Journal Article

Implementation fidelity of a strategy to integrate service delivery: learnings from a transitional care program for individuals with complex needs in Singapore

Nurjono, Milawaty, Toh, Sue-Anne Ee Shiow, Vrijhoef, Hubertus Johannes Maria, Shiraz, Farah, Yoong, Joanne Su-Yin, Ang, Ian Yi Han, Shrestha, Pami

2019

Overview

Background To cope with rising demand for healthcare services in Singapore, Regional Health Systems (RHS) comprising of health and social care providers across care settings were set up to integrate service delivery. Tasked with providing care for the western region, in 2012, the National University Health System (NUHS) – RHS developed a transitional care program for elderly patients with complex healthcare needs who consumed high levels of hospital resources. Through needs assessment, development of personalized care plans and care coordination, the program aimed to: (i) improve quality of care, (ii) reduce hospital utilization, and (iii) reduce healthcare-related costs. In this study, recognizing the need for process evaluation in conjunction with outcome evaluation, we aim to evaluate the implementation fidelity of the NUHS-RHS transitional care program to explain the outcomes of the program and to inform further development of (similar) programs. Methods Guided by the modified version of the Conceptual Framework for Implementation Fidelity (CFIF), adherence and moderating factors influencing implementation were assessed using non-participatory observations, reviews of medical records and program databases. Results Most (10 out of 14) components of the program were found to be implemented with low or moderate level of fidelity. The frequency or duration of the program components were observed to vary based on the needs of users, availability of care coordinators (CC) and their confidence. Variation in fidelity was influenced predominantly by: (1) complexity of the program, (2) extent of facilitation through guiding protocols, (3) facilitation of program implementation through CCs’ level of training and confidence, (4) evolving healthcare participant responsiveness, and (5) the context of suboptimal capability among community providers. Conclusion This is the first study to assess the context-specific implementation process of a transitional care program in the context of Southeast Asia. It provides important insights to facilitate further development and scaling up of transitional care programs within the NUHS-RHS and beyond. Our findings highlight the need for greater focus on engaging both healthcare providers and users, training CCs to equip them with the relevant skills required for their jobs, and building the capability of the community providers to implement such programs.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Aged / Care and treatment / Caregivers / Case management / Chronic illnesses / Continuity of care / Costs / Data collection / Delivery of Health Care - organization & administration / Discharge / Elderly patients / Evaluation / Frailty / Geriatrics / Government Programs / Health Administration / Health care costs / Health care industry / Health care policy / Health Informatics / Health Personnel / Health services utilization / Hospitals / Humans / Implementation fidelity / Integrated care / Integrated delivery networks / Interdisciplinary aspects / Management / Medical care quality / Medical care utilization / Medical economics / Medical records / Medicine / Medicine & Public Health / Mental disorders / Mixed methods / Mixed methods research / Needs analysis / Needs Assessment / Nursing Research / Older people / Organization / Patient care / Patient Care Management / Patient satisfaction / Population / Post-discharge care / Public Health / Research Article / Singapore / structure and delivery of healthcare / Transitional care / Transitional Care - organization & administration