Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2019 Mar 19;19(1):177.
doi: 10.1186/s12913-019-3980-x.

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

Milawaty Nurjono  1 , Pami Shrestha  2 , Ian Yi Han Ang  2 , Farah Shiraz  2   3 , Joanne Su-Yin Yoong  4 , Sue-Anne Ee Shiow Toh  2   5 , Hubertus Johannes Maria Vrijhoef  6   7   8
Affiliations

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

Milawaty Nurjono et al. BMC Health Serv Res. .

Abstract

Background: To 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.

Methods: Guided 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.

Results: Most (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.

Conclusion: This 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.

Keywords: Implementation fidelity; Integrated care; Mixed methods; Post-discharge care; Transitional care.

PubMed Disclaimer

Conflict of interest statement

Ethical approval and consent to participate

The National Healthcare Group, Singapore, Domain Specific Review Board (DSRB) reviewed and approved this study protocol (DSRB Ref: 2016/00410). Written informed consent were obtained from participants included in interviews and non-participatory observations. Waiver of consent was granted by DSRB for retrospective reviews of medical records. To maintain confidentiality of the research participants, analysis was conducted only on de-identified data.

Consent for publication

Not applicable.

Competing interests

PS, IYHA, FS, and SAT are a part of the NUHS-RHS planning office which is involved in the planning and development of programs under the purview of the NUHS-RHS.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
The logic model of NUHS-RHS transitional care program
Fig. 2
Fig. 2
A convergent mixed method study to evaluate implementation fidelity of NUHS-RHS transitional care program
Fig. 3
Fig. 3
Moderating factors influencing implementation fidelity of NUHS-RHS transitional care program
See this image and copyright information in PMC

References

    1. Population and Vital Statistics. https://www.moh.gov.sg/resources-statistics/singapore-health-facts/popul....
    1. Vogeli C, Shields AE, Lee TA, Gibson TB, Marder WD, Weiss KB, Blumenthal D. Multiple chronic conditions: prevalence, health consequences, and implications for quality, care management, and costs. J Gen Intern Med. 2007;22(Suppl 3):391–395. doi: 10.1007/s11606-007-0322-1. - DOI - PMC - PubMed
    1. Tan C. Innovating for future health. Singap Med J. 2016;57(10):533–538. doi: 10.11622/smedj.2016164. - DOI - PMC - PubMed
    1. Tan W. Singapore healthcare: challenges today and building a better tomorrow. Singapore Med Assoc News. 2009;2009:34–43.
    1. Stange KC. The problem of fragmentation and the need for integrative solutions. Ann Fam Med. 2009;7(2):100–103. doi: 10.1370/afm.971. - DOI - PMC - PubMed

Publication types