The Big Read: When home is where the hospital bed is

SINGAPORE: Ever since the stringent no-visitor rule in hospitals was temporarily imposed at the height of the COVID-19 pandemic, Mr Paul Osmond George, who has ischemic heart disease and cardiomyopathy, has had a phobia of being hospitalised.

The 46-year-old’s condition is managed with medication to reduce fluid build-up and dilation of blood vessels to allow his heart to pump blood to the rest of his body. 

In January, when an upper respiratory tract infection caused a huge fluid build-up in Mr George’s body, leading to coughing and vomiting, his cardiologist at Sengkang General Hospital (SKH) advised hospitalisation for a more effective diuretic medication treatment.  

However, given Mr George’s aversion to hospitals, he immediately took up his doctor’s offer - with “no second thoughts or worries” - to recover at home under the Mobile Inpatient Care-at-Home (MIC@Home) pilot, aimed at making “virtual wards” a viable alternative to traditional hospital care. 

“(My condition) would have been better dealt with in hospital, especially if something happened, but I prefer home,” said Mr George, who was a general manager at a European multinational firm here before he had to stop working due to his medical condition.

Following daily Zoom calls with SKH doctors and visits twice a day from nurses to administer drugs, he was discharged from the programme after six days. 

“Receiving treatment in the comfort of my home was easier for me and my spouse,” Mr George said, adding that it also helped knowing that he could be admitted to the hospital if necessary. 

New mum Fatin Farzana Miswan, 31, also decided to make use of the MIC@Home scheme after her baby had jaundice just five days after birth in February. 

Jaundice - which occurs when a yellow substance called bilirubin builds up in the blood - is common in newborns because their livers are still developing and might not be able to get rid of bilirubin as quickly as needed. Bilirubin is formed when red blood cells break down. 

As a first-time parent, the geologist was fraught with anxiety, given her baby’s tender age and the arrangements she and her husband would have to make to visit the child in hospital.

“I’ll be thinking and worrying about what is happening to my daughter,” said Ms Farzana. “We also don’t have a car, so I think it’d be quite difficult for us to commute back and forth to the hospital.”

She was also breastfeeding at the time, which added another layer of stress for her. 

Newborns need to be fed about eight times a day, and it would not be feasible for Ms Farzana to be at the hospital for every feeding.

When she took her daughter to a polyclinic, Ms Farzana was told her baby’s bilirubin levels were within a range where she could undergo phototherapy treatment under the MIC@Home pilot at KK Women’s and Children’s Hospital. 

“When the option of having KKH@Home was proposed to us, I thought it would be good for me as a breastfeeding mother,” said Ms Farzana. 

Babies with jaundice are placed in a cot or incubator fitted with blue light that changes the bilirubin to a form that can easily pass out of the body.

Setting up a “virtual ward” in her home was a seamless process. The phototherapy machine was delivered to her flat, before KKH nurses came to advise her on how long to administer phototherapy treatment, and how to take her baby’s vital signs and record them on an app.

“It was quite an easy process, especially because the phototherapy machine isn’t very complicated. It’s just switching on and off. There were no fancy buttons or anything,” said Ms Farzana.

Being connected to the nurses through a WhatsApp group also eased her worries, especially when she had questions about her daughter’s care. 

“We were quite assured that our daughter would be okay because we had the medical support we needed,” she said.

While virtual wards may still be a novelty for many Singaporeans, they are not new - similar models have been widely adopted overseas. 

Virtual wards were first piloted in England in 2005 and have since been further scaled up by the country's National Health Service, with more than 10,000 virtual beds available. 

It is now looking at expanding it further to reach 40 to 50 virtual ward “beds” per 100,000 people, which would mean more than 50,000 admissions a month.

In Australia, the concept has been taken further with the setting up of a standalone virtual hospital in Adelaide. There, nurses and doctors will provide round-the-clock care through videoconferencing technology and wearable devices to monitor patients remotely. 

In Singapore, the Ministry of Health launched the MIC@Home pilot in April 2022 as part of ongoing efforts to future-proof the healthcare system in a rapidly ageing Singapore.

The pilot was an extension of the COVID-19 Virtual Ward programme launched in September 2021 to free up bed capacity in Singapore’s COVID-19 wards for the more seriously ill when Singapore experienced a spike in coronavirus cases.

MIC@Home offers eligible patients with certain conditions - such as skin infections, urinary tract infections, and congestive heart failure with fluid overload - the option of being cared for in the comfort of their own homes instead of a hospital ward.

Speaking in Parliament on Mar 6 during a debate on his ministry’s budget, Minister for Health Ong Ye Kung announced that from Apr 1, the MIC@Home service will become “mainstream” and be offered as part of public hospitals’ regular services.

Mr Ong said the rationale is so that Singapore is not trapped in the mindset of “building hospitals” when thinking about expanding healthcare capacity.

“There is potential to better anchor care outside of hospitals and in the community,” said Mr Ong. 

Like Mr George and Ms Farzana’s baby, not all patients require “high-acuity care” and constant monitoring in a hospital throughout their treatment course.

“Many need convalescent care and rehabilitation, with the assurance that additional medical help is readily available,” added Mr Ong.

As of end-2023, more than 2,000 patients had used MIC@Home, which saved about 9,000 hospital bed days. 

Other hospitals that now offer MIC@Home are Changi General Hospital (CGH), Singapore General Hospital (SGH), Khoo Teck Puat Hospital (KTPH), Tan Tock Seng Hospital (TTSH) and hospitals under National University Health System (NUHS).

Currently, there are 104 MIC@Home virtual beds across all these hospitals.

In response to TODAY’s queries, MOH said it aims to provide up to 300 MIC@Home virtual beds this year in light of the move to make it a mainstream service.

With virtual wards poised to become a fixture in Singapore’s healthcare landscape, TODAY spoke to hospitals and patients about their experiences with the MIC@Home programme, as well as doctors and experts on what the mainstreaming of the service means for the nation’s healthcare services.

GETTING A VIRTUAL HOSPITAL BED

Before a patient is selected for MIC@Home, the hospital has to first evaluate them for suitability based on the following criteria and get their consent, various hospitals with the MIC@Home pilot told TODAY: 

• Suitability of the medical condition and whether the patient’s condition is stable
• The patient is able to self-care, such as being able to perform activities of daily living independently. This includes washing, dressing, feeding, toileting, mobility and transferring. Or they should have a dedicated caregiver at home to assist with these activities
• Patients have a suitable home environment and social situation to support safe recovery at home
• Patients have access to telecommunications, preferably at least a smart device, with internet connectivity to facilitate teleconsultations

Patients come from three main areas: The emergency department, inpatient wards and specialist outpatient clinics. 

SGH@Home’s lead, Dr Michelle Tan, said the majority of cases it handles consist of general medical conditions such as exertional rhabdomyolysis (often from spinning exercise), dengue fever, severe infections requiring intravenous antibiotics, and poorly controlled diabetes requiring closer monitoring and management.

For KKH, its MIC@Home programme sees children with common conditions such as dengue fever, skin infections, eczema and urinary tract infections, as well as women with stable gynaecological conditions and wounds, said Dr Kelly Low, co-lead for KKH@Home as well as head and consultant, general paediatrics service.

While patients are recommended to take up MIC@Home, it is still presented as an option and they can decline it at any time. 

Clinical Assistant Professor See Qin Yong at CGH noted that “patients are able to make an informed choice on whether to proceed with the home-based care”. 

“Patients are able to continue their treatment in the hospital if they prefer,” said Asst Prof See, who is also a consultant at CGH's Department of Care and Health Integration.

Dr Tan, who is also head and senior consultant of Family Medicine Continuing Care at SGH, said that some patients have declined to be part of MIC@Home as they are more familiar with receiving medical treatment in the hospital.

“This will require a mindset change in patients and their caregivers to accept this new model,” Dr Tan said.

Other reasons patients do not take up MIC@Home include the lack of caregiving support at home or if their home environment is not suitable for MIC@Home.

HOW PATIENTS ARE CARED FOR UNDER MIC@HOME

Patients under MIC@Home are generally loaned monitoring devices, namely blood pressure monitoring sets, thermometers, and pulse oximeters, depending on their medical condition. 

Healthcare workers can monitor patients via a dashboard that contains all the pertinent information on their conditions. 

Doctors will review patients daily through video calls and visit them at home based on their clinical needs. Nurses will also visit most patients at least once daily for intravenous infusions or blood tests. 

If needed, the hospital’s physiotherapists and occupational therapists can see patients at home, and the latter can return to the hospital for scans if these are required.

Just like a normal hospital ward, a specialist consultant is in charge of every patient admitted to the programme.

The consultants work with a team of junior doctors, nurses, therapists, and administrative staff to ensure each patient gets the care and support they need round the clock.

Doctors and nurses on the MIC@Home teams do not have any duties in the ward and are solely focused on teleconsultations and home visits.

They communicate with patients and their families using messaging platforms such as Telegram, WhatsApp, and phone calls.

The size of the teams and the number of patients they care for vary. NUH’s team, for instance, is 80 strong and consists of doctors, nurses, allied health professionals, and administrative staff. SGH@Home’s team is made up of 10 doctors and nurses. 

Should the patient’s medical condition suddenly escalate, MIC@Home teams are trained to “recognise these signs early and ensure a seamless transition back to hospital care when necessary”, said Dr Stephanie Ko, a consultant at the division of advanced internal medicine at NUHS and lead of NUHS@Home.  

Patients and caregivers are also advised to immediately go to the emergency department should the patient’s medical condition deteriorate.  

Dr Tan said that to ensure patients adhere to their treatment plans, they and their families are counselled on their roles to support optimal and safe recovery.

Patients are also advised to stay at home for the duration of their recovery, as well as the diet and rest required. 

In some cases, SGH’s dietetics team also conducts reviews for the patient, said Dr Tan. 

As MIC@Home relies heavily on stable internet, contingency plans are in place in the event of a sudden lost connection, which are also discussed with the family beforehand.

“We fall back on good old pen and paper records and phone calls,” said Ms Sally Oh, director of patient support services at KKH.

Once the patient has completed treatment and is assessed to have recovered, they will be discharged, and a suitable outpatient follow-up will be arranged.

DOES MIC@HOME COST MORE OR LESS?

In his parliamentary speech, Mr Ong said MIC@Home is not set to cost more than a regular hospital stay, and might be projected to cost the same or less. 

“Patients can be assured that they will not pay any more for this service than they do in a public hospital as all our hospitals intend to price MIC@Home similar to or lower than a normal ward,” Mr Ong said. 

MIC@Home will be supported by subsidies and insurance and savings schemes such as the Integrated Shield Plan, and the Central Provident Fund’s MediShield Life and MediSave, if applicable.  

With MIC@Home still a work in progress, there has been some debate as to how much it should cost. Some feel that the programme should cost less than a regular hospital stay, given the lack of hospital settings and use of its facilities.  

However, Assistant Professor Ian Ang, from Saw Swee Hock School of Public Health (SSHSPH) at the National University of Singapore, said: “Even though the patients are not in the physical hospital facilities, the cost is not necessarily cheaper in providing the care - telemonitoring devices are used, and there are still mobile care teams that will travel to the homes of the patients who need certain in-person care treatments.”  

Adjunct Assistant Professor Melvin Seng, also from SSHSPH, said he will not be surprised if MIC@Home costs more initially, as starting new programmes usually requires higher costs. 

This is due to the set-up of equipment and processes, as well as the training of healthcare providers, patients and caregivers. 

“The good news is that, in the long run, there should be cost savings once the programme is well set up, running smoothly and with good uptake,” said Asst Prof Seng, who is also an occupational medicine specialist.

WHAT IT MEANS FOR CAREGIVERS

While the MIC@Home programme allows patients to recover in the comfort of their homes, the knock-on effect of this arrangement is also keenly felt by their caregivers. 

Mr Adrian Tiam, a 53-year-old private hire driver, felt reassured having his daughter Charlotte recuperate at home in February after she was diagnosed with dengue fever and required hospitalisation due to a dangerously low platelet count of 50,000 per ml. 

Platelets help to clot a person’s blood and prevent excessive bleeding. When the platelet count is low, one may have trouble stopping bleeding.  

Since normal platelet counts are between 150,000 and 450,000 per ml.

When Charlotte, 16, and Mr Tiam went to CGH, they had to wait 12 hours before she finally got a bed close to midnight and was warded for one night.  

“I felt nervous and uneasy in a new environment as I had to sleep in the hospital overnight,” said Charlotte.

The student was “quite happy” to be told by the CGH@Home team later that while her platelet count was still low, she would be eligible for the pilot programme to recover from home. 

Once back home, Charlotte was instructed to take her temperature, blood oxygen level, and blood pressure three times a day: At 9am, 1pm, and 4pm.

These vital sign readings will be automatically uploaded to CGH@Home’s command centre, where a medical team monitors patients around the clock.  

A nurse also went to her house to do a blood test for Charlotte. 

“I definitely felt well taken care of, as the nurses and doctor would call me if I didn’t take my blood pressure readings at my normal times,” said Charlotte.  

Mr Tiam said having Charlotte recover at home meant he and his wife could watch over her “24 hours a day”, and did not have to make special arrangements at work to accommodate the hospital’s visiting hours. 

“You can just be at home, and we can request to work from home to care for her, it (MIC@Home) made it really easy and good for us,” said Mr Tiam. 

He also noticed that Charlotte’s mood improved when she was at home for three days in the virtual ward. 

“She appeared to be much more cheery and happier ... She also seemed to be less worried about her illness,” said Mr Tiam. 

The same can be said for 64-year-old Sarbjit Singh, who was diagnosed with lower limb cellulitis, a bacterial infection, during his holiday in Malaysia in January.

After returning to Singapore, the director and chief executive officer of a pest control company saw a general practitioner who advised him to go to a hospital immediately. 

When he arrived at SGH, the doctor said that his condition was serious. If left untreated, Mr Singh might need to amputate his leg.

Mr Singh needed antibiotics to be administered three times a day, and while hospitalisation was recommended, there were no beds available for him at that time. 

After a day of waiting, Mr Singh was offered the MIC@Home service, which he readily accepted.  

During his eight days under the programme, he received intravenous antibiotics at home, and the SGH care team went to his house daily three times a day to clean his wound and change bandages until he recovered. 

“The good part is that when you are home, you get your own food compared to the hospital, (where) sometimes you don’t like the food,” he said. 

More than that, Mr Singh said the undivided attention the doctor and nurse gave him put him much at ease, and alleviated any worries he might have had.

“The doctors who visited me felt less rushed than those in the wards because they only had one patient. They have time to explain and we can ask questions too,” said Mr Singh.

He added that MIC@Home makes visiting even more hassle-free as there are no fixed visiting hours, confusing, maze-like buildings to navigate or difficulty in finding parking.

Mr Singh’s wife and main caregiver, Ms Jessie Kaur, worked from home while her husband was recovering and “did not feel any stress”.

“I knew he was in good hands with the doctors and the nurses,” said the 60-year-old manager at a technology company.

“There’s nothing like recovering in your comfort zone, which is at home with your family.”

WHAT MEDICAL PROFESSIONALS THINK OF MIC@HOME

Doctors and healthcare professionals say that there are many benefits to making the MIC@Home service mainstream.

Dr Desmond Wai, a gastroenterologist and hepatologist in private practice, noted that while the hospital is a good place to care for those who require intensive treatment, it is not the best place for patient recovery.

“The hospital, like I tell my patients, is a dangerous place.” 

He explained that although he and his nurses follow best practices, such as wearing gloves and washing their hands, patients can still pick up hospital-associated infections, which might even prolong the stay of older, more vulnerable patients.

​Hospital-acquired infections are those caught in a hospital setting, usually occurring 48 hours after admission to the healthcare facility. 

Furthermore, Dr Wai finds that patients recover better at home, where a familiar environment results in them eating and sleeping better, which aids in their recovery.

“A lot of patients tell me, ‘the moment I go home, my appetite improves’. They love to see their children, sit in their favourite chair, hold their favourite mug, have their favourite pillow ... (Recovering at) home gives a better, psychological and social environment,” he added.

Agreeing, Dr Ko of NUHS said: “There are many benefits to receiving treatments at home rather than in hospitals, especially for the older population.”

Apart from better sleep and appetite, patients recovering at home also walk around more - which helps in the healing process. 

“We know that many older persons who are admitted to the hospital have an increased risk of confusion, decline in their function and getting infections from the hospital,” said Dr Ko.

Another doctor, who works in a public hospital and spoke to TODAY on condition of anonymity as he is not authorised to speak to the media, said MIC@Home is a good idea as it “frees up beds for patients that have more acute conditions that have the potential to deteriorate and require round-the-clock care”.

Furthermore, this lessens the physical load on both the medical and nursing teams by requiring them to make rounds on fewer patients, said the doctor.

A private-practice nurse who also runs the Instagram account SGNightingales added: “Emergency departments are crowded with new cases, including readmissions. With MIC@Home’s assistance, we can provide better follow-up care, reducing hospital admission rates.  

“This alleviates strain on staff, especially amidst widespread manpower shortages,” the nurse said. 

While Dr Wai supports MIC@Home going mainstream in hospitals, he is concerned about manpower issues.

With doctors and nurses making trips to patients’ homes, he wonders how manpower will be allocated to ensure productivity.

Agreeing, the public hospital doctor who did not want to be named added: “Not all patients are technologically savvy, which may take up more time in the initial stages. 

“But then again, logistics can be improved and streamlined.”

In light of MIC@Home becoming mainstream, the various hospitals told TODAY they are in the process of ramping up resources, though they all declined to provide specific figures.

NUHS is hiring more staff, especially nurses and doctors who are passionate about integrating hospital care into the community, said Dr Ko.

“The CGH@Home team has increased its virtual bed capacity and expanded its care for patients with a wide range of medical acuities,” said Asst Prof See.

Ms Oh of KKH said that KKH@Home is also expanding to include more clinical conditions.

DEALING WITH PUBLIC WARINESS AND FUTURE CHALLENGES 

In order for initiatives like MIC@Home to achieve mainstream success, public perceptions of traditional care need to change.

Asst Prof Ang of SSHSPH said: “The public has to be convinced with data and evidence that such a new care model will not compromise their recovery, and also have an open mindset for this paradigm shift in the evolving forms of healthcare in Singapore with the times.”

He added that there might be some growing pains, with many initially giving a frosty reception to MIC@Home. 

However, Singapore has had the benefit of introducing this initiative after COVID-19, where the telehealth and telemonitoring landscape is more advanced, and people are familiar with its mechanisms.

Still, while patients and their caregivers who participated in MIC@Home have praised the initiative, some people remain sceptical.  

Mr Hayden Ng, 33, has not been hospitalised in recent months.

But he would still not choose to recover at home if given the option even though he believes MIC@Home is a good initiative to lessen the load for hospitals.

The social media manager said that since he is single and lives with his elderly mother, having him recover at home “doesn’t seem like a good idea”.   

He is not sure that she can cope with the “extra stress and responsibilities needed” for being his caregiver if he chooses MIC@Home.

“At the same time, I’d prefer to be near the healthcare staff in case my condition suddenly worsens,” said Mr Ng. “This would give me more peace of mind.”

While those under MIC@Home are given a number to call in case of medical emergencies, Mr Ng said this does little to make him feel safe if his medical condition were to take a turn for the worse.

“I still need to explain everything to the person on the line for them to fully understand and assess my condition before sending help,” he added. 

Public relations manager Karina, who declined to give her full name, shared Mr Ng’s sentiments.  

The 35-year-old said of the programme: “I would feel insecure and a bit uncomfortable if I’m a patient or a family member of a patient.

“Being in the hospital makes me feel like I can focus on recovering and not have to worry about anything else.

“Conversely, if I’m at home, I overthink and worry about day-to-day stuff. I feel obliged to still go about my usual chores, which I guess may, in a way, hinder my rest and recovery,” she said.

While she understands that medical staff are just a phone call or message away, having them physically present or nearby would instantly assuage any doubts or concerns that she has about her recovery. 

“I’m quite prone to overthinking, and I’d worry that there would be no medical personnel to tend to my questions or help me if I need anything,” she said.

The constant worry and monitoring of her condition would also be detrimental to her mental health, which might impede her recovery, she added. 

While public perception is one factor in ensuring that MIC@Home reaches mainstream success like in the United Kingdom or Canada, Asst Prof Ang said equal consideration must be given to managing the manpower supply and training of healthcare workers.

“To ensure the successful implementation of MIC@Home, it does not just require adequate healthcare manpower.” 

What is also important is to have “healthcare manpower that is trained and able to comfortably adapt to this new mode of care delivery and monitoring of patients in their homes or residences outside of the traditional inpatient ward setting”, he said. 

Still, some doctors are more sanguine about the move to make home hospitalisations a norm.

“People usually think you have to be in a hospital to get treatments like intravenous drips under a doctor’s watchful eye,” added Dr Ko of NUHS.

“But we have shown that it is not only possible but that it is also safe and works well, changing how people think about home-based care.”

This article was originally published in TODAY.