“Transitional Care” Programme Evaluation Study

With a rapidly aging population and increased prevalence of complex chronic diseases, hospitals in Singapore are experiencing very high bed-occupancy rates which interfere with the efficient delivery of acute care services. The Transitional Care (TC) programme aims to reduce repeated hospital admissions through post-discharge home visits by doctors, nurses, and therapists to ensure appropriate medical treatment is delivered in the community and to increase care-giver competency. The TC programme also aims to facilitate the transition of frail and complex patients from the hospital to their own homes and prevent hospital re-admissions.

Specific objectives

  1. To evaluate the impact of the Transitional Care Service in reducing hospital utilisation
  2. To describe and compare the impact of the TC service by subgroups of TC patients based on severity of needs
  3. To identify patient characteristics associated with TC service utilisation
  4. To compare the difference in the total cost of hospital services utilisation between TC patients and control patients during the 6 months post hospital discharge


The study population consists of all patients who were admitted to Khoo Teck Puat Hospital and referred to the TC Programme from 1 April 2012 to 31 March 2014 who met the eligibility criteria.

From these 880 eligible patients, exclusion criteria were applied, for a sample size of 779 eligible participants. Patients were further excluded if they were re-admitted or died within 7 days after discharge from hospital resulting in the final study sample size of 698.

In the final study sample size of 698, 536 were enrolled in TC service and assigned into the Intervention group, while 162 who rejected the TC service were in the Control group.

We examined the impact of TC service on hospital utilisation including outcome events of interest (emergency medical visits, hospitalizations, and cumulative hospital bed-days) at 1, 3, and 6 months post discharge. In addition, we used multiple linear regression to test the association between hospital utilisation and TC service adjusting for covariates.


Ministry of Health, Singapore