BACKGROUND
Yishun Health (YH) is a regional hospital system caring for 300,000 people in the north of Singapore that has embarked on a multi-year, whole regional health system transformation to improve outcomes. Care and services delivery transformation to enable greater person-centeredness and value-driven integration of care during residents’ episodes of acute medical crisis or complex elective patient care needs is based on the Unified Care Model (UCM) and provides a case study on the use of Health System Transformation Playbook (HSTP).

METHODS
HSTP is a design, systems, and complexity-thinking enabled implementation science methodology to design and test health system transformation and care integration actions, anchored on an iterative 3-step process involving storytelling, model building and pathfinding that together tackles the scale of complex adaptive systems through time. The UCM, as well as its interdependent population segmentation model and performance framework are conceptual models arising from YH’s ongoing practice and model building using the HSTP. Facilitated storytelling and group model building sessions involving staff from medical, nursing, allied and operations etc., were conducted using the abovementioned models to iterate and distill “minimally viable services model product components” (MVSPC) i.e., new care processes and enabler processes that exemplify UCM.

RESULTS
The following MVSPC were identified to integrate care towards the UCM and are being deployed through a Episodic Care Transformation Committee:
(i) Ambulatory emergency care unit to avoid admitting patients with lower acuity and without chronic illnesses or social needs.
(ii) Fast-track short-stay wards, with standardized care processes to turnaround patients with higher medical needs but without social needs.
(iii) Higher allied health-resourced wards to reduce length of stay for lower acuity patients with high/complex social needs.
(iv) Real-time patient segmentation “calculator” and inpatient segment-based bed allocation model.
(v) Patient flow center to coordinate transitions of care beyond the hospital.

DISCUSSION
MVSCP were generally not new ideas but the challenge was in ensuring that numerous services model and enabler processes being transformed and implemented at the same time by different teams and at different sites work well together at scale to integrate care for each population segment to produce significant systemic impact. YH’s prioritization of MVSPC were facilitated using HSTP methodology and MVSPC were prioritized to be able to address urgent stakeholder needs while exemplifying a more integrated and transformed crisis and complex care experience for different Episodic Care population segments. The transformation committee is an effective operational decision-making and service planning governance platform to synthesize and coordinate deployment of various MVSPC.

CONCLUSION
Use of UCM and HSTP engages stakeholders in a more systemic and practice-driven process to effectively iterate and integrate care coherently for different population segments at scale to accelerate health system transformation towards people-centered and value driven care.

The Lower Limb Preservation (LLP) demonstration project is built on the Canadian Ontario Health Team (OHT) model, and is a new way of organizing and delivering care that is more connected to patients in local communities, with the goal of better coordinated, more integrated care.

LLP project focus is on reducing health inequities and preventing avoidable lower limb amputations through community chiropody clinics and hospital-community-primary care partnerships.

We aim to serve marginalized and underserved populations across Toronto, Canada. There is a concerted effort to reach transient communities (homeless or under housed), Black, Indigenous and People of Colour, and those who do not regularly seek health care.

We have partnered with the following groups and organizations within the OHT to co-design the integrated clinical pathways and models of care:

- Community Health Centers: non-profit organizations that provide primary health and health promotion programs for individuals, families and communities.
- Homeless shelters and drop-in centers where hot meals are provided (including one specifically for Indigenous populations).
- University Health Network: A multi-site hospital that provides quaternary, specialized care in downtown Toronto.
- Primary Care networks including one that focuses on people living on the street and in shelters, encampments and precarious housing across Toronto

Our project team led the co-design of an OHT integrated clinical pathway and care model with the goal to reduce incidence of avoidable lower limb amputations. Pathway includes early identification of those at risk, chiropody foot care services provided in high priority/need communities, and health promotion and education to enable person-centered control over health.

Hospital-Community-Primary care partnerships include a shared resource delivering care in both community and hospital settings, collaboration between the hospital emergency department and community homeless shelters, primary care networks and hospital outpatient clinic, and joint health education and promotion session delivery by community and hospital providers.

Partnering and building relationships at the Hospital-Community-Primary care level allows for a cross continuum, integrated care delivery of health care beyond hospital walls to congregate and underserved populations within Toronto.

Results:

Since October 2023 launch, LLP project has shown promising results and evoked great excitement amongst all partners.

Community chiropody clinics are scheduled through Spring 2024. To date, all clinics have reached capacity and provided much needed chiropody and foot care services to many underserved pockets within the region. Joint health education and health promotion sessions have also been highly attended.

As time progresses, impacts include: strengthened hospital-primary-community care partnerships, regular screening and foot care, earlier treatment and health promotion, and reduced incidence of avoidable lower limb amputations.

Learning for International Audience:

Power of Partnerships - Hospital-Community-Primary care partnerships have played a vital role in addressing health determinants by providing care to those in underserved, high priority communities, improving population health longer-term, and reducing health inequities. This partnership has helped to build new connections and establish trust with marginalized and underserved communities.

Next Steps:

Implement all aspects of the pathway, focusing on hospital ED and community shelters along with social medicine partnerships, and demonstrate value to obtain sustainable funding.

Background
Healthcare transitions are burdensome and involve risk for patients. Improving patients’ experiences of their care journey also improves clinical safety in healthcare transitions. To asses patients’ experiences it may be useful to apply a valid and reliable patient-reported experience measure (PREM).

Learning for audience
1. Gain in-depth understanding of living healthcare journeys across settings.
2. Understand that flexibility, access and navigation, and kindness are the key to quality care across healthcare settings.
3. See a proposed method for assessment of patient-experienced quality in healthcare transitions.
Research
• Aims:
o To explore what is essential for perceived quality of care among Danish patients when being in healthcare transitions across different settings.
o To develop and test a patient-reported experience measure for patient assessment of transitions in healthcare (PATH).
• Setting: The work took place at two university hospitals in Denmark. Adults were included to reflect the population broadly. This included people living with multiple diseases, older people, younger adults, people with psychiatric disorders, and women who had given birth. The main inclusion criterion was involvement of hospitals, general practitioners, and municipal healthcare.
• Methodology: This work is inspired by Max van Manen’s phenomenology of practice. The PREM development follows the framework suggested by the COSMIN group.
• We have demonstrated that it is possible to capture the complex phenomenon of “living healthcare transitions” quantitatively through PATH. During the next year, PATH will be used for the evaluation of two interventions to improve patient journeys. Preliminary results for these interventions will be presented.
• Sustainability: We have developed a manual for PATH and the PREM is free to use. We wish to collaborate on use and further revision of PATH to ensure the relevance of the PREM and its propagation. The idea is to promote an international consensus on the construct of patient-experienced quality in healthcare transitions, and assessment hereof.
• Through the iterative process of qualitative interviews, development, pilot-testing, and field-testing of PATH we have demonstrated how an understanding of people's lived experiences of healthcare transitions can be scaled to larger population surveys for a quantitative assessment. This will facilitate larger-scale planning and evaluation of improvement projects, supporting implementation research and quality work.
Ethics
According to Danish law, no ethics permissions were required for this study. The study was approved by the legal department at the Research and Innovation Organistion (RIO), University of Southern Denmark (SDU); Notification number 10.953. , and their guidelines were followed along with the ethical principles of the Declaration of Helsinki. All participants were informed about guaranteed anonymity, that they could withdraw consent at any time, and that data handling according to current standards would be kept confidential.

1. Background

Enabling older adults to engage with and participate in their care planning requires specific geriatrician input to overcome the complex challenges facing frail patients in the community setting. Planning for future events is an integral component of the evolving collaboration between the older person, those closest to them and members of a multi-disciplinary team.

2. Methods

I conducted a literature review using key terms on PubMed. I also reviewed the World Health Organisation’s (WHO) Integrated care for older people (ICOPE): Guidance for person-centred assessment and pathways in primary care1, as well as reviewing the guidelines and framework for the Irish National Integrated Care Programme for Older persons2. Observing and participating in complex cases in an ambulatory community setting showed the practical considerations involved in complex case management.

3. Discussion

While standardised care pathways have always been a solution for ensuring patient safety, improving risk-adjusted patient outcomes, increasing patient satisfaction and optimising scarce resources, studies have shown that standardised care pathways are more effective in contexts with predictable care trajectories and low uncertainty and complexity3. A person-centred care plan engages older persons as stakeholders in their own care.

Adopting the WHO’s ICOPE framework requires assessment of intrinsic capacity and promptly diagnosing and managing losses, both functional and cognitive. Early identification of complex cases involving multi-morbidity, polypharmacy and advancing frailty allows an integrated care team to pool expertise and facilitate patient autonomy in the decision-making process.

Specific ambulatory community geriatrician hubs within Community Healthcare Organisations (CHO) enables complex cases to be individually managed in conjunction with a multi-disciplinary team. Identifying unrecognised or unvoiced needs and taking proactive steps to plan for preventative, personalised care is a key component of a multi-modal service.

4. Conclusion

A shift towards an integrated, people-centred approach demands increased community level interventions with coordinated services, such as screening, assessment and

management. On personal reflection, it appears that the majority of older persons linked in with an ambulatory hub benefit hugely from specialist MDT input.

However, a subsection of older persons in the community need more in-depth specialist support, highlighting the need for increased support in an integrated care model. Establishing the concept of shared care requires transfer of information and knowledge pooling. There is undoubtedly a gap for complex case discussion in the community. A solution to this could include virtual case conferences, facilitating collaboration and coordination between services that provide community led support to older persons and other service providers. Further strengthening of pathways and systems to ensure care plan suitability requires reciprocal buy-in from tertiary centres.

Background: Social conditions influence children’s morbidity, well-being and health equity from pre-conception throughout their life course. Hospital in- and outpatient admissions offer an excellent non-stigmatizing opportunity for the detection of social needs, the initiation of counselling and referrals to social services, if needed. However, it is not yet routine practice to measure social conditions systematically in child health care. Thus, the aim of our study is to develop an instrument to measure social conditions and screen for health-related social needs in children within in- and outpatient hospital care for children in Germany.

Methods: Based on items of an existing Canadian screening tool and additional items identified through a recent systematic review we will define a pool of possible items for the new instrument. A Delphi panel will select appropriate items based on an adapted UCLA/RAND method. Where needed, items will subsequently be culturally adapted. The Delphi panel will consist of interdisciplinary experts from medicine, psychology, social work, nursing and public health as well as parent and patient representatives. Throughout the project, we collaborate with social workers and practitioners at the department of general paediatrics in Düsseldorf to ensure feasibility and integration of the newly developed instrument into routine health and social care pathways.

Results: The result of our study will be the first German-language questionnaire completed by parents, capturing social conditions and health-related social needs of children and families in a broad age range (0 to 18 years). We will present preliminary findings of the Delphi process, including the item pool compiled for evaluation as well as items considered appropriate to measure social conditions and identify needs and the level of agreement between the experts. In addition, we will report reasons for adaptation of items to fit the German context. Specifically, we will discuss how contextual factors (e.g. health insurance and national welfare systems) influence changes in the wording of the items.

Lesson learned and next steps: Insights from this study will contribute to advancing the measurement of social conditions and identification of health-related social needs of children in the German health care system. The study contributes to the existing evidence, which mainly originates from studies in North America, and increases the understanding of how different contexts of social and health care systems affect the content, process and form of screening for social needs. The development of the parent-reported social condition and health-related social needs instrument will be followed by pilot testing and validation at the paediatric wards and clinics in Düsseldorf. Over a period of three months, all parents of children admitted to the outpatient clinics (neuropediatric, endocrinology, gastroenterology, pulmonology, social paediatric centre) and respective inpatient wards will be asked to fill out the parent instrument. During this phase, we offer easily accessible support by hospital social services for all families participating in the study. After feasibility testing and validation, we plan to transfer the instrument to routine care, as the first element of a system to refer families to social supports if and as needed.