“Ageing-In-Place” Programme Evaluation Study

The Ageing in Place (AIP) programme is an intervention for North Singapore based on the concept of “integrated care” to address the needs of resource-intensive patients who have chronic conditions and complex social needs. AIP was implemented in 2011 and targeted patients who were frequently admitted to Khoo Teck Puat Hospital. AIP embeds a network of community health nurses (CNs) who seek to improve health of the individuals who are frequent users of inpatient hospital care by assessing, monitoring, and assuring social, medical, and rehabilitation needs as well as caregiver support in the home environment. In addition to serving patient needs, the methods used by AIP are designed to prevent delayed discharges and reduce hospital readmission rates, thus easing pressure on hospital resources. By tailoring services to specific patient needs, it is hoped that AIP will improve the provision of healthcare service in the outpatient setting and reduce overall healthcare costs.

Specific objectives

  1. To determine if the AIP programme met its overall processes and outcome goals (healthcare utilization, quality of life)
  2. To identify the most effective components of the intervention
  3. To assess significant unintended impacts of the programme
  4. To understand patients’ and caregivers’ experiences of AIP through qualitative study
  5. To explore how AIP would fit into the wider healthcare environment and economy


The study population of the AIP programme consists of all patients who have been admitted to Khoo Teck Puat Hospital at least three times within any six-month period after August 1st 2012 (when the programme and hospital operation stabilized).

The treatment and control groups were defined based on the patients’ residential location. The AIP programme was made available to 10 political areas within the Knoo Teck Puat Puat Hospital’s ambulance zone. The patients living with the 10 areas served by the AIP programme comprised the intervention area, and those patients living in the remaining area of the ambulance zone made up the control group.

The primary data sources used for this study are electronic administrative data from Khoo Teck Puat Hospital, which includes patients’ basic socio-demographic, diagnosis, admission, and discharge information. Qualitative data were collected from face-to-face interviews for a sample of programme participants, caregivers, and rejecters of the programme.

As AIP is a complex intervention, we utilized a mix of quantitative and qualitative methodology in a single study to more fully understand the effects of the programme.