Care Transformation through CH-PLUS: Advancing Early, Integrated, Multidisciplinary Rehabilitation

Background

Under Singapore’s Community Hospital of the Future initiative, Tan Tock Seng Hospital’s Integrated Care Hub launched the Community Hospital-Progressive Level-Up Scheme (CH-PLUS) to address delays in care transition, fragmented transfers, and limited access to diagnostics for patients with stroke and hip fracture.

Purpose

To evaluate the impact of CH-PLUS on care transitions, efficiency, functional outcomes and safety.

Methods

A quasi-experimental evaluation compared 410 patients admitted with stroke or hip fracture who requires rehabilitation enrolled in CH-PLUS from July 2024 to June 2025 with 59 historical controls from October 2023 to March 2024. Outcomes included length of stay (LOS), Modified Barthel Index (MBI), timeliness, patient experience and safety.

Results

The average acute hospital to community hospital length of stay decreased from 44.7 to 34.3 days, while community hospital length of stay was reduced from 28.6 to 23.0 days. Functional recovery improved, with Mean Modified Barthel Index gains increasing from 36.6% to 41.8%. Timeliness of care also improved, as reflected by a reduction in average wait time from 3.7 to 2.7 days. Patient experience showed a positive trend, with the compliment-to-complaint ratio increasing from 9.4:1 to 11.5:1. Importantly, these improvements were achieved without compromising safety, with comparable outcomes observed in unplanned transfers back to acute hospital (11.9% vs 14.1%) and readmissions (5.8% vs 7.5%), while mortality and serious reportable events remained at 0% in both groups.

Conclusions

CH-PLUS is a scalable, person-centred rehabilitation model that integrates financing, diagnostics, and multidisciplinary teamwork to deliver earlier and more coordinated post-acute care.

Key messages

• CH-PLUS improves care transitions and rehabilitation efficiency, reducing length of stay and wait times while enhancing functional recovery in stroke and hip fracture patients.

• An integrated, multidisciplinary rehabilitation model can improve outcomes and patient experience without compromizing safety, supporting scalable post-acute care in ageing populations.