Table 1.
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 |
|
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 |
|
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 |
|
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 |
|
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) |
|
Not reported |
|
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) |
Monitor patients’ progress |
78 ± 7.72 years |
|
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 |
|
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) |
|
64.5 ± 9.8 years |
|
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) |
|
69.7 ± 11.04 years |
|
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 |
|
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 |
|
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 |
|
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 |
|
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 |
|
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 |
|
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 |
|
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 |
|
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 |
|
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) |
|
27 ± 7 years |
|
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) |
|
79 ± 8 years |
|
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) |
|
Not reported |
|
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) |
|
Patients: 27 ± 5 years Caregivers: 51 ± 14 years |
|
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) |
|
Case managers: 37 ± 9 years |
|
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) |
|
59 ± 10 years |
|
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) |
|
Not reported |
|
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) |
|
72 ± 9 years |
|
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) |
|
Not reported |
|
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) |
|
71.4 ± 10.6 |
|
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 |