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Introduction
According to the Non-Communicable Disease (NCD) Report by the World Health Organization (2021), NCDs, i.e. cardiovascular disease, cancer, chronic respiratory disease and diabetes, are the leading cause of mortality, resulting in 41 million deaths globally in 2016. The rising prevalence of long-term NCDs presents a significant challenge and priority for healthcare systems worldwide (World Health Organization, 2021). Combined with the increasing prevalence of multimorbidity, most patients with long-term NCDs also have multiple comorbidities (Violan et al., 2014). Multimorbid patients have complex care needs and medication regimes that are difficult to cope within out-of-hospital settings, which lead to more frequent readmissions and increased acute healthcare utilization, making them high-risk, high-cost patients (Thompson and Saran, 2016; World Health Organisation, 2016).
In particular, the transitional period from hospital to home presents a vulnerable time for these high-risk complex care patients due to the fragmentation of care as healthcare practitioners do not follow complex patients when they move to different care settings (Naylor and Keating, 2008). This puts them at risk of poor clinical outcomes, including frequent and premature rehospitalisations, prolonged length of stay (LOS), functional decline, inability to perform activities of daily living (ADLs) and even death (Aminzadeh and Dalziel, 2002; Bo et al., 2016; Tsilimingras and Bates, 2008). In 2010, Singapore's 30-day readmission rate rose from 11.6 to 19.0% in patients aged 65 years and above, indicating early readmissions for a significant portion of patients (Lim et al., 2011). Additionally, the average cost per patient classified as “frequent admitters” (admitted ≥3 times within the past year) was S$29,547, compared to S$2,419 for patients with chronic disease (Saxena et al., 2017). These frequent admitters contributed to a disproportionate consumption of healthcare expenditure and bed shortages, putting a strain on finite healthcare resources. However, the same study revealed that some frequent admitters managed to resolve their acute issues and remain admission free (Saxena et al., 2017). Supporting this, a systematic review of 34 studies also found that a significant proportion of readmissions was preventable, with the median being 27% (van Walraven et al., 2011). This suggests an avenue to relieve healthcare consumption through transitional care programs (TCPs).
Transitional care is defined as a range of time-limited interventions targeted at coordination and continuity...