Evaluation

CRiHSP intends to evaluate models of care that optimise continuity and co-ordination, particularly as facilitated by innovative IT developments, including:

1. Modality characterisation at the individual, team and clinic level;

2. Evaluation of the impact on processes and outcomes of care.

NUHS Regional Health Systems Office (RHSO) Community Care Team (CCT)

Funder: National University Primary Healthcare
Duration: Oct 2023 – Apr 2025
Lead Investigator: Marie Ng
Contributors: Koh Wee Ling, Neo Sin Hui, Yee Wei Lim, Jose M Valderas

Funder:	National University Primary Healthcare
Duration:	Oct 2023 - Apr 2025
Lead Investigator:	Marie Ng
Contributors:	Wee Ling Koh, Sin Hui Neo, Yee Wei Lim, Jose M Valderas

The evaluation will focus on two components of the CCT programme: the Community Health Post (CHP), which provides community-level chronic disease management, an Hospital to Home (H2H), which facilitates transitional care for discharged patients.

The primary objective of this evaluation is to assess programme impact by comparing key outcomes indicators – such as proportion of patients with optimal chronic condition control, medication adherence, and healthcare utilisation – between programme patients and a selected control group.

Additionally, the evaluation aims to measure the programme’s sustainability and scalability for long-term operation and expansion to a larger eligible population.

Community Health Post – Providing Healthcare Support in Your Neighbourhood – NUHS

Community Care Team – Hospital to Home | NUHS

A final report and mainstreaming proposal will be submitted to the MOH Program Evaluation Unit by the end of FY 2025.

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NUHS Regional Health Systems Office (RHSO) Nursing Home Support Team+ (NHST+)

Funder: National University Primary Healthcare
Duration: Oct 2023 – Apr 2025
Lead Investigator: Marie Ng
Contributors: Koh Wee Ling, Neo Sin Hui, Yee Wei Lim, Jose M Valderas, Laurie Goldsmith, Nithya Palanivelu, Aparna Sudheen

Funder:	National University Primary Healthcare
Duration:	Oct 2023 - Apr 2025
Lead Investigator:	Marie Ng
Primary Contributors:	Wee Ling Koh, Sin Hui Neo, Yee Wei Lim, Jose M Valderas
Secondary Contributors:	Laurie Goldsmith, Nithya Palanivelu, Aparna Sudheen

The primary objective of the evaluation is to determine the effectiveness and impact of the NHST+ care model, implemented by St.Luke’s Hospital in partnership with All Saints Home. The model aims to enhance the nursing home’s end-of-life capabilities and deliver quality geriatric and palliative care in-situ. Specifically, the evaluation will quantify key outcome indicators, such as reduction in emergency department visits and hospital admissions, and the proportion of deaths aligned with patients’ prior decisions. It will also include macro-level process monitoring to track implementation progress and fidelity, as well as sustainability and scalability assessments to evaluate the programme’s long-term viability.

The secondary objective of the evaluation is to identify and analyse key success factors and learning opportunities of the collaboration with St. Luke’s Hospital as a community partner and operationalization of the NHST+ programme in Nursing Homes.

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