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Transitional care encompasses a range of services designed to promote care integration as patients transfer between different locations or different levels of care. Transitional care programmes have been proven to produce positive outcomes in reducing hospital readmissions and improving patients’ health outcomes. However, little is known about the benefits of the programmes on healthcare cost and the published results have been inconsistent. With increasing healthcare expenditures and limited public healthcare resources, cost-benefit analyses become paramount in informing healthcare resource allocation decisions. This perspective paper describes the approaches used in estimating the total costs of a bundle of transitional care services from an academic medical centre, identifies the key methodological challenges encountered in the process of cost-benefit analysis, and recommends potential solutions to tackle these challenges. By providing a comprehensive perspective on the methodological challenges, this paper encourages program evaluators to take these possible challenges into consideration for future cost-benefit analyses.

Introduction: The growing prevalence of dementia is of concern in Singapore as it poses significant health, social and economic burden on individuals, families and the healthcare system. While it widely known that dementia is best managed by a multidisciplinary team of healthcare providers working together across different healthcare settings, dementia care has been primarily delivered by tertiary hospitals in Singapore. Hospital-centric dementia care is insufficient because needs of persons with dementia PWDs and their caregivers extend beyond medical needs and are best provided for in the community. As demand continues to rise, the healthcare system now faces the challenges of ensuring sustainability, appropriateness and quality of dementia care. To cope with these, the CARITAS network was established in 2012 to foster integrated, person centered care across different healthcare settings through i formation of primary care and community PCC providers network ii empowerment of PCC to manage PWD in the community iii empowerment of caregivers and iv integration between tertiary hospital and PCC through clinical, professional and functional integration. With these strategies, the CARITAS aims to provide a comprehensive, accessible, responsive, individualized, trans-disciplinary, accountable and seamless care for PWDs in the northern part of Singapore within their community. Methods: To support further development of the CARITAS network, this study was designed as a formative evaluation. Using sequential exploratory mixed methods, we aim to examine the degree of care integration within the CARITAS network, identify moderating factors that affect its implementation by taking into consideration the context in which it operationalized so as to identify areas for improvements. Guided by the Rainbow Model of Integrated Care RMIC, the RMIC measurement tool RMIC-MT was first administered to 100 healthcare providers within the CARITAS network. Then, based on the findings from the RMIC-MT, 30 healthcare providers and caregivers were invited to participate in interviews to gather insights into the moderating factors of the implementation of the CARITAS network. Data from the various sources will initially be analyzed according to their data types and subsequently triangulated according to the RMIC. Recommendations for improvements will then be made. Results & Discussions: The results which will be presented at the conference have significant implications on a few levels. It will potentially i provide information for improvement of the CARITAS network, ii provide insights to other countries that are experimenting with new models of dementia care and iii contribute significantly to the international literature on improvement science. Lessons Learned: In the evaluation of complex healthcare intervention such as the CARITAS network, it is essential to conduct process evaluation in conjunction with outcome evaluation so as to account for variability in implementation. Without process evaluation, it would be difficult to determine actions to take for improving the intervention. Limitations: As this is a single site study, findings gathered from this study needs to be interpreted with consideration of the context in which the CARITAS network is implemented. Suggestions for future research Future research should be conducted to examine the effectiveness of the CARITAS network in improving its intended outcomes.

Introduction : Frequent admitters FA, defined as patients with three or more inpatient acute hospital admissions within one year, account for about 27% of episodes and incur high healthcare costs. National University Health System Regional Health System NUHS-RHS Integrated Interventions and Care Extension NICE, launched in 2014, targeted FA with the aim of reducing avoidable hospital utilisation. NICE patients were assigned a case manager who customised their care plan based on holistic needs assessment. NICE provided post-discharge home visits and/or phone calls to monitor patients’ progress, appropriate referrals to community health and social services, and consolidated care under one team. We retrospectively evaluated NICE’s effect on reducing utilisation over 1-year post-enrolment: all-cause admissions ADM, emergency admissions EM, emergency department visits ED, specialist outpatient clinic visits SOC, and total inpatient length of stay LOS. Methods : NICE patients enrolled between June 2014 to December 2015 were grouped as cases n=668. Unenrolled patients who were FA during the same period were designated as potential controls n=5,714, taking their third admission date during this period as proxy date of enrolment. Propensity score matching was conducted with the following: gender, race, age, residential housing type, number of comorbidities at enrolment, date of enrolment and pre-enrolment utilisation 1-year prior. This resulted in 604 matched case-control pairs. As the variance of each measure of utilisation is greater than its mean, negative binomial regression was used to model post-enrolment utilisation, adjusting for log-transformed pre-enrolment levels and matching propensity score, with an offset term to account for potential mortality during follow-up. We report incidence rate ratios IRR of cases to controls, with 95% confidence intervals 95%CI. Results : Cases unadjusted mean=6.7 had significantly fewer post-enrolment SOC than controls unadjusted mean=8.6, IRR=0.86 95%CI: 0.77-0.97. No statistically significant differences were observed for post-enrolment ADM, EM, ED, and LOS. Discussion : The results suggest that NICE provided adequate post-discharge follow-up care that patients would otherwise seek from SOC, thus potentially decreasing patients’ time and cost burden. For a significant proportion of patients in both groups, post-enrolment ADM, EM, ED, and LOS may have regressed to a low mean following an acute period of high admissions, resulting in floor effects which limit any further reductions in a 1-year period. Conclusion : NICE had an impact in reducing patients’ SOC post-discharge. Lessons Learned : The higher than expected variability in the utilisation patterns suggest FA are a heterogeneous group, and stratification could allow for more targeted interventions that better cater to care needs. Limitations : Patients were not randomised into cases and controls, but inherent bias from confounding factors was mitigated with matching. Different patient profiles and needs possibly also led to implementation inconsistencies. Suggestions for Future Research : Future research could stratify FA into subgroups and explore programme effects in reducing readmissions within patient subsets over a longer follow-up period. Targeted interventions for various subsets could be tested and inform future iterations of such programmes. Cost-benefit analysis should be conducted to determine if the savings from reduced SOC that are attributable to NICE outweighs the cost to run the programme.

Introduction: Patients with multiple morbidities and complex needs are putting a strain on the resources of the health system, particularly on hospitals. The current fragmented hospital and disease centric care is unable to cope with the growing healthcare needs facing the modern day health system [1,2]. Therefore, integrated care interventions have been developed to improve the quality and efficiency of care by coordinating healthcare services in a person-centric manner with the aims of reducing health and social burden on the healthcare systems including hospitals [2]. However, the methods and outcomes of interventions used are different and evidence of the effectiveness of the interventions are not consistent. There is also a lack of understanding on why and how integrated care interventions work or do not work under certain circumstances. Based on the CMO (context, mechanism and outcomes) [3] model, we aim to summarise and compare the existing evidence of the context, mechanism and outcomes of hospital-led integrated care interventions from published peer-reviewed systematic reviews. Methods: A review of existing systematic reviews is being conducted to find out what works, for whom, and under what circumstances hospitals can provide effective integrated care interventions. The review will address the following questions: (1) what are the programmes available? (2) Who is the target population? (3) In what respect of integrated care (i.e., patient, system, organisation)? (4) What are the outcomes measured (e.g. healthcare utilizations, healthcare outcomes (QoL, quality of care mortality rates, etc.), costs) and how effective are they? (5) If they are effective, how do they work in different settings and for different populations? (6) What are the underlying mechanisms of these interventions? (7) What causes the heterogeneity in outcomes of hospital-led integrated care programmes? Based on the WHO definition of integrated care [4] and Rainbow Model of Integrated Care (RMIC) definition of system and organisation integration [5], articles are searched through PubMed, Scopus, Web of Science and Cochrane Database of Systematic Reviews for the period 2006-2016 (N=2290). A systematic review is included if it describes hospital-led interventions that involve system or organisation integration, involve an acute care setting as the lead, and have the outcomes of the interventions evaluated. Titles for inclusion are screened independently by three reviewers using predetermined criteria. Data are extracted and quality of review is assessed according to the Joanna-Briggs Institute guidelines.[6] Findings on context and mechanism are analysed to explain about outcomes. Complete findings will be presented during ICIC17. Discussion: The findings from the review will help inform policy-makers and healthcare professionals on the design of integrated care programmes that will most likely yield their desired outcomes, based on their target populations and context of the health system. The review will also provide an overview of how to bridge the gap between the development of interventions and successful implementation of hospital-led integrated care [2]. For researchers, the review will indicate the strength of existing evidence and identify directions for future research.

Introduction: The Regional Health System (RHS) is a very recent concept in Singapore’s healthcare system. Despite our good record in raising the coverage and quality of healthcare for our residents while keeping healthcare expenditure relatively low, the growing and rapidly ageing population will impose hitherto unimagined challenges. The RHSes are an important part of Singapore’s response and will need to play a critical role in meeting the challenges. From its first mooting to the current development-in-progress, the RHS has evolved in conceptualisation and implementation in Singapore's six health regions. This presentation describes how these nascent RHSes are developing, and how they compare with international examples of regional systems that have done well. We also discuss en passant how healthcare systems in very different countries can (and how they perhaps should not) learn from one another across international borders. Method: To compare Singapore’s RHSes both between the different local RHSes and with RHSes in other countries, a conceptual framework depicting key elements of the RHSes and their interactions is described as a basis for description and comparison, much along the dimensions of the conceptual framework for Integrated Care proposed by Pim Valentijn et al. Results: We describe the key features of the RHS in Singapore in terms of their geography, population catchment, patient and client flows, clinical and operational services, community health and social support, financing, informational platforms, organisational culture, and clinical and corporate governance. As the six regions within Singapore have been encouraged to experiment and find their own best approach, we compare the differences between how they have both diverged and converged in their development. These essential similarities across the six regions are drawn out and summarised as common concepts for the RHSes in Singapore. The “common core” is compared with how RHSes in other countries have developed. In passing, the learnings from other countries that have rooted well in Singapore suggest some insights into how we can successfully learn from other, very different, health systems. 3 World Congress on Integrated Care, Mexico City, Mexico, 19-21 November, 2015 International Journal of Integrated Care – Volume 15, 17 Nov – URN:NBN:NL:UI:10-1-117362 – http://www.ijic.org Discussion: While the RHS has become a fixture in the healthcare landscape of Singapore, we still have much to learn about how we should develop these partnerships. While the different regions have in fact developed innovative and interesting approaches to integrating care, questions remain about (a) how one region’s successes are best transferred to others, (b) how these others then manage with such implants alongside their own experiments, (c) how such a wide diversity of models will be managed in the larger healthcare system. Also of interest are the needed adaptations in the nationwide health financing and other governmental policies to support these developments. Many fine examples of how care has been integrated for the better health and life of the population are founded on cohesive and coordinated regional partnerships, whether they are defined in geopolitical terms (eg Canterbury in New Zealand, Jonkoping in Sweden, and Torbay in the United Kingdom) or through corporate entities (eg Geisinger and Kaiser Permanente in the United States). These however differ substantially in some ways from the RHSes in Singapore. Learning from these examples requires the student to be discriminating in terms of both what can be usefully imported and adapted, and what requires a change in the larger environment to successfully take root. Salient lessons are discussed. Conference abstract Spanish Introduccion: El Sistema Regional de Salud (RHS) es un concepto muy reciente en el sistema de salud de Singapur. A pesar de nuestro buen record en el aumento de la cobertura y calidad de la asistencia sanitaria para nuestros residentes, manteniendo el gasto sanitario relativamente bajo, el crecimiento y el rapido envejecimiento de la poblacion impondra retos inimaginables. El RHS es una parte importante de la respuesta de Singapur y tendra que jugar un papel fundamental en el cumplimiento de los retos. Desde su primera discusion para el desarrollo en curso actual, el RHS ha evolucionado en la conceptualizacion e implementacion en seis regiones sanitarias de Singapur. Esta presentacion describe como este RHS es naciente y esta en desarrollo, y como se comparan con ejemplos internacionales de sistemas regionales que han hecho bien. Tambien discutimos en una pasada como los sistemas de salud en paises muy diferentes pueden (y la forma en que quiza no deberian) aprender unos de otros a traves de fronteras internacionales. Metodo: Comparar el RHS de Singapur, tanto entre los distintos RHS locales y con RHS en otros paises, un marco conceptual que representa los elementos clave del RHS y sus interacciones se describen como una base para la descripcion y comparacion, tanto por las dimensiones del marco conceptual para Atencion Integrada propuesto por Pim Valentijn y otros. Resultados: Se describen las principales caracteristicas de la RHS en Singapur en terminos de su geografia, de captacion de la poblacion, pacientes y flujo de clientes, servicios clinicos y operacionales, la salud de la comunidad y de apoyo social, financiacion, plataformas de informacion, la cultura organizacional, clinicas y del gobierno corporativo . Como se ha alentado a las seis regiones de Singapur para experimentar y encontrar su propio y mejor enfoque, comparamos las diferencias entre la forma en que ambos han divergido y las convergentes en su desarrollo. Estas similitudes esenciales a traves de las seis regiones se extraen y se resumen como conceptos comunes para el RHS en Singapur. El "nucleo comun" se compara con la forma en que el RHS se ha desarrollado en otros paises. De paso, los aprendizajes de otros paises que han arraigado bien en Singapur sugieren algunas ideas sobre como podemos aprender con exito de otros sistemas muy diferentes de salud. Discusion: Mientras que el RHS se ha convertido en un referente en el panorama de la salud de Singapur, todavia tenemos mucho que aprender acerca de como debemos desarrollar estas asociaciones. Mientras que las diferentes regiones han desarrollado enfoques innovadores e interesantes para la integracion de la atencion, siguen habiendo dudas sobre (a) como los exitos de una region estan mejor transferidos a otros, (b) como estos otros entonces arreglan con dichos implementos junto a sus propios experimentos, (c ) como se gestionara una amplia diversidad de modelos de este tipo en el sistema de salud mas grande. Tambien de interes son las 3 World Congress on Integrated Care, Mexico City, Mexico, 19-21 November, 2015 International Journal of Integrated Care – Volume 15, 17 Nov – URN:NBN:NL:UI:10-1-117362 – http://www.ijic.org adaptaciones necesarias en el financiamiento de la salud a nivel nacional y otras politicas gubernamentales para apoyar estos desarrollos. Muchos buenos ejemplos de como el cuidado se ha integrado para la mejora de la salud y la vida de la poblacion se basan en asociaciones regionales unitarias y coordinadas, ya sea que se definen en terminos geopoliticos (por ejemplo Canterbury en Nueva Zelanda, Jonkoping en Suecia, y Torbay en los Estados Unido) o a traves de entidades corporativas (por ejemplo Geisinger y Kaiser Permanente en los Estados Unidos). Sin embargo, estos difieren sustancialmente en algunos aspectos de los RHS en Singapur. Aprender de estos ejemplos requiere que el estudiante tienen que ser exigentes en terminos de lo que puede ser util de importar y adaptar, y lo que requiere un cambio en el entorno mas amplio para afrontar con exito desde la raiz. Se discuten las lecciones mas destacadas.