Implementation fidelity of a strategy to integrate service delivery: learnings from a transitional care program for individuals with complex needs in Singapore

Abstract

BackgroundTo cope with rising demand for healthcare services in Singapore, Regional Health Systems (RHS) comprising of health and social care providers across care settings were set up to integrate service delivery. Tasked with providing care for the western region, in 2012, the National University Health System (NUHS) – RHS developed a transitional care program for elderly patients with complex healthcare needs who consumed high levels of hospital resources. Through needs assessment, development of personalized care plans and care coordination, the program aimed to: (i) improve quality of care, (ii) reduce hospital utilization, and (iii) reduce healthcare-related costs. In this study, recognizing the need for process evaluation in conjunction with outcome evaluation, we aim to evaluate the implementation fidelity of the NUHS-RHS transitional care program to explain the outcomes of the program and to inform further development of (similar) programs.MethodsGuided by the modified version of the Conceptual Framework for Implementation Fidelity (CFIF), adherence and moderating factors influencing implementation were assessed using non-participatory observations, reviews of medical records and program databases.ResultsMost (10 out of 14) components of the program were found to be implemented with low or moderate level of fidelity. The frequency or duration of the program components were observed to vary based on the needs of users, availability of care coordinators (CC) and their confidence. Variation in fidelity was influenced predominantly by: (1) complexity of the program, (2) extent of facilitation through guiding protocols, (3) facilitation of program implementation through CCs’ level of training and confidence, (4) evolving healthcare participant responsiveness, and (5) the context of suboptimal capability among community providers.ConclusionThis is the first study to assess the context-specific implementation process of a transitional care program in the context of Southeast Asia. It provides important insights to facilitate further development and scaling up of transitional care programs within the NUHS-RHS and beyond. Our findings highlight the need for greater focus on engaging both healthcare providers and users, training CCs to equip them with the relevant skills required for their jobs, and building the capability of the community providers to implement such programs.Electronic supplementary materialThe online version of this article (10.1186/s12913-019-3980-x) contains supplementary material, which is available to authorized users.

Assessment of the implementation fidelity of a strategy to scale up integrated care in five European regions: a multimethod study

“…Most studies that assess the implementation fidelity focus on the implementation of national (complex health) interventions or programmes. [26][27][28] Consequently, we were not able to compare our findings to similar studies. Notwithstanding, our study shows that assessing the implementation of an international stepbased scaling up strategy by using the modified version of the Conceptual Framework for Implementation Fidelity 17 is feasible.…”

“…This corresponds to other studies who also explored the implementation fidelity with a lack of defined points of references for assessment. 26 27 30 The opportunity to work closely with programme implementers ensured us to be kept up to date on the changes regarding revisiting reference points with the evolution of the strategy.…”

Conducting a Cost-Benefit Analysis of Transitional Care Programmes: The Key Challenges and Recommendations

“…This was not surprising as there was no established workflow or guideline in documentation built into the operations protocol ahead of time to facilitate the consolidation of cost data. Even if there was, the tough balance would have to be struck between being detailed, accurate, and in line with the frontline job priorities that the healthcare team is serving [13].…”

Shifting Care from Hospital to Community, A Strategy to Integrate Care in Singapore: Process Evaluation of Implementation Fidelity

“…Learning from these, a regular patient engagement with the goal of improving the design of the program should be explored for further development of the RSC program. Since patients in Singapore are largely passive [43], it would be important to activate patients to participate by offering flexibility in the levels of engagement and approach, and including a reward mechanism to incentivize participation.…”