Development and Implementation of a Unified Care Model Performance Framework in the Yishun Zone Regional Population Health System

• DOI: 10.5334/ijic.icic23074
• Publication Date: 2024-01-17T18:12:15Z
• Authors: Yeuk Fan Ng; Ken Wah Teo; Yun Hu; Rachel Hui Fen Lim; Mable May Po Yap; Naiying Liu
• Keywords: Integrated Care

Background / Objective: Governance and Leadership Subsystem (GLS) of health systems governs but also directs Service Delivery (SDS) transformation. Performance management (PM) is a key GLS activity. Coherent PM frameworks improve SDS governance, system performance ultimately population outcomes.
 Yishun Health (YH) an integrated care organization within National Healthcare Group (NHG) caring for 320,000 residents in northern Singapore as the Zone Regional Population System (YZ). YH designed deployed Unified Care Model (UCM) future-state model to integrate transform its care/services with partners. A redesigned framework going beyond disease-condition services, specialty-departments, institutions-partners was required.
 Method: segmentation achieved using NHG River-of-Life model, dividing YZ into four Lifelong segments (LLC) one Episodic segment (EC). Employing UCM, LLC EC were further sub-segmented cascade ever smaller populations unique needs envision future needs/demand-supply matching form microsystems delivery.
 UCM Framework (UCMPF) conceptualized by adapting IHI’s Quadruple Aim annual outcomes Dartmouth’s Clinical Value Compass 90-day microsystems. Ability govern then modelled clinical logic models, enabling curation input, process, output indicators domains standardized strategies i.e. “Horizontal Logic”. “Vertical Logic” employed aggregate relevant or microsystem outcome up higher order GLS, such i) person need/demand centric mesosystems e.g. community geographically, ii) provider-centred site-based disease condition-services program, institution-partners, culminating whole macrosystem indicators. UCMPF dual enabled stakeholders visualize interdependencies more coherently co-create at all levels YZ.
 
 Results: Exceeding 1,300 existing across institution-partners discovered systemically visualized Indicator Menus, revealing how current impacted different SDS. Numerous leadership conversations conducted activities UCMPF, spawning many working level discussions, which continue be ongoing between senior clinicians administrators prioritize PM. Technical definitions prioritized initiated support informatics enterprise data warehouse dashboard redesign. Discussion/Conclusion: employs systemic design visualization approach mitigate complexity Menus reduce cognitive difficulty relate their measurement efforts micro mesosystem jumpstarts whether contribute not towards macrosystem. therefore supports our integration activity, co-creation hypothesized accelerate transformation better