Major shift in healthcare that could mean having to build one less hospital

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SINGAPORE - From April, Singapore is adding virtual hospitals to the healthcare scene. Once these have been fully integrated and scaled up, the Mobile Inpatient Care at Home (MIC@Home) scheme could replace the need for another large public hospital.

 

Patients on the scheme remain at home but are looked after by hospital medical teams, either through videoconferencing and teleconferencing, or in person. They are provided with any equipment they might need, such as a blood pressure monitor, thermometer and walking frames.

 

The Ministry of Health Office for Healthcare Transformation (MOHT) launched a sandbox on the scheme in April 2022 with one hospital each from the SingHealth cluster (Singapore General Hospital) and National Healthcare Group cluster (Khoo Teck Puat Hospital – KTPH), and all hospitals under the National University Health System (NUHS), which had trialled a similar scheme called NUHS@Home since 2020 that has treated close to 4,000 patients.

 

In August 2023, the rest of the public hospitals were added. Health Minister Ong Ye Kung said in Parliament on March 6 that as at end 2023, more than 2,000 patients have benefited.

 

“This translates to around 9,000 hospital bed days saved. Having done this for several months, we are convinced that the scheme works well for the patients, and has great potential to relieve stress at hospitals,” he said.

 

With the two-year sandbox deemed a success, the MIC@Home scheme – the name used varies with hospitals – becomes mainstream from April, with patients getting subsidies, insurance and MediSave coverage the same way they would if they were in hospital.

 

A Ministry of Health (MOH) spokesman said: “Patients may consult their doctors on their eligibility for the MIC@Home programme.”

 

Conditions for eligibility include patients being clinically stable and unlikely to require intensive hospital care, able to care for themselves independently, or having sufficient caregiving support, and having an Internet connection so they can communicate with the doctors or nurses in charge.

 

MOHT said the scheme, which started with patients with skin infections, urinary tract infections and congestive heart failure with fluid overload, will be extended to other areas, including paediatric medicine, obstetrics and gynaecology, rehabilitation medicine, and elective surgeries.

 

Schemes similar to MIC@Home are practised in many countries, such as Britain, France and Australia. Hospitals in Barcelona, Spain, have been doing it for about 60 years.

 

There are major advantages for patients, the hospital and the nation.

 

Good for patients

 

For patients like Mr Ong Jia Rong, 37, the advantage is the comfort of his own home and home-cooked food, instead of being stuck in a hospital ward with other patients.

 

The project manager for an interior design contractor had gone to the National University Hospital (NUH) on the night of March 18 when he noticed a large red rash on his right calf, though it was neither painful nor itchy.

 

He was hospitalised on March 19, diagnosed with severe bullous cellulitis, a bacterial skin infection, and started intravenous antibiotic treatment the following day. He would have needed to remain in the hospital for about 10 days, but after two days, he opted for NUHS@Home.

 

Mr Ong said he is confident of the team treating him and feels more comfortable at home. “At home, I can walk around and even do some work, such as replying to e-mails.”

 

As the infection is severe – covering his entire right calf from knee to ankle – with blisters oozing liquid, he needs to have antibiotics given intravenously three times a day. The dressing also needs changing several times a day.

 

A nurse from NUH goes to his home three times a day to give him the intravenous antibiotic and change the dressing.

 

On March 25, Dr Sandra Tan, an advanced internal medicine consultant looking after Mr Ong, checked his wound, which had become bigger, because she was concerned, even though the results of his blood tests were good.

 

After checking the wound, she is confident he will recover, but she extended the antibiotic treatment to 10 days from the original seven.

 

Mr Ong might require even longer treatment, and Dr Tan wants him to return to NUH to have a cannula (thin tube) surgically inserted, should it be needed. But that would be a day surgical procedure, and he would be able to go home on the same day.

 

Mr Ong said he does not know how he got infected. Dr Tan said the bacteria likely got in through the cracks in his toes caused by a fungal infection, which she is also treating. She said serious cellulitis infections requiring hospitalisation are not uncommon, with NUH admitting about 50 such patients each month.

 

Dr Stephanie Ko, an advanced internal medicine consultant who has been in charge of the NUHS@Home scheme since its inauguration in 2020, said one doctor and three or four nurses are rostered each month to care for all patients who opt for the scheme.

 

The team will be expanded from April to cater to MOH’s directive for each of the three clusters to provide 100 MIC@Home “beds” – this equates to caring for about 100 patients at any one time – by the end of 2024. The current total among the three clusters is about 100 MIC@Home beds.

 

Under the scheme, the doctor would do a daily video call with the patient, the same way doctors do ward rounds for inpatients in the hospital.

 

If necessary, the nurse who visits the patient would take photos for the doctor. With high-definition photos, it is as good as, or even better than, seeing the wounds in person. But like Dr Tan did with Mr Ong, the doctor would go to the patient’s home if deemed necessary.

 

Dr Ko said being treated at home may also be good for older patients, who fare better in their home environment.

 

“We know that many older patients who are admitted to the hospital have an increased risk of confusion, decline in their function, and getting infections from the hospital. 

 

“At home, patients generally tend to sleep and eat better, and walk around more, which helps in their recovery,” she said, adding that older and frailer patients are discouraged from walking on their own in hospital, for fear that they might fall.

 

For those who are near the end of life, MIC@Home allows for a transfer to palliative care with little disruption, she added.

 

Dr Ko said the NUHS hospitals – NUH, Ng Teng Fong General Hospital (NTFGH) and Alexandra Hospital (AH) – are also looking to include cancer and transplant patients under MIC@Home. Because transplant recipients are particularly susceptible to infections, they would usually require an isolation room. It would be better for them to be treated at home if possible.

 

The MOH spokesman said: “During their MIC@Home stay, patients have round-the-clock access to care delivered by a team of healthcare professionals via teleconsultations and home visits until they are deemed fit for discharge. 

 

“The patients’ conditions are monitored remotely by the care teams with equipment such as wearable biosensors, intermittent blood pressure meter and blood oxygen saturation probe. If a patient deteriorates, care escalation protocols will be triggered, including the option for the care team to activate emergency medical services.”

 

Good for hospital

 

A cursory glance at the scheme might give the impression that it would cost the hospital more in terms of manpower needs, since a nurse, and sometimes a doctor, would need to visit the patient at home. With all the travelling time, it means they can treat fewer patients per day.

 

While that is true, and there is also the transportation cost for staff, the reality is that it actually costs less, said Mr Johnny Chan, operations and administration lead for NUHS@Home. He said the savings come to about 10 per cent under the pilot, but cost savings are projected to increase to 15 per cent to 20 per cent eventually with scale.

 

“Running a hospital costs a lot more than people expect,” he said. “For patients in the hospital, there needs to be three nursing shifts. There are also the porters and housekeeping staff.”

 

Mr Chan said costs can also be reduced with better technology. For example, a nurse visits Mr Ong three times a day to set up the intravenous antibiotic drip. But there are infusion pumps that require the nurse to go just once a day and set the pump to provide the antibiotics three times a day. The patient carries the pump in a sling bag.

 

Because of the savings, bills for patients on MIC@Home are also slightly lower.

 

Dr Boh Toon Li, a consultant in geriatric medicine at KTPH and the lead clinician for KTPH@Home, said: “The team leverages technology, such as tele or video consultation, to virtually review patients whenever clinically appropriate. This helps to maximise efficient use of manpower resources, while ensuring the patient receives safe and good care under the service.”

 

She added that the scheme helps to relieve the high demand for beds. KTPH is particularly bed-strapped, recording 100 per cent occupancy fairly often in recent months.

 

“On top of this, the virtual hospital model offers more flexibility in capacity and planning for emergency preparedness, as seen during the Covid-19 pandemic outbreak,” Dr Boh said.

 

Dr Ko added that home care frees up beds for more critical patients. She said about 5 per cent to 10 per cent of patients could be on the MIC@Home scheme. Today, about half the patients turn down the offer for various reasons, including lack of buy-in. But she thinks this will change as it becomes mainstream.

 

She assured that help is always just a phone call away. For a small number of patients, their condition required them to return to the hospital. When this happens, an ambulance is used, and they are taken directly to the ward.

 

As for the nursing staff, it would mean that more of them can work on a day shift rather than a graveyard shift.

 

Patients who opt for the scheme can be sent home directly from the emergency department (ED) after their condition has been assessed and treatment has been decided on or has started. Or, like Mr Ong, they can choose to switch to MIC@Home after a day or more in a hospital ward.

 

Good for the nation

 

In 2023, more than half a million patients were admitted to public hospitals, an increase of about 4 per cent over the previous year. With Singapore’s rapidly ageing population, the demand for hospital services will continue to increase in the coming years.

 

More hospital beds are being added, as the gradual opening of the Woodlands Health campus continues in 2024. There is also the building of the Eastern General Hospital in Bedok, followed by another hospital in Tengah, as well as a possible not-for-profit private hospital on the horizon.

 

Not only will there be more older patients, but those who are frail and elderly also tend to stay in hospital for longer. The average inpatient stay has gone up, from 6.1 days in 2019, to seven days in 2022.

 

As a result, public hospitals have been facing a severe bed crunch for the past few years, with patients sometimes stuck in the ED for two days or more, waiting for a vacant bed in the wards.

 

General hospitals are expensive to build, costing more than $1 million per bed they provide. The 700-bed NTFGH, which opened in 2015, cost $800 million. Woodlands Health, the latest to be built, cost about $1 billion, but its 1,400 beds include hundreds of community and long-term care beds, not just the more expensive acute hospital beds.

 

By the end of 2024, there should be about 300 MIC@Home beds – about the size of AH. In future, the number could be double that, or even more, as hospitals say they expect 5 per cent to 10 per cent of their inpatients to opt for the scheme. This would be about the size of NTFGH.

 

Not having to build yet another hospital would result in significant savings that can be better used to improve the provision of healthcare. It would also free up land in land-scarce Singapore.

 

 

Source: The Straits Times © SPH Media Limited. Reproduced with permission.

 

 

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