Integrating acute and subacute care through dynamic adaption of care intensity: The Integrated General Hospital Pilot in Singapore

Abstract

Introduction: Conventional healthcare systems consist of facilities which provide different intensities of care. Typically, patients with acute conditions receive high intensity care in acute hospitals, then transferred to step-down facilities for subacute and rehabilitative care when their acuity levels drop. This means shifting patients from one facility to another to receive different types and intensity of care, resulting in care fragmentation, multiple handovers between care teams and system inefficiency. We piloted a new Integrated General Hospital (IGH) concept where intensity of care is dynamically varied to match the acuity of patients’ conditions without moving them across different facilities. Methods: This study was aimed at evaluating the feasibility of a novel care model where a simple acuity-tier system is used to define acuity and match care intensity for each patient. Over a 3-month period, 1379 patients were assigned different acuity-tier levels (Level 1, 2 or 3) upon admission, which were revised regularly during their hospitalization to guide the intensity of care. Level 3 patients (highest acuity) were given the highest intensity of medical care, frequent monitoring of vital signs and twice daily medical reviews. Level 2 patients (intermediate acuity) were reviewed on alternate days. Level 1 patients (lowest acuity) had less frequent monitoring and weekly medical reviews. Concurrently, nursing and rehabilitative care was dynamically stepped up or reduced according to acuity level and care needs. Results: The acuity mix by total patient-days over this period was, 49%, 14% and 37% for Acuity Levels 3, 2 and 1, respectively. 47% of patients were assigned varying levels of acuity throughout their inpatient journey as they experienced dynamic changes in their illness trajectory. The acuity level for 53% of patients remained unchanged throughout their hospitalization. Each patient was successfully assigned an acuity level and received an intensity of care matched to their acuity label. By implementing a dynamic patient-allocation system, all wards had a balanced mix of patients with different acuity levels. Clinicians, nurses and allied health practitioners communicated effectively through this novel acuity-tier system which enabled targeted care from individual areas to match patients’ needs. Twice weekly multidisciplinary meetings further enhanced team work and integration of care. As a result, the average length of high-intensity acute care received by patients was reduced to 3 days. Physical transfer from acute hospital to step-down facility was omitted for all patients. Conclusion: This novel IGH care model using a simple acuity-tier system to define acuity and dynamically match care intensity is feasible and effective. This model also integrates acute and subacute care seamlessly through dynamic adaption of care intensity and addresses the issues of care fragmentation and system inefficiency observed in the conventional model where intensity of care is rigidly assigned to each type of care facility. Limitations: As this is an early pilot using a novel care model, the scalability and relevance in a bigger and more complex health system is currently unclear. Future research: We aim to include analysis of patient outcomes and validate this model of care in a larger patient cohort.

Keywords

• integrated care
• rehabilitation
• acuity level
• healthcare