Despite having received extensive care throughout the duration of their hospitalisation, patients who have been discharged often need to be readmitted, as their conditions deteriorate due to sub-optimal care and support that is available in the community post-discharge. These high-risk patients tend to be 65 years and above, and hospitalised for an average of 10 days each time they are admitted.
To solve this problem, a predictive model that targets patients at risk of multiple readmissions was developed. Using over a thousand indicators, which include patient age, the number of inpatient admissions and total length of stay in the past two years, the model automatically analyses multi-dimensional ailments, ranging from basic illnesses, chronic diseases to end-of-life conditions, to predict if patients will be re-admitted three or more times over the next 12 months.
The care management team is alerted when a high-risk patient is first admitted. This early alert allows them to prepare and allocate resources, and tailor care plans according to the patient’s needs after he is discharged. Patients are then enrolled into the Hospital to Home (H2H) programme, which allows them to receive care through home visits and phone follow ups by the required healthcare professionals that include doctors, nurses, allied health professionals and case managers. With adequate community-based care and support services, patients can be timely and safely discharged from the hospital and remain well at home.
The benefits of the predictive model extend to healthcare professionals as well. Instead of having to manually go through the daily inpatient admission list, case managers can focus on high-risk patients. This enables the care team to provide targeted intervention to high-risk patient groups.
Other benefits include freeing up public healthcare resources and enhancing operational and cost efficiencies. With the establishment of clear goals and discharge criteria, hospitals are able to strengthen their links with the community and safely hand over the care of patients to their primary care givers.
This model has been deployed across all public hospitals in Singapore and is now an integrated part of the patient assessment workflow for the H2H programme.