Impact of a patient-centered medical home demonstration on quality of life and patient activation for older adults with complex needs in Singapore

Abstract

Abstract Background The first Patient-Centered Medical Home (PCMH) demonstration in Singapore was launched in November 2016, which aimed to deliver integrated and patient-centered care for patients with bio-psycho-social needs. Implementation was guided by principles of comprehensiveness, coordinated care, shared decision-making, accessible services, and quality and safety. We aimed to investigate the impact of implementing the PCMH in primary care on quality of life (QoL) and patient activation. Methods The study design was a prospective single-arm pre-post study. We applied the 5-level EuroQol 5-dimension (EQ-5D-5L) and Visual Analog Scale (EQ VAS) instruments to assess health-related QoL. The CASP-19 tool was utilised to examine the degree that needs satisfaction was fulfilled in the domains of Control, Autonomy, Self-realisation, and Pleasure. The 13-item Patient Activation Measure (PAM-13) was used to evaluate knowledge, skills and confidence in management of conditions and ability to self-care. Multivariable linear regression models with random intercepts were applied to examine the impact of the PCMH intervention on outcome measures at 3 months and 6 months post-enrolment, compared to baseline. Results We analysed 165 study participants enrolled into the PCMH from November 2017 to April 2020, with mean age 77 years (SD: 9.9). Within-group pre-post (6 months) EQ-5D-5L Index (β= -0.01, p-value = 0.35) and EQ VAS score (β=-0.03, p-value = 0.99) had no change. Compared to baseline, there were improvements in CASP-19 total score at 3 months (β = 1.34, p-value = 0.05) and 6 months post-enrolment (β = 1.15, p-value = 0.08) that were marginally out of statistical significance. There was also a significant impact of the PCMH on the CASP-19 Pleasure domain (β = 0.62, p = 0.03) at 6 months post-enrolment, compared to baseline. We found improved patient activation from a 15.2 % reduction in the proportion of participants in lower PAM levels, and a 23.4 and 16.7 % rise in proportion for higher PAM levels 3 and 4, respectively, from 3 months to 6 months post-enrolment. Conclusions Preliminary demonstration of the PCMH model shows evidence of improved needs satisfaction and patient activation, with potential to have a greater impact after a longer intervention duration.

Keywords

• Patient-centered medical home
• Patient-centered care
• Older adults
• Geriatrics
• Quality of life
• Patient activation