project co-lead, inpatients tend to remain in bed more. A period of prolonged inactivity can lead to deconditioning or a weakening in physical and mental functions. In contrast, patients tend to be more active when recovering at home. Inpatients, too, may catch infections from other patients, putting them at risk of having to stay longer in hospital.
While this service has benefits for patients, not all are eligible to recover at home, said Dr Tan.
Patients’ home environment must be suitable for recovery, and they must have access to smart devices for communicating data with their care team. If they are living alone, patients must be independent, are able to perform basic daily activities and follow instructions, and have minimal fall risks.
Above all, they have to be clinically stable, so those who undergo orthopaedic procedures like hip fractures and do not suffer from other acute conditions are likely to be suitable for home recovery. Those who had a heart attack or stroke, on the other hand, are unlikely to be suitable.
Patients with infections requiring antibiotic therapy are also often eligible, especially if the source and area of their infection is clear, and the patient is responding to treatment. “SGH@Home would be useful to enable the patient to complete the treatment,” said Dr Tan, adding that antibiotic treatment usually needs a few days to complete.
As patients recovering at home will not have nurses to monitor their vital signs like blood pressure, oxygen level and temperature, they must do so themselves. They are given or loaned items such as hypertension monitors, pulse oximeters and thermometers if they do not have them, said Ms Tang Woon Hoe, Manager, PHICO-Integrated Continuing Care Services, SingHealth, and RHS-Office for Integrated Care, SGH.
“Patients need to download the app on their smart devices, which will regularly remind them to monitor their vital signs and to send the clinical team their readings. These will then be auto-calculated onto a dashboard for the team’s review,” said Ms Tang.
Although they are at home, patients will still have access to medical care round the clock, as the service works with private medical care service providers for out-of-office-hours care.
With close and regular monitoring, the team is usually able to tell when patients start to show signs of deterioration. “For example, if the patient has a fever that does not respond to antibiotics, the blood pressure starts to drift downwards, or the heart rate climbs very high, the team would arrange for transport to send the patient back to SGH,” said Dr Tan.
“We also prepare the patient for the possibility that he may need to call 995 for an emergency such as a sudden heart attack, stroke or other medical emergency unrelated to the patient’s condition,” Dr Tan added.
The hospital-at-home care model is not a new concept, having been implemented in Australia, the United Kingdom, Europe and the United States since the 1990s. International studies show that this care model reduces cost, healthcare utilisation and readmissions, and provides greater caregiver satisfaction and lowers mental stress. In the elderly, it reduces functional decline and delirium associated with acute hospitalisations, Dr Tan said.
SGH@Home is supported by the Ministry of Health (MOH) under its two-year MOH Office for Healthcare Transformation (MOHT) sandbox programme, which also includes virtual home pilots by the National University Hospital and Yishun Health Medical Home. Data from the programme, expected to end in March 2024, will help MOH decide if this virtual ward pilot should become a mainstream service and be offered to patients widely.
Virtual ward allows quick response
<<Some members of the virtual ward care team with the doctor’s home visit medical bag and green bag containing items such as hypertension monitor and thermometer for patients to check their vitals at home.>>
The idea for a virtual ward at SGH came about as early as in September 2021, but the hospital’s plan for a small pilot was disrupted by the resurgence of the COVID-19 pandemic a few months later.
Undertaking the task of establishing a larger-scale virtual COVID-19 ward in February 2022 had its rewards, as SGH quickly found that with the blueprint for this model of care in place, the hospital has been able to respond quickly to other situations that may have unexpected developments.
“By providing medical treatment at the patients’ home and leveraging telehealth technology and partnership with private care providers, SGH@Home allows for variable hospital capacity,” said Dr Michelle Tan, Consultant and Head, Department of Family Medicine and Continuing Care, SGH.
“Access to hospital-level medical care will no longer need to be tied to a fixed capacity of physical inpatient beds, which increases the flexibility of acute hospital care capacity.”
As the predecessor of the SGH@Home virtual ward, the COVID-19 ward required patients to monitor their vitals and report the results to their care team, and to check in daily with their care team via phone calls or video conferencing. They also had access to private healthcare partners in the community.
“With the Omicron wave, we expanded the programme to 100 beds. At the peak, the occupancy rate was over 80 per cent but, as the patient load went down in April and May, we contracted the bed numbers to 25. With the new wave (in July 2022), we re-expanded the programme,” she said.
In May, SGH set up a virtual ward for rhabdomyolysis cases that had started increasing. The patients were mostly in their 20s and early 30s, and often did not need a prolonged hospital stay. This cohort of 12 patients stayed at SGH for one to two days, and were then sent home to recover for another three to four days.
“In a tight bed situation, the few days spent at home are still significant. Every bed that is available means that we are able to manage the tight emergency department situation better,” said Dr Tan.
During their home recovery, doctors saw the patients at home intermittently, while video consultations to review patients were made every other day. Nurses visited the patients to help them with intravenous hydration and took their blood regularly. The patients were given hotlines to call in an emergency, and after-hours access to third-party care partners.
The virtual ward team foresees SGH@Home to be important in addressing dengue — a perennial and endemic condition. In the first half of 2022 alone, nearly 18,000 cases were recorded, compared to the 5,258 cases in 2021.
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