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. 2023 May 25;11(11):1546. doi: 10.3390/healthcare11111546

Table 1.

Characteristics of articles reviewed.

Author and Year of Publication Activities Conducted Mean Age of Study Participants Eligibility Criteria Aim of Programme Financing Model Cost to Patient Training of Care Coordinators Team Composition Care Setting Type of Chronic Disease Length of Follow-Up Mode of Contact Frequency of Follow-Up
Ang et al. [28]
(2019)
Book appointments
Provide programme information
Provide financial counselling
Referral to appropriate resources
58 ± 16 years
  • Patients with chronic conditions who had at least 1 NUH SOC appt in the past year

  • Clinically stable to be right-sited

Reduce hospital resource utilisation (Right-siting of care) Not reported Not reported Not reported Specialist physician + Primary care physician + Nurse + Allied health professional Both Primary care & Hospital Mixed Not reported Face-to-face Not reported
Chandran et al. [29]
(2013)
Assess clinical needs
Assess medication compliance
Conduct case finding
Deliver disease-specific education
Document care in electronic medical record systems
Monitor patient’s progress
Provide programme information
Refer to appropriate resources
Reinforce treatment compliance
Screen for eligibility to enrol
72 ± 10 years
  • Aged > 50 years old

  • History of low trauma fragility fracture

  • Agree for at least 2 years follow-up

Optimise disease management Not reported Not reported Nurse Specialist physician Hospital (Outpatient + Inpatient) Osteoporosis 2 years Phone call + Face-to-Face 6 follow-ups over 2 years
Chow et al. [30]
(2014)
Act as a resource point for patients to call in for assistance/clarification
Deliver tailored disease-specific education
Deliver psychoeducation
Deliver self-management education
Escalate to physician
Identify red flags
Monitor patient’s progress
Provide psychosocial support
63 ± 13 years
  • Patients aged ≥21 years old

  • Recently discharged for diabetes-related hospitalisation with HbA1c >7%

  • Agree to phone follow-ups

Reduce hospital resource utilisation (Transition from ward to home) Not reported Not reported Nurse Specialist physician Hospital (Outpatient) Diabetes 6 months Phone call 4 follow-ups over 6 months
George et al. [31]
(2016)
Deliver self-management education
Identify red flags
Monitor patients’ progress
Provide smoking cessation counselling
Reinforce appointment and medication compliance
73 ± 10 years
  • Patients clinically diagnosed with COPD or possible COPD

  • Agree to be enrolled in a Disease Management Programme

Optimise disease management Not reported Not reported Not reported Specialist physician + Primary care physician Both Primary care & Hospital Chronic Obstructive Pulmonary Disease Not reported Phone call Weekly or every 2 months depending on acuity
Ha et al. [32]
(2020)
  • Advocate for patients’ preferences

  • Collaborate with other care providers and with caregivers

  • Deliver patient education

  • Develop personalised care plans

  • Liaise with and coordinate care processes between various stakeholders

  • Empower caregivers

  • Referral to appropriate resources

Not reported
  • Disease severity

  • Extent of caregiver support

Reduce hospital resource utilisation (Right-siting of care), support caregivers and optimise disease management Funded by MOH No charges to patient Not reported Specialist physician + nurse + allied health professional + primary care physician Both Primary care & Hospital Dementia Not reported Phone calls + home visits Not reported
Ha et al. [33]
(2020)
  • Acts as a resource point for patients to call in for assistance/clarification

Deliver patient education
Monitor patients’ progress
78 ± 7.72 years
  • Patients with dementia identified with behaviours deemed challenging by caregivers and/or caregivers with caregiver burden

  • Condition not stable/not suitable to receive care in the ambulatory dementia clinic

Reduce hospital resource utilisation (Right-siting of care) and support caregivers Partially charity dollar funded Yes Not reported Specialist physician + case manager + community-based counsellors Off-site (ambulatory community clinic + at home) Dementia 4 months Home visits Not reported
Jafar et al. [34]
(2016)
Identify red flags
Provide psychosocial support
Reinforce treatment compliance
66 ± 10 years
  • Patients ≥ 40 years old

  • Diagnosed with hypertension

  • Uncontrolled BP

  • Visited a participating polyclinic ≥ 2 times in the past 1 year

  • Have no admission 4 months prior to recruitment

  • Agreed to be enrolled

Optimise disease management Not reported Not reported Nurse Specialist physician + Primary care physician + Nurse Primary care Hypertension 3 months Phone call 2 follow-ups over 3 months
Jafar et al.
[35]
(2022)
  • Coordinate with physician for care

  • Collect requisite outcome data (clinical + patient reported health status)

  • Empower patients

  • Monitor patients’ progress

  • Reinforce treatment compliance

64.5 ± 9.8 years
  • Patient aged ≥40 years with previously diagnosed hypertension

  • Visited an enrolled clinic ≥2 times during prior 12 months

  • Singaporean citizens or permanent residents

Optimise disease management Partially subsidised by MOH Yes Nurse Primary care physician + nurse + research coordinator Primary care Hypertension 2 years Phone call Monthly for first 3 months, then 3-monthly thereafter
Jiang et al. [36]
(2019)
  • Conduct home visits

  • Coordinate appointments

  • Deliver disease-specific education

  • Monitor patients’ progress

  • Promote self-care

  • Use of mobile application to educate, monitor and engage with nurse if needed

69.7 ± 11.04 years
  • Patients aged ≥ 21 years old

  • Clinically diagnosed with chronic heart failure

  • Able to read and understand English or Chinese

  • Owned and used smartphones in their everyday lives

  • Able to be followed up at home after discharge from hospital

Optimise disease management through self-care Not reported Not reported Nurse Nurse Off-site (post-discharge) Chronic heart failure 6 weeks Home visits Bi-weekly
Lai et al. [37]
(2019)
Assess clinical needs
Assess caregiver needs
Conduct home visits
Identify red flags
Refer to appropriate resources
Not reported
  • Patients aged ≥ 65 years old and their caregiver

  • Had uncomplicated memory loss for ≥6 months

Optimise disease management Not reported Not reported Not reported Specialist physician + Primary care physician + Nurse + Allied health professional Primary care Dementia Not reported Phone call + Home visits Not reported
Lee et al. [38]
(2015)
Act as a resource point for patients to call in for assistance/clarification
Assess clinical and social needs
Assess compliance to care plans
Assess level of health literacy
Assess medication compliance
Coach caregivers and assess their competency
Conduct home visits
Coordinate follow-up visits with specialist care providers
Deliver patient education
Identify red flags
Monitor patients’ progress
Provide medication reconciliation
Provide psychosocial support
Refer to appropriate resources
68 ± 15 years
  • Patients aged > 21 years old

  • Recently discharged home with high readmission risk

  • ≥2 unplanned admissions within the past 90 days

Reduce hospital resource utilisation (Transition from ward to home) Not reported Not reported Nurse with specialised training in care coordination Specialist physician + Primary care physician + Nurse + Allied health professional Off-site (Post-discharge only) Mixed 3 months Phone call Weekly
Lim et al. [39]
(2015)
Act as a resource point for patients to call in for assistance/clarification
Collect data for programme evaluation
Coordinate appointments
Counsel patients on care process
Liaise with and coordinate care processes between various stakeholders
Monitor communication gaps between stakeholders
Provide financial counselling
Track prescriptions
54 ± 14 years
  • Patients who attend a tertiary rheumatology clinic

  • Clinically stable to be right-sited

Reduce hospital resource utilisation (Right-siting of care) Not reported Not reported Not reported Specialist physician + Primary care physician + Nurse Hospital (Outpatient) Musculoskeletal disease Not reported Phone call Not reported
Lim et al. [40]
(2018)
Act as a resource point for patients to call in for assistance/clarification
Book appointments
Coach caregivers
Coordinate with physician for care
Coordinate transfer of care from SOC to Family Medicine Clinic
Monitor patients’ progress
Provide psychosocial support
Recruit eligible patients to programme
64 ± 14 years
  • Patients with stable chronic diseases on follow-up at Family Medicine Clinic

  • Patients with complex care needs on shared care between hospital and Family Medicine Clinic

Reduce hospital resource utilisation (Right-siting of care) Not reported Not reported Nurse Not reported Primary care Mixed Not reported Phone call Not reported
Low et al. [41]
(2017)
Act as a resource point for patients to call in for assistance/clarification
Assess caregiver competency
Assess compliance to care plans
Assess level of health literacy
Assess medication compliance
Coordinate follow-up visits with specialist care providers
Deliver patient education
Enable patient activation
Identify red flags
Monitor patients’ progress
Provide tailored care planning
Referral to appropriate resources
71 ± 14 years
  • Patients aged ≥ 21 years old

  • Have high risk of readmission

  • Have ≥ 1 admission in the past 90 days

  • Planned for discharge home

  • Admitted in participating wards

Reduce hospital resource utilisation (Transition from ward to home) Not reported Not reported Nurse Specialist physician + Primary care physician + Nurse + Allied health professional Off-site (Pre- and post-discharge) Mixed 3 months Phone call + Home visits Weekly
Low et al. [42]
(2015)
Act as a resource point for patients to call in for assistance/clarification
Coordinate care with hospital specialists
Conduct home visits
Conduct medication reconciliation
Deliver self-management education
Monitor patients’ progress
Provide nursing care
Provide recommendations for physician reviews
Refer to appropriate resources
Not reported
  • Patients with sub-acute or ≥3 chronic conditions requiring follow-up, or those with limited mobility that restricts access to healthcare services

  • Not enrolled in other transitional care interventions

  • ADL independent

  • Do not have a caregiver at home

Reduce hospital resource utilisation (Transition from ward to home) Fee for service Yes Nurse Specialist physician + Primary care physician + Nurse + Allied health professional Off-site (Post-discharge only) Mixed 6 months Phone call + Home visits Not reported
Mustapha et al. [43]
(2016)
Assess clinical needs
Coach caregivers
Coordinate family conference
Deliver disease-specific education
Monitor patients’ progress
Provide psychosocial support
Refer to appropriate resources
Not reported
  • Patients with chronic diseases or have end-of-life care issues

Reduce hospital resource utilisation (Transition from ward to home) Not reported Not reported Nurse with specialised training in care coordination Not reported Off-site (Pre- and post-discharge) Mixed Not reported Phone call Not reported
Nurjono et al. [44]
(2019)
Act as a resource point for patients to call in for assistance/clarification
Assess clinical and social needs
Coach caregivers
Develop personalised care plans
Deliver psychoeducation
Manage patients’ social issues
Monitor patients’ progress
Promote self-care
Provide psychological support
Refer to appropriate resources
Not reported
  • Patients who are elderly and/or with complex healthcare needs

  • Diagnosed with multiple chronic conditions

  • Have limited mobility

  • Presence of a caregiver at home

Reduce hospital resource utilisation (Transition from ward to home) Funded by MOH Yes Nurse Not reported Off-site (Post-discharge only) Mixed 3–12 months Phone call Not reported
Prabhakaran et al. [45]
(2019)
Assess clinical needs
Deliver tailored psychoeducation
Develop tailored care plan
Empower patients
Identify red flags
Monitor patients’ progress
Referral to appropriate resources
Reinforce compliance to care plans
37 ± 13 years
  • Patients aged ≥ 21 years old

  • Discharged from ED with poorly controlled asthma

  • Did not have complex comorbidities

  • Own a mobile phone and able to use SMS

  • Agree to enrol in the programme

Optimise disease management Not reported Not reported Nurse Not reported Hospital (Outpatient) Asthma 3 months Phone call + algorithm-based automated text messages Ad hoc
Verma et al. [46]
(2012)
  • -

    Coordinate resources and services

  • -

    Deliver psychoeducation

  • -

    Identify strengths and resources and improve coping skills

  • -

    Mediate or negotiate with stakeholders on patients’ behalf

  • -

    Provide crisis management

  • -

    Provide supportive counselling

  • -

    Refer to appropriate resources

  • -

    Set care goals

  • -

    Support stress management

27 ± 7 years
  • Patients aged 16–40 years old

  • Have first-episode psychotic disorder, not secondary to substance abuse or medical conditions

Optimise disease management Funded by MOH Not reported Combination of nurse and non-nurse Specialist physician + Primary care physician + Nurse + Allied health professional Hospital (Outpatient) Psychosis 2 years Phone call Not reported
Wee et al. [47]
(2014)
  • -

    Coach patients and families

  • -

    Collaborate closely with hospital physicians to plan and deliver care

  • -

    Conduct home visits

  • -

    Develop care plan

  • -

    Enable self-management

  • -

    Monitor patients’ progress

  • -

    Refer to appropriate resources

  • -

    Screen eligibility for programme enrolment

79 ± 8 years
  • Elderly adults discharged home

  • Have complex care needs

  • Have limited social support

  • Not on follow-up with other case management or disease management programmes

Reduce hospital resource utilisation (Transition from ward to home) Funded by MOH No Combination of nurse and non-nurse Specialist physician Off-site (Pre- and post-discharge) Mixed 2 months Phone call + Home visits Not reported
Wee et al. [48]
(2015)
  • -

    Conduct home visits

  • -

    Deliver psychoeducation

  • -

    Develop tailored care and medication plan

  • -

    Monitor patients’ progress

  • -

    Refer to appropriate resources

  • -

    Screen eligibility for programme enrolment

Not reported
  • Elderly adults discharged home

  • Have complex care needs

  • Have limited social support

  • Not on follow-up with other case management or disease management programmes

Reduce hospital resource utilisation (Transition from ward to home) Funded by MOH No Not reported Not reported Off-site (Pre- and post-discharge) Mixed 2 months Phone call + Home visits Not reported
Wong et al. [49]
(2019)
  • -

    Act as a resource point for patients to call in for assistance/clarification

  • -

    Collaborate with other care providers and with family members

  • -

    Conduct home visits

  • -

    Deliver psychoeducation

  • -

    Deliver self-management education

  • -

    Facilitate hospital admission

  • -

    Monitor patients’ progress

  • -

    Provide crisis management and support

  • -

    Provide psychosocial support

  • -

    Refer to appropriate resources

Patients: 27 ± 5 years
Caregivers: 51 ± 14 years
  • Patients aged 16–40 years old

  • Diagnosed with first-episode psychotic disorder, not secondary to substance abuse or medical conditions

Optimise disease management Not reported Not reported Not reported Specialist physician + Primary care physician + Nurse + Allied health professional Hospital (Outpatient) Psychosis 3 years Phone call + Home visits Not reported
Wong et al. [50]
(2019)
  • -

    Advocate for patients’ preferences

  • -

    Conduct home visits

  • -

    Deliver psychoeducation

  • -

    Develop tailored care plan

  • -

    Empower patients and encourage strength building

  • -

    Partner with other care providers and/or caregivers

  • -

    Provide psychosocial support

  • -

    Mediate conflict between patient and caregiver

  • -

    Monitor patients’ progress

  • -

    Refer to appropriate resources

  • -

    Support crisis management

Case managers: 37 ± 9 years
  • Patients aged 16–40 years old

  • Diagnosed with first-episode psychotic disorder, not secondary to substance abuse or medical conditions

Optimise disease management Not reported Not reported Combination of nurse and non-nurse Specialist physician Hospital (Outpatient) Psychosis 3 years Phone call + Home visits Not reported
Wong et al. [51]
(2016)
  • -

    Act as a resource point for patients to call in for assistance/clarification

  • -

    Deliver psychoeducation

  • -

    Monitor patients’ progress

  • -

    Identify red flags

  • -

    Provide psychosocial support

  • -

    Refer to appropriate resources

  • -

    Reinforce compliance to care plans and medication

  • -

    Screen eligibility for right-siting of care

59 ± 10 years
  • Post-elective Percutaneous Coronary Intervention patients

  • Did not have a myocardial infarction 2 months prior to enrolment

Reduce hospital resource utilisation (Right-siting of care) Not reported Not reported Nurse Specialist physician Off-site (Pre- and post-discharge) Coronary artery disease Not reported Phone call Not reported
Wu et al. [52]
(2015)
  • -

    Assess clinical needs

  • -

    Collect data for programme evaluation

  • -

    Deliver psychoeducation

  • -

    Develop tailored care plan

  • -

    Encourage influenza vaccination

  • -

    Liaise between step-down care partners, primary care physicians and patients

  • -

    Offer advance care planning

  • -

    Optimise patients’ medication regime

  • -

    Refer to appropriate resources

  • -

    Reinforce compliance to care plan

Not reported
  • Patients ≥ 40 years old

  • Current/ex-smokers

  • Have persistent/recurrent COPD-related respiratory complaints

  • Not enrolled in other disease management programmes

Optimise disease management Not reported Not reported Not reported Specialist physician + Primary care physician + Nurse + Allied health professional Off-site (Post-discharge only) Chronic Obstructive Pulmonary Disease Not reported Phone call Not reported
Wu et al. [53]
(2018)
  • -

    Assess clinical needs

  • -

    Coordinate appointments

  • -

    Empower patients

  • -

    Encourage influenza vaccination

  • -

    Deliver psychoeducation

  • -

    Deliver self-management education

  • -

    Offer advance care planning

  • -

    Optimise patients’ medication regime

  • -

    Refer to appropriate resources

  • -

    Reinforce compliance to care plan

72 ± 9 years
  • Patients ≥ 40 years old

  • Current/ex-smokers

  • Have persistent/recurrent COPD-related respiratory complaints

  • Not enrolled in other disease management programmes

Optimise disease management Funded by MOH Not reported Not reported Specialist physician + Primary care physician + Nurse + Allied health professional Off-site (Post-discharge only) Chronic Obstructive Pulmonary Disease Not reported Phone call Every 3–4 months
Yeo et al. [54]
(2012)
  • -

    Facilitate transition between care settings

  • -

    Monitor patients’ progress

  • -

    Participate in care quality audit

  • -

    Provide programme information

  • -

    Refer to appropriate resources

Not reported
  • Diabetes patients seen at SGH Diabetes Centre

  • Clinically stable for right-siting of care

Optimise disease management Not reported Not reported Not reported Specialist physician Hospital (Outpatient) Diabetes 1 year Phone call Not reported
Xu et al. [55]
(2022)
  • Health and geriatric assessment

  • Health coaching for disease prevention

  • Chronic disease monitoring

  • Education on self-care, medication and disease management

  • Advanced care planning facilitation

  • Refer to community health and social care agencies

71.4 ± 10.6
  • Patients with multiple chronic conditions

  • Patients aged ≥ 60 years old

  • Require assistance managing their chronic conditions

Reduce hospital resource utilisation (Transition from ward to home) Not reported Not reported Nurse Nurses with different experiences and qualifications Off-site (community nursing post or patient home) Mixed 2 years Phone calls + home visits Not reported