Nurjono Milawaty, Shrestha Pami, Ang Ian Yi Han, Shiraz Farah, Yoong Joanne Su-Yin, Toh Sue-Anne Ee Shiow, Vrijhoef Hubertus Johannes Maria
Centre for Health Services Research and Policy Research, Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore.
Regional Health System Planning Office, National University Health System, Singapore, Singapore.
BMC Health Serv Res. 2019 Mar 19;19(1):177. doi: 10.1186/s12913-019-3980-x.
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.
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.
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.
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.
为应对新加坡对医疗服务不断增长的需求，成立了由跨护理环境的医疗和社会护理提供者组成的区域卫生系统（RHS），以整合服务提供。2012年，负责为西部地区提供护理的国立大学卫生系统（NUHS）-RHS为消耗大量医院资源、有复杂医疗需求的老年患者制定了一项过渡性护理计划。通过需求评估、制定个性化护理计划和护理协调，该计划旨在：（i）提高护理质量，（ii）减少医院利用率，以及（iii）降低医疗相关成本。在本研究中，认识到需要结合结果评估进行过程评估，我们旨在评估NUHS-RHS过渡性护理计划的实施保真度，以解释该计划的结果，并为（类似）计划的进一步发展提供信息。
以实施保真度概念框架（CFIF）的修改版为指导，使用非参与性观察、病历审查和计划数据库评估影响实施的依从性和调节因素。
发现该计划的大多数（14个中的10个）组成部分以低或中等保真度实施。观察到计划组成部分的频率或持续时间因用户需求、护理协调员（CC）的可用性及其信心而有所不同。保真度的变化主要受以下因素影响：（1）计划的复杂性，（2）通过指导协议提供便利的程度，（3）通过CC的培训水平和信心促进计划实施，（4）不断变化的医疗参与者反应能力，以及（5）社区提供者能力欠佳的背景。
这是第一项评估东南亚背景下过渡性护理计划特定背景实施过程的研究。它为促进NUHS-RHS内外过渡性护理计划的进一步发展和扩大提供了重要见解。我们的研究结果强调需要更加注重吸引医疗服务提供者和用户参与，培训CC以使其具备工作所需的相关技能，以及增强社区提供者实施此类计划的能力。
