Integrating aged care in Singapore—the ACTION framework

In Singapore the public healthcare organization, Agency for Integrated Care (AIC), (www.aic.sg), centrally coordinates and facilitates the transition of patients from acute care settings to care facilities in the community. In one of AICs recent projects, teams of care coordinators were formed and based at public acute hospitals. Known as Aged Care Transition (ACTION) Teams, they actively identify elderly patients who need assistance with obtaining community care, facilitate the transition of care and track the outcome. Since its implementation in 2008, ACTION has coordinated the care of about 5000 patients, and helped to surface issues and challenges at various levels, from service provision to policies on community care. The effectiveness of care coordination in improving the integration of care for the aged has been studied quantitatively and qualitatively. AIC is expanding its roles beyond care referral and coordination, and into developing the capacity and quality of primary care and community care, and connecting the various healthcare providers for better health outcomes. AIC will also be implementing a new national care assessment framework for more accurate and uniform identification of individual needs for community care. One of AICs new strategies to engage and support sub-acute and community care providers is to extend the base of ACTION Teams to them so that the needs of patients and caregivers can be identified and met promptly. This will prevent unnecessary escalation to acute care or residential care, thereby enabling the patients to be cared for in their own homes as far as possible. The contribution of the hospital-based ACTION Teams towards care integration for the aged will be further enhanced through the introduction of a risk stratification tool. One of the aims is to identify patients who could benefit from follow-up management by the community-based ACTION Teams. By learning from best practices internationally and local experimentations—“Think International, Act Local”—AIC continues to enhance its care coordination framework to better care for the aged.