The study aims to find out whether placed-based care (PBC), helps patients receive better support when they return home after leaving the community hospital, compared with the usual care provided.
Participant is (male or female) ≥ 50 years of age at Recruitment.
Participant is expected to discharge to the community.
Participant is able to converse in either English, Mandarin, or Malay
Participant is able to sign the written informed consent.
Participant is planned for hospice discharge.
Participant is planned for nursing home placement, transitional shelter or care facilities
Parallel
SingHealth Community Hospitals Place-based Care
Other interventionPlace-based Care (PBC) at SingHealth Community Hospitals represents a significant evolution of these approaches, addressing the limitations of fragmented care by integrating social prescribing with structured transitional care. Within community hospital settings, PBC encompasses five core domains: coordinated specialist outpatient follow-ups, linkage to community resources, medication adherence support, primary care transition planning, and caregiver education and self-care empowerment. This integrated model shifts the conventional discharge process from a primarily episodic and medically driven approach to a comprehensive, person-centred care pathway that incorporates both clinical and social assessment, coordinated care planning, supported transition, and structured follow-up. By embedding social prescribing within the continuum of care, PBC aims to improve both clinical outcomes and patient experience during vulnerable transition periods.
Care Transition Quality (CTM-15)
The CTM-15 is the primary outcome measure for this study and aligns closely with the five core domains of the PBC intervention: specialist outpatient clinic (SOC) follow-up coordination, community resource linkage, medication adherence support, primary care transition planning, and caregiver and self-care capability. The CTM-15 is a validated 15-item instrument that assesses the quality-of-care transitions from the patient's perspective, capturing key domains such as medication management, understanding of the care plan, preparation for self-care, and coordination across healthcare settings.
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This trial is not recruiting at the moment. You can still explore other options:
