Right-Site Care Programme with a community-based family medicine clinic in Singapore: secondary data analysis of its impact on mortality and healthcare utilisation

ObjectiveStable patients with chronic conditions could be appropriately cared for at family medicine clinics (FMC) and discharged from hospital specialist outpatient clinics (SOCs). The Right-Site Care Programme with Frontier FMC emphasised care organised around patients in community rather than hospital-based providers, with one identifiable primary provider. This study evaluated impact of this programme on mortality and healthcare utilisation.DesignA retrospective study without randomisation using secondary data analysis of patients enrolled in the intervention matched 1:1 with unenrolled patients as controls.SettingProgramme was supported by the Ministry of Health in Singapore, a city-state nation in Southeast Asia with 5.6 million population.ParticipantsIntervention group comprises patients enrolled from January to December 2014 (n=684) and control patients (n=684) with at least one SOC and no FMC attendance during same period.InterventionsFamily physician in Frontier FMC managed patients in consultation with relevant specialist physicians or fully managed patients independently. Care teams in SOCs and FMC used a common electronic medical records system to facilitate care coordination and conducted regular multidisciplinary case conferences.Primary outcome measuresDeidentified linked healthcare administrative data for time period of January 2011 to December 2017 were extracted. Three-year postenrolment mortality rates and utilisation frequencies and charges for SOC, public primary care centres (polyclinic), emergency department attendances and emergency, non-day surgery inpatient and all-cause admissions were compared.ResultsIntervention patients had lower mortality rate (HR=0.37, p<0.01). Among those with potential of postenrolment polyclinic attendance, intervention patients had lower frequencies (incidence rate ratio (IRR)=0.60, p<0.01) and charges (mean ratio (MR)=0.51, p<0.01). Among those with potential of postenrolment SOC attendance, intervention patients had higher frequencies (IRR=2.06, p<0.01) and charges (MR=1.86, p<0.01).ConclusionsIntervention patients had better survival, probably because their chronic conditions were better managed with close monitoring, contributing to higher total outpatient attendance frequencies and charges.

Tier 3 Interventions

Chapter 9 discusses Tier 3 cases, youths who have severe, chronic, and complicated absenteeism. Such students have often exceeded the legal limit for truancy, attend class sporadically when they do go to school, and/or frequently leave school prematurely. Attendance problems have lasted for months or years. Youths with Tier 3 problems have failing grades, few credits, and little knowledge of their current coursework. They are often socially detached and may display anxiety and oppositional behavior about the prospect of returning to school. Tier 3 attendance problems often involve deteriorating relationships between parents and school officials. Interventions include addressing comorbid problems and contextual variables, enhancing academic remediation and integration, establishing school attendance, and increasing parent and family involvement in school attendance. Intervention strategies may involve an expansion of the procedures described in this therapist guide, alternative educational schools and programs, specialized programs, and second-chance programs.