Implementation fidelity of a strategy to integrate service delivery: learnings from a transitional care program for individuals with complex needs in Singapore

Milawaty Nurjono, Pami Shrestha, Ian Yi Han Ang, Farah Shiraz, Joanne Su-Yin Yoong, Sue-Anne Ee Shiow Toh, Hubertus Johannes Maria Vrijhoef

Research output: Contribution to journalArticle

6 Citations (Scopus)


Background: To cope with rising demand for healthcare services in Singapore, Regional Health Systems (RHS)
comprising of health and social care providers across care settings were set up to integrate service delivery. Tasked
with providing care for the western region, in 2012, the National University Health System (NUHS) – RHS developed
a transitional care program for elderly patients with complex healthcare needs who consumed high levels of
hospital resources. Through needs assessment, development of personalized care plans and care coordination, the
program aimed to: (i) improve quality of care, (ii) reduce hospital utilization, and (iii) reduce healthcare-related costs.
In this study, recognizing the need for process evaluation in conjunction with outcome evaluation, we aim to
evaluate the implementation fidelity of the NUHS-RHS transitional care program to explain the outcomes of the
program and to inform further development of (similar) programs.
Methods: Guided by the modified version of the Conceptual Framework for Implementation Fidelity (CFIF),
adherence and moderating factors influencing implementation were assessed using non-participatory observations,
reviews of medical records and program databases.
Results: Most (10 out of 14) components of the program were found to be implemented with low or moderate
level of fidelity. The frequency or duration of the program components were observed to vary based on the needs
of users, availability of care coordinators (CC) and their confidence. Variation in fidelity was influenced
predominantly by: (1) complexity of the program, (2) extent of facilitation through guiding protocols, (3) facilitation
of program implementation through CCs’ level of training and confidence, (4) evolving healthcare participant
responsiveness, and (5) the context of suboptimal capability among community providers.
Conclusion: This is the first study to assess the context-specific implementation process of a transitional care
program in the context of Southeast Asia. It provides important insights to facilitate further development and
scaling up of transitional care programs within the NUHS-RHS and beyond. Our findings highlight the need for
greater focus on engaging both healthcare providers and users, training CCs to equip them with the relevant skills
required for their jobs, and building the capability of the community providers to implement such programs.
Original languageEnglish
Article number177
Pages (from-to)177
Number of pages14
JournalBMC Health Services Research
Issue number1
Publication statusPublished - 19 Mar 2019


  • Integrated care
  • Post-discharge care
  • Transitional care
  • Implementation fidelity
  • Mixed methods

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