A Randomised Control Trial of a Transitional Care Model in Singapore General Hospital

A Randomised Control Trial of a Transitional Care Model in Singapore General Hospital

To find out if a transitional care model can reduce the rate of unscheduled readmission to the Department of Internal Medicine (DIM) in SGH

Hospital with high readmission rate is view as having lower quality of care High readmission rate is view as wasteful healthcare spending

Primary Aim:

To find out if a transitional care model can reduce the rate of unscheduled readmission to the Department of Internal Medicine (DIM) in SGH A readmission episode is defined as an episode of readmission to any tertiary hospital within 30 days after index discharge from SGH

Secondary Aim:

To find out if a transitional care model can reduce the number of visits to the emergency department in SGH To find out the quality of our transitional care model by using a care transition measure (CTM-15)

Inclusion criteria

-More than 1 admission in the last 90 days

Exclusion Criteria

• Subject is a non-resident
• Subject has no local home address
• Subject is from a long-term care facility during index admission
• Subject is unable to participate in telephone surveillance
• Subject is discharged before takeover
• Subject has impaired decision making capacity without surrogate decision maker
• Subject is pending or currently in critical care unit
• Subject or caregiver is mentally unstable
• Subject is haemodynamically unstable
• Subject requires acute inpatient respiratory support
• Subject requires acute inpatient dialysis support
• Subject pending surgical intervention
• Subject pending transfer to other specialist discipline
• Primary team consultant declined to participate in this research