key: cord-1012849-b45nngtb
authors: Yoon, Sungwon; Goh, Hendra; Chan, Angelique; Malhotra, Rahul; Visaria, Abhijit; Matchar, David; Lum, Elaine; Seng, Bridget; Ramakrishnan, Chandrika; Quah, Stella; Koh, Mariko S.; Tiew, Pei Yee; Bee, Yong Mong; Abdullah, Hairil; Nadarajan, Gayathri Devi; Graves, Nicholas; Jafar, Tazeen; Ong, Marcus EH.
title: Spillover effects of COVID-19 on essential chronic care and ways to foster health system resilience to support vulnerable non-COVID patients: a multistakeholder study
date: 2021-11-12
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2021.11.004
sha: 2a6a7230b18d0f0e5b5f1f6bbff042d4ff5ca9a3
doc_id: 1012849
cord_uid: b45nngtb

Objectives Little empirical research exists on how key stakeholders involved in the provision of care for chronic conditions and policy planning perceive the indirect or ‘spillover’ effects of the COVID-19 on non-COVID patients. This study aims to explore stakeholder experiences and perspectives of the impact of COVID-19 on the provision of care for chronic conditions, evolving modalities of care and stakeholder suggestions for improving health system resilience to prepare for future pandemics. Design Qualitative study design. Setting and participants This study was conducted during and after COVID-19 lockdown period in Singapore. We recruited a purposive sample of 51 stakeholders involved in care of non-COVID patients and/or policy planning for chronic disease management. They included healthcare professionals (micro-level), hospital management officers (meso-level) and government officials (macro-level). Methods In-depth semi-structured interviews were conducted. All interviews were digitally recorded, transcribed verbatim and thematically analyzed. Results Optimal provision of care for chronic diseases may be compromised through the following processes: lack of ‘direct’ communication between colleagues on clinical cases resulting in rescheduling of patient visits; uncertainty in diagnostic decisions due to protocol revision and lab closure; and limited preparedness to handle non-COVID patients’ emotional reactions. While various digital innovations enhanced access to care, a digital divide exists due to uneven digital literacy and perceived data security risks, thereby hampering wider implementation. To build health system resilience, stakeholders suggested the need to integrate digital care into the IT ecosystem, develop strategic public-private partnerships for chronic disease management, and give equal attention to the provision of holistic psychosocial and community support for vulnerable non-COVID patients. Conclusions and Implications Findings highlight that strategies to deliver quality chronic care for non-COVID patients in times of public health crisis should include innovative care practices and institutional reconfiguration within the broader health system context.

Globally, millions of people have been infected with the COVID-19 virus. Current evidence suggests 3 that people with underlying chronic conditions are more susceptible to the infection due to 4 weakened immunity. 1 For example, a meta-analysis found that patients with diabetes had about 2.4 5 times higher odds of being infected. 2 Similarly, patients with pulmonary diseases were found to have 6 a 4-fold increased risk of contracting the What is more alarming is that underlying 7 chronic conditions are strongly associated with disease severity. Studies consistently demonstrate 8 that COVID-19 fatality rate is much higher in patients with more than one chronic condition. 4, 5 9

10 Patients with underlying chronic conditions are not only affected directly by the COVID-19 pandemic 11 but also indirectly. The unprecedented scale of the pandemic prompted a collective shift towards 12 immediate care for COVID-19 patients, resulting in considerable reorganization of healthcare 13 services for non-COVID patients. At the peak of the pandemic, healthcare professionals (HCPs) from 14 various specialties were deployed to the frontline to increase full crisis capability. 6 In-person clinic 15 appointments and ancillary services were either postponed, or operated with minimum human 16 resources to limit the chance of infection. 7 Such disruptions to routine services could have a spillover 17 effect on continuity of care for vulnerable patients with chronic conditions who require long-term 18 follow-up management. Patients may also have lesser community-based support due to the 19 suspension of social services. 8 Indeed, a recent World Health Organization survey of 134 countries 20 shows that the pandemic had a profound impact on the delivery of healthcare, with services for 21 chronic care and psychosocial services severely compromised in at least 44% of the countries 22 studied. 9 23 24 Experiencing delays in much-needed diagnostics, therapeutics and surgeries could have dire 25 consequences for patients with underlying chronic conditions. Even as regular healthcare services 26 J o u r n a l P r e -p r o o f have gradually resumed over time in some countries, evidence suggests that pandemic has a far-27 reaching effect on health-seeking behaviors of patients with underlying chronic conditions. A survey 28 in the United States found that about 42% of patients with chronic diseases have defaulted 29 attending regular follow-ups, which may in turn lead to delay in timely detection and treatment. 10 30

Another study observed that urgent or emergency care avoidance was significantly higher in adults 31 with two or more underlying medical conditions compared to those with a single condition. 11 An 32 increased rate of exacerbations such as stroke, heart attack, and falls due to poorly managed chronic 33 conditions have been also reported amid Often, these complications would require an 34 extended period of treatment and rehabilitation, which may add to the already strained healthcare 35 system. In short, the literature invariably indicates that with the COVID-19 pandemic placing 36 demands on the healthcare system, deferred essential chronic care may constitute what some have 37 referred to as a "hidden harm" that could disproportionately impact health outcomes of non-COVID 38 patients with underlying chronic conditions. 39 40 Although the existing literature provides an essential insight into the implications of the COVID-19 41 pandemic for non-COVID patient care, it is primarily characterized by a large volume of non-42 empirical publications (e.g., letters, opinion pieces, commentaries) based on anecdotal cases. In 43 addition, few empirical studies that used existing healthcare data or cross-sectional surveys tended 44 to focus on a single chronic condition (e.g., cancer, cardiovascular condition) or practice (e.g., 45 primary care) in isolation. [15] [16] [17] We aimed to fill this gap by exploring the experience and views of 46 stakeholders involved in direct care of patients with underlying chronic conditions and/or policy 47 planning for chronic disease management regarding the impact of COVID-19 control measures on 48 non-COVID patients. We also sought to understand the stakeholders' experience of evolving 49 modalities of care and their suggestions for increasing health system resilience to prepare for future 50 pandemics. 51 52 J o u r n a l P r e -p r o o f

Singapore is a multi-ethnic city-state located in Southeast Asia, where more than 15% of its total 56 population aged 65 years and above. This study was conducted within the SingHealth Regional 57

Health System. SingHealth is the largest regional healthcare system in Singapore serving more than 58 50% of the country's population by offering a complete range of medical care through a network of 59 five national specialty centers, three hospitals and nine public primary care clinics. 18 To better meet 60 the increasing demands of an ageing population, the government has actively expanded step-down 61 care services in the past decade to mitigate the burden on restructured hospitals while ensuring 62 optimal care for older adults discharged into community. The concept of step-down care refers to 63 the provision of 'slow healthcare' for older persons who may need more dedicated long-term care, 64 and it can be broadly categorized into three main groups: center-based services (daycare and 65 community rehabilitation centers), residential-based services (nursing homes and community 66 hospitals), and home-based services (home nursing and home hospice care). 19 In terms of healthcare 67 financing, government subsidies form the bulk of the support to ensure that healthcare services 68 remain affordable and accessible for all, with subsidies dependent on income levels. 20 To sustain 69 long-term financing, every citizen is automatically enrolled into government-run healthcare 70 insurance schemes based on the principle of self-reliance: MediShield is designed to meet 71 hospitalization cost for catastrophic illnesses through co-payment while MediSave is a mandatory 72 savings account scheme to offset general healthcare costs. Finally, MediFund is an endowment 73 scheme to assist individuals who are unable to afford healthcare expenses despite the existing 74 schemes. 21 75 76 J o u r n a l P r e -p r o o f Despite the excellent provision of specialized services and extensive network of healthcare financing, 77 the surge in COVID-19 infections placed considerable strains on the health system. Mass outbreaks 78 in foreign worker dormitories in April 2020 spurred the government's decision to impose a two-79 month lockdown known as the Circuit Breaker (CB) to contain the transmission of the During this period, most of the regular chronic care services were suspended. Following 81 emergent signals of an increasing burden on emergency visits by non-COVID-19 patients, possibly 82 due to postponed care, guidelines were subsequently amended to allow general practices to provide 83 non-urgent care, provided that strict safety measures were adhered to. Clinicians were also 84 expected to triage patients before scheduling their visits, using teleconsultation (video or phone) to 85 manage the patient load while ensuring continuity of care. 23 Against this background, this study was 86 conducted during and after the CB period to understand the impact of service disruptions on chronic 87 care for non-COVID patients. 88

The study was introduced to various clinical teams in the SingHealth healthcare institutions. Eligible 90 participants were 1) doctors, nurses, allied health professionals (AHP)/government officials and 91 hospital management officials; 2) involved in the provision of care for chronic services or related 92 policy planning. Participants were also identified from the study team's professional networks and 93 recommendations by other study participants. Potential participants were invited by email and 94 provided with background information. We used a purposive sampling approach based on 95 profession and area of expertise to maximize the diversity of experiences and opinions. In addition 96 to micro-level stakeholders (healthcare professionals on the ground), we engaged with stakeholders 97 responsible for policy planning and implementation at macro-level (government officials) and those 98 who operated policies at meso-level (hospital management). As data collection and concurrent 99 analyses progressed, the variation in emergent themes was explored by recruiting subsequent 100 participants for interviews to improve our understanding of specific aspects of the studied 101 J o u r n a l P r e -p r o o f phenomenon. Informed consent was sought via email, in addition to audio-recorded verbal consent 102 that was taken prior to commencing the interview. During open coding, transcripts were analyzed to develop categories of information. This allowed for 127 subthemes to be derived from the data instead of pre-existing ideas. During axial coding, common 128 subthemes were grouped into unifying themes. The iterative process of independent coding and 129 consensus meetings continued until no new emergent themes were identified. The codes were 130 independently applied to all transcripts, and coding discrepancies were resolved by iterative 131 discussions. For rigor and transparency, we anchored our methodology according to the 132 Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. 30 133 134

A total of 51 stakeholders participated in the one-on-one interview. The recruitment rate was 91% (5 139 individuals declined participation for reasons of lack of time and interest). Efforts were made to 140 ensure that participants were of different designations and seniority levels to better capture a 141 holistic view of the spillover effects of the COVID-19 control measures on chronic care for non-142 COVID patients. For HCPs, participants' clinical home departments included cardiology, oncology, 143 pulmonology, endocrinology, surgery, emergency medicine, primary care, family medicine and 144 nursing among others. Data saturation was reached after the 48 th interview, with no new themes 145 emerging from subsequent interviews. We conducted three additional interviews beyond data 146 saturation to ensure that point of information redundancy was achieved. Table 1 colleagues on patient cases which "cannot be resolved simply by a video or phone consult", thereby 158 leading to inefficient patient care and potential negative health outcomes. In addition, revised 159 protocols and limited diagnostics posed uncertainty in clinical decision making. As one participant 160 noted, closure of the lung function laboratory hindered clinicians from making a confirmed diagnosis, 161 treating patients based on "clinical signs" (#24 Doctor, F). Access to clinical services was reported to 162 be limited due to a reduction in staffing and team segregation. The effects seem to have been more 163 pronounced in patients who required physiotherapy as AHPs could not move between institutions to 164 provide care. Notably, some participants recounted how they felt unprepared for managing non-165 COVID patients' emotional reactions and behaviors (e.g., anger, frustration and anxiety) due to 166 cancellation or postponement of chronic care services. 167

In the context of care in the community, it was commonly mentioned that access to health and 169 social services such as elder day-care centers, medical escort transportation and community nursing 170 services was significantly curtailed or suspended. Participants narrated how care disruption between 171 the hospital and the community put some older patients at greater health risk. Social isolation 172 during the lockdown period was one of the key issues pointed out. A ban on home visits by 173 community nurses and the closure of senior activity centers during the lockdown appeared to have 174 "a profound impact on well-being" of the older patients with restricted mobility who lived alone 175 (#29 Nurse, F). It was not also uncommon to observe deterioration of health status in patients with 176 underlying chronic conditions. Some healthcare participants acknowledged that there were 177 inevitable exacerbations due to the cancellation of appointments and screening or delayed surgeries. 178 (Table 3) . Self-management support clustered around a few 187 modalities including video consultation, phone consultation, and medication delivery, which were 188 available pre-COVID but utilized significantly more during the pandemic. As noted by the participants, 189 video consultations have been adopted by many clinical specialties during the pandemic to enable 190 continued service provision. Participants commonly mentioned that video consultations were well 191 received by patients and showed promises for wider implementation. The virtual platform 192 supported joint consultation, allowing HCPs from multidisciplinary teams such as social workers and 193 dietitians to come on board with the clinician during the session to formulate "a more 194 comprehensive care plan for the patient" (#6 Nurse, F). However, many participants raised concerns 195 about potential data breach when consultations were conducted on digital platforms and felt 196 cybersecurity concerns may hinder the wider implementation of digital consultations. In addition, 197 some HCPs participants from certain clinical specialties (i.e., surgery, podiatry and physiotherapy) 198 expressed a low sense of receptiveness for digital health as they perceived that the quality of 199 medical advice might be compromised by the lack of direct interactions with patients, which could 200 result in unintended negative patient outcomes. 201 202 Participants also described novel ways of providing care that emerged during the COVID-19 203 pandemic. Some of the models depicted by the participants included a nurse-led platform for real-204 J o u r n a l P r e -p r o o f time communication for general health information/community resources, remote monitoring of 205 patients using telehealth kits (e.g., blood pressure monitors, pulse oximeters) sent to patients and 206 telehealth kiosks. One of the notable developments was the telehealth kiosk launched in the 207 community centres. Recognizing that video consultation might not reach the underserved and non-208 tech savvy older patients, the Kiosk featured multiple touchscreen devices capable of supporting 209 video consultation with a primary care doctor or specialist, supported by on-site staff for the set-up. Table 4 shows the suggestions by participants on how the health system might be strengthened to 220 better prepare for the next pandemic. On top of the current care modalities, most participants 221 expressed an urgent need to harness health information technology to enhance access to chronic 222 care and system resilience. Despite the perceived usefulness of the virtual consultations, additional 223 administrative workload was noted by several participants, for example, having to use two 224 computers, "one for consultation and another for writing down the case note" (#18 Government 225

Official, M). It was stressed by many that integration of digital platforms into the hospital IT 226 ecosystem would be vital in improving work efficiency and data safety. In addition, participants 227 Our findings showed that stakeholders observed an unprecedented disruption in the provision of 255 care for chronic conditions. In particular, the workforce adjustment to support acute COVID-19 care 256 appeared to result in less optimal chronic care services. Although this finding is generally in line with 257 commentaries published during the pandemic, 31, 32 our study further elucidated the context in which 258 optimal chronic care was compromised: disruption in 'direct' communication between team 259 members; uncertainty in clinical decisions; and under-preparedness to handle emotional responses 260 of patients with chronic conditions. There was also an indication that reduced access to social 261 services and discontinuity of care between the hospitals and the community engendered 262 preventable adverse events. Notably, limited step-down care options resulting from pandemic 263 measures disproportionately affected older patients with comorbidities and complex care needs 264 when they transitioned from hospital to home; depression and functional decline seemed to feature 265 prominently among those who live alone as a result of social isolation and absence of rehabilitation 266 support. This finding sheds light on the need to critically assess care pathways and develop 267 contingency plans to ensure continuity of care for patients in needs of post-acute and long-term care. 268 A few systematic reviews conducted during the COVID-19 pandemic demonstrated that delayed or 269 marginalized chronic care could lead to a higher risk of complications and poorer health outcomes. As the COVID-19 pandemic exposed the vulnerability of the health system in the management of 301 chronic diseases, there was strong consensus among participants on the need for increasing 302 resilience of the health system to prepare for future exigencies. At the service level (micro), 303 stakeholders advocated for stronger and closer care coordination at different levels of the health 304 system during pandemic times. As they are often the first point of contact with patients, disruptions 305 of care continuity may have been more deeply felt. Technological innovations such as 'fit' of virtual 306 consultations with current IT system and mHealth based chronic care management were perceived 307 to be of importance to minimize the risk of disruption to chronic care. At the meso and macro levels, 308 institutional reconfiguration such as PPPs was recognized by stakeholders as a new way to mitigate 309 burdens on public healthcare infrastructure and improve the provision of chronic care for non-310 COVID patients. A body of literature has demonstrated that PPPs played a critical role in response to 311 epidemics such as H1N1, Ebola and MERS, through raising awareness, strengthening disease 312 surveillance and developing diagnostics and vaccines. [42] [43] [44] Our finding similarly noted that was the impetus to building collaboration between the government and private sectors to manage 314 COVID-19 patients. However, evidence of the role of PPPs in chronic disease management amid fast-315 moving disease outbreaks is largely absent. Arguably, from a health system perspective, the 316 pandemic response cannot be effective without a holistic approach to supporting quality care for 317 both COVID and non-COVID patients alike. More work needs to be done to develop a robust and 318 sustainable framework of PPPs that addresses the needs of patients with underlying chronic 319 conditions and maintain service efficiency during a large-scale pandemic. An illuminating example is 320 a national initiative where a network of private GP clinics provides multidisciplinary team-based care 321 for patients with complex care needs through government funding and administrative support. A 322 defining feature of this initiative is to mobilize more private care sector resources to move care 323 beyond the hospital to community. Amid the pandemic, an expansion of such PPP models may help 324 acute hospitals clear the backlog and build capacity for pandemic surges while vulnerable non-COVID 325 patients with chronic conditions are safely managed closer to home. 45 326 327 At the time of writing, very few empirical studies explored the experience and impacts of the COVID-328 19 control measures on chronic care management. 15 This study adds to the knowledge gap by 329 providing a detailed account of how COVID-19 affected the delivery of healthcare care services for 330 non-COVID patients with underlying chronic conditions. Our study also illuminates the current 331 opportunities and challenges pertaining to the emerging modalities of care and suggestions for 332 improving a robust and resilient health system during and beyond the pandemic. Notwithstanding its 333 strengths, the study has a few limitations. Despite efforts to engage a wide range of stakeholders, 334 workforce deployment during the peak of COVID-19 outbreak limited our ability to recruit a 335 balanced number of stakeholders at three levels of involvement (i.e., macro, meso and micro). In 336 particular, the voice of direct bedside care providers was largely absent; due to manpower shortages 337 resulting from the deployment, we did not take an active approach to recruit these care workers in 338 order to avoid further disruption to inpatient care. Taken together, we acknowledge that these 339 might have influenced the themes generated. Lastly, we did not explore the views and experience of 340 vulnerable non-COVID patients with chronic conditions as the important end-users of the health 341 system, which will be presented in a separate study. Incorporating perspectives from other 342 stakeholders involved in the health system, such as patient advocacy groups, clinic managers and 343 medical insurance companies, may have strengthened the credibility of the findings and contributed 344 richer understanding. J o u r n a l P r e -p r o o f Disruption to communication and teamwork rendering less efficient patient care and rescheduling "My clinic was taken over by other consultants as I was deployed [elsewhere] . So, I think this would invariably have much effect on patient care. Every time, when there is a change in the provider in the clinic, it causes a bit of service disruption." #23 Doctor, F "Let's say if I want my colleague to see this patient for a second opinion, it can be very challenging because my colleague may belong to another team [due to redeployment], so communication is disrupted. And most of the time, the case cannot be resolved simply by a video or phone consult, so we have to get the patient come back another day just to see someone else. Some patients do have a poorer outcome on their next visit, but not all." #15 AHP, M Uncertainty in clinical decision making due to revision of treatment protocol and suspension of laboratory services "Nebulizing procedure was straightaway stopped in the department. If the patients did require nebulizer, we started giving them via a spacer. How effective that was, I'm not very sure, but we have to make some adjustment during that [Circuit Breaker] period." #19 Nurse, F "Some diagnostic tests cannot be done during this pandemic. For instance, when diagnosing asthma, we will need to perform a lung function test, but the lung function lab was closed during that time, so we could not do a proper diagnostic test. Hence, we had to treat the patient based on clinical signs and symptoms rather than confirming the diagnosis." #24 Doctor, F Unprepared to handle patients' emotional responses "There was also a lot of anger involved because appointments and surgeries were postponed. So, in general, I feel that patients are a little bit more angsty nowadays, especially when they are informed having to repeat tests because the waiting time is certainly longer now. But, that is because we are understaffed at this moment due to redeployment." #2 Doctor, F "[From the ground] there was quite a lot of distress during that time, especially among elderly [with chronic diseases] when they could not get the services required in the hospital due to changes in protocols and they [doctors] could not do much neither as J o u r n a l P r e -p r o o f they had to follow these guidelines stipulated [by the Ministry]." #14 Government Official, M Diminished support and management of patients Reduced access to routine therapy and diagnostics "We used to have physiotherapists that come to our clinic to help with chronic diseases related rehabilitation. But now we don't have physiotherapists anymore. The inability to received regular chronic care makes it difficult for the patients to control their disease at home, so they end up getting admitted because of this." #21 Doctor, F "Before COVID-19, we [respiratory technologists] used to go to private hospitals if there is a referral. However, this practice is suspended to avoid cross-institutional transmission. So patients from the private hospital cannot obtain the required services [lung function tests]" #5 AHP, M Limited access to community social services "As the Senior Activity Centres were closed, the seniors stopped coming to the day care centre, and many of them started to deteriorate in their health due to reduced physical activities and movement." #16 Hospital Management Officer, M "Medical Escort Transport services and community nursing [were listed as non-essential by the Ministry] have to stop during circuit breaker. As a result, many elderly patients cannot come for their appointments or receive nursing visits, making them even more vulnerable. But it was necessary as our main aim at that time was to break the transmission chain" #14 Government Official, M Longer waiting time for treatment or surgery and rejection of admissions "Let's just say for malignancies; usually we don't stop surgeries for malignancy. However, sometimes because of the decrease in slots due to lessened manpower, some may get pushed back by one or two weeks. Then some of them are not comfortable coming to the hospital, so they postpone it by themselves a little bit more. But all these add up to delays for about a month, and sometimes when they come in, their physical condition is a lot worse." #43 Nurse, F "There was some not so necessary hospitalization that was avoided. However, we do see that it results in poorer disease outcome in such patients." #16 Hospital Management Officer, M Discontinuity of care between hospital and community "Usually, we also provide podiatry services to patients in the community; about once a week, one of us will go down to the polyclinic. However, as most of us were deployed during the Circuit Breaker period, podiatry services in the polyclinic were suspended to prevent different podiatrists visiting [the polyclinic] each week. As a result, residents in the community who need services like diabetic foot screening have to specifically come back to the hospital, causing them a bit of inconvenience." #13 AHP, M "Community nursing services was decreased during the Circuit Breaker period. Before that, community nurses do visit the homes of my patients who are discharged from the wards to manage their chronic diseases. But home visits and nursing services were suspended because of the pandemic." #24 Doctor, F Adverse patient outcomes Deterioration of existing conditions "I have also seen patients with abnormal chest X-rays, that were delayed with subsequent follow-ups, or did not make subsequent follow-ups, resulting in some diagnosis getting delayed, including that of possible cancer." #2 Doctor, F "As appointments are cancelled, by the time patients come to see us, some damage to their heart has already occurred." #12 Hospital Management Officer, M Social isolation "Another impact of COVID-19 on the elderly is undeniably social isolation. They don't really go exercise or go out as usual anymore. It becomes harder for them to communicate and interact with one another, especially when movement and social activities are restricted. This caused distress and had profound impact on their wellbeing" #29 Nurse, F "As their movement was restricted, elderly who are living alone tend to experience social isolation, especially when senior activities centres are closed." #30 Hospital Management Officer, M "With the joint video consultation, nurses and social workers are able to come together on the same platform during the consult. They can give the doctor feedback on the patient's condition, and then together with the doctor, devising a more comprehensive care plan for the patient. Most importantly, they can do it at the comfort of their homes, without having to come to the hospital, and the patients like it a lot as it is very convenient." #6 Nurse, F "We started to do more medicine delivery during the Circuit Breaker [lockdown period] for patients with stable conditions. They are happy because they didn't want to come to the hospital anyway just to collect their medication." #11 Nurse, F "I think the first challenge [for teleconsultation] seems to be cybersecurity. We have zero-tolerance for data breach. We are not so keen to use the usual Zoom® platform as it might not be secure enough; we need to have a special platform that is cleared by hospital or ministry. So that's a limiting factor. And I suppose following the previous cyber-attack on our institution, vigilance is very high, and the tolerance for lapses is zero." #50 Doctor, M "We are having difficulty to get patients on board with the idea, because a lot of patients they come to us for treatment. That means they come to us for in-person procedure, not only for consultation. Often, we need to do physical assessments as well which cannot be done via teleconference." #15 AHP, M J o u r n a l P r e -p r o o f

Novel delivery system to improve chronic care (Nurse-led platform for real time communication; Remote monitoring; Telehealth Kiosk in the community) "We started tele-vital signs monitoring during the pandemic. We started off first with hypertension, so it was tele-blood pressure monitoring. We are now moving on into diabetes, which includes both tele-blood sugar monitoring and glycated haemoglobin A1c monitoring. The idea is to empower patients to care for their chronic conditions by themselves at home, with the support from the healthcare team, without them visiting the clinics unnecessarily." #25 Hospital Management Officer, M "We launched the telehealth kiosk initiative at the peak of COVID-19 infection. So, we placed electronic devices like tablets at Community Centres. This allows residents with low SES to have a video consultation with the doctors and nurses in the hospital. Residents like this because services are provided free-of-charge." #6 Nurse, F "The Nursing Department has launched AskMissy, an enquiry platform for the public to address any healthcare-related queries they may have. The nurse on-duty will address questions and make clinicallysound suggestions to the enquirer. So far, it is well received by the public, but we are still thinking about ways to reach the not so tech-savvy elderly patients." #31 Nurse, F "For patients who are not IT savvy, or IT connected, who do not have access to video conferencing or devices, or even internet at their home, they are basically shut off from the virtual healthcare system such as teleconsulting and tele-vital signs monitoring." #25 Hospital Management Officer, M

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Opportunities and challenges for telehealth 453 within, and beyond, a pandemic

Promoting population health with public-458 private partnerships: Where's the evidence?

J o u r n a l P r e -p r o o f intelligence-enabled hospital platforms that allow for the acquisition of reliable health information "Inter-linkages between IT systems need to be improved. As of now, the Clinic Management System, or whatever data management system the hospital is using, is not directly linked to the video consult platforms. So, clinicians often need to have two computers, one for them to type in the case note, and then another for video consultations. It might be more efficient if there is an integrated platform." #18 Government Official, M "…mHealth app should allow patients to view, request and reschedule their appointments. Not only it offers convenience at their fingertips, but it also frees up the workload from clerical staff. Within the app, if we can arrange for medication delivery and e-counseling with the pharmacist, that would be great too." #50 Doctor, M "Through AI-based platforms, patients can ask the pandemic or non-pandemic related questions on hospital forum or other platforms like that, and then a moderator can answer their queries and try to match them to the right services if required. At least they don't obtain medical information from unverified sources." #19 Nurse, F Reconfiguring existing institutional arrangements  Public-private partnerships  Close coordination between primary and tertiary care  Round-the-clock support for urgent care"What Singapore has tried to do was to see how we can arrive at public-private partnerships where we can work directly with private healthcare providers in providing care. For example, at the community isolation facilities, medical care over there comes under the oversight and provision of a private hospital. Exploring this partnership for non-COVID care will not only reduce the strain on public hospitals during a pandemic but also to maximize efficiency in the delivery of care for chronic patients." #1 Doctor, M "I think the collaboration between the primary care and tertiary care can be better, for example, some chronic diseases that are being managed at the hospitals can be outsourced to the GPs. I believe this would greatly reduce the hospital's workload during the pandemic." #11 Doctor, F J o u r n a l P r e -p r o o f "We also wanted to provide silent hour support. So silent hour is when the medical teams are not there during off-office hours from 6 pm to the next day 8 am. During the Circuit Breaker period, we saw many urgent yet not emergency cases coming in and choking up the A&E. So, by having 24/7 access to teleconsultation either with a doctor or nurse will help triage and bring in only patients who really need emergency care. This will be very beneficial in the next pandemic by lessening the workload of the hospital." #18 Government Official, M Holistic care  Continuity of social services for selected vulnerable patients  Safeguarding mental health of non-COVID patients "Because of the cessation of activities, many older patients dare not to go out to exercise anymore. In the past, they used to exercise in groups in the morning. So I think the sudden shift to a sedentary lifestyle worsens their medical and mental health. I think safeguarding the patient's psychological health during a pandemic is equally important too. Maybe the senior activity centres can organize video chatting sessions for the residents to catch up with one another even when they cannot gather physically." #28 Doctor, F "Social services such as medical escort and befriending services should be allowed to continue to operate even during the Circuit Breaker [period] . Missing out on an appointment or loneliness during lockdown contributes to deterioration of overall wellbeing in these patients." #43 Nurse, F