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Increasingly, we are recognising that health and social integration must gain more prominence to ensure that discharged patients continue to receive care and support in the community. These individuals need a range of services that goes beyond social integration to prevent a relapse or a premature return to the hospital; and to help them regain as much independence as possible.
So how can we shape care for the future? We can and have started through the 3 ‘I’s: integration, innovation and investment.
Integration is the process of combining two or more things to create a seamless “one” experience. It is about putting on the lens of the patient, and be intentionally flexible, personalised and seamless when extending help and treatment to the patient. This may sound simple but the barrier is the expert lens of issuing instructions and lack of consideration for co-existing factors that time does not permit one to pay attention to.
Greater collaboration across the social and healthcare sector is needed to provide integrated care. Holistic and coordinated care would ensure that patients do not fall through the cracks.
Principles to guide the application of integrated care
These are principles that can guide the application of integrated care.
i. Clear and committed leadership
We need leaders to come together to discuss, establish a common purpose and focus on desired outcomes. We also need a common set of values and vision across the sector to provide clear direction for the team’s service provision and for supporting and supervising team members.
ii. Training and education
Integration begins with the patient’s perspective as the organising principle of service delivery. As such, leaders may need to adjust systems and routines or even come up with new regulations to facilitate integration. Cross-training of professionals is necessary to bring about a shared perspective to facilitate coordination and encourage mutual respect across systems.
iii. Good understanding of roles
Social care services can provide insight regarding how patients live and this can contribute to the success of healthcare intervention. Information-exchanges amongst professionals (with patient’s and family’s consent) and with family members are important. Information technology can facilitate standardised communication protocols, shared patient information, single assessment procedures and defined care pathways. Exchanges of information would help form a strong network of trust and relationship surrounding the patient, where appropriate support can be activated for the patient whenever necessary.
Challenges to integrated care
Who owns the patient and her problems? There is no easy answer to this question as there is often no clear ownership. This leads to a lack of role clarity and time is spent waiting for responses from various parties involved in the patient’s care.
The lack of home care and informal support for discharged patients is another challenge. The lag between formal care and home care leads to a ‘cliff effect’ once the patient is discharged. For better integration of care, we need to cultivate the informal care support system, expand and integrate the informal care network into the care management process.
Innovation requires us to look inward and outward. When looking inward, we reflect on how our services, interventions and work processes are affecting patients and how we can improve.
Looking outward means firstly, keeping in touch with emerging trends and social issues. Secondly, building upon ideas within and beyond the sector; and tailoring them to the relevant context. Thirdly, collaborating with other disciplines (e.g the technology industry, the marketing industry and increasingly the digital industry) to co-create solutions.
Examples of innovation in healthcare
i. Support of patients with high medical and social needs
Ms Zahara Mahmood, winner of the 2017 Outstanding Social Worker Award, was recognised for her innovative spirit in leading the “Neighbours for Active Living programme” under the Eastern Health Alliance. The programme bridges the medical-social divide through a combination of practical social assistance with targeted healthcare assistance. It reduces relapses, complications and re-admissions of seniors in eastern Singapore who have high medical and social needs and frequent hospital admissions.
ii. Interventions via video
The Ministry of Health (MOH) piloted tele-rehabilitation though video to reach out to home bound patients to make rehabilitation exercises more accessible in 2017. Patients do exercises with wearable sensors and the therapist reviews their exercises through video links and the results from the sensors. Such forms of interventions are becoming more widespread and have been found to be both effective and efficient.
Challenges to innovation
The lack of time, knowledge, awareness and appreciation of the multi-layered knowledge required to understand the environment better, are common challenges to innovation.
There is also the preference for things to remain the same even though the benefits of change are rationally larger.
Investment is the act of putting resources into a particular product or instrument, with the hopes that it will bear returns in the long run. Particularly in human services, investment is about putting resources (often including time), in ourselves and others.
Investment in self, others and health-social integration
Investing in the self means continuously improving ourselves through training, education, and seeking mentorship and supervision. It also includes self-care so that we can last the long journey of integration, innovation and investment.
Leaders lead people into the future. When we invest in people, we need to think long term. An important role of leaders is to prepare those under them to be ready for the challenges of the future. Leaders need to challenge themselves and ask “how can social workers and social service practitioners step up and step out to work with partners from other disciplines and agencies?”.
With better medical care, more older persons and persons with disabilities are living longer. More will need to be done to integrate help, services and programmes to achieve client satisfaction. Structures, systems and processes led by human service practitioners who mindfully and purposefully integrate services and innovate will better prepare us for the current reality and the future. Finally, we must continue to invest in people and encourage experimentation, innovation and collaboration to deliver good outcomes for those we serve.
Fostering Innovation In Social Work Practice. (2017, March 21). Retrieved from MSF Cares: https://msfcaresblog.com/2017/03/21/fostering-innovation-in-social-work-practice/
Lloyd, J., & Wait, D. S. (2006 ). Integrated Care – A Guide for Policymakers.
Director-General of Social Welfare
Ministry of Social and Family Development