Evaluating an enhanced community of care model for high-risk older people in Singapore

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January 2019 to March 2022


Implementing partners:

Lead research institution: Duke-NUS Medical School, Dr Nur 'Adlina Maulod (Principal investigator)
Other participating research institutions: Singapore General Hospital, Dr Low Lian Leng (Co-principal investigator)

Location of research:


Total Budget:
US$ 60,000


Without appropriate care for older persons in place, health services may inadvertently place older patients in acute care facilities. This could drive up health care costs for patients, their families and the health system, and may not offer the most appropriate level of care. Preventing unnecessary readmissions to hospitals and use of emergency and outpatient department services is key to enabling more sustainable health care use by older people.

Low socioeconomic status (SES) has been well-established as an independent risk factor for various adverse outcomes including unnecessary hospital utilisation and readmission. In Singapore, public rental housing is a measure of low SES and is independently associated with increased readmission risk and frequent emergency department use. The reasons behind these associations include an inability to navigate a complex healthcare system, lower health literacy and misalignment of patient and caregiver goals. Enhanced Community of Care (ECoC) is a care model that incorporates health coaching using motivational interviewing techniques and facilitates the integration of health and social care for older populations living in low-income communities in Singapore. ECoC aims to empower patients with respect to self-care as well as improve patient understanding and management of transitions in care, for example, from hospital to the home.


To assess the impact of the ECoC model on reducing unnecessary utilisation of acute health services and empowering patients for the management of personal health.


  1. The original protocol aimed for 150 participants of low-SES older patients, 50 years and older, in a non-randomised control study to evaluate ECoC. However, as a result of COVID-19 restrictions, between May 2019 and July 2021, complete data (i.e., those who completed the baseline and post-180-day follow-up surveys) were collected from only 59 participants. 
  2. A qualitative review of the implementation and experience of health coaching was planned but could be conducted with three participants only.
  3. The main outcomes planned to be evaluated included unnecessary utilisation of acute health services, as measured by lower rates of unscheduled hospital readmissions, emergency department and specialist outpatient clinic visits in the intervention arm. Patient improvements in self-care and health knowledge were to be assessed qualitatively and quantitatively by using a version of Hibbard’s Patient Activation Measure (PAM-13).


Given the suboptimal recruitment, the research was unable to generate conclusive findings.  However, a research paper about the impact of the COVID-19 pandemic on health research with older people will be published, which elucidates six factors that were key to ensuring continuity during a health emergency when conducting research with older people. These were:

  1. Building and maintaining rapport with older research participants;
  2. Ensuring that interview questions are concise and easily understood by older participants;
  3. Developing strategies to minimise the risks and rate of participant drop-out in research projects with long follow-up phases, especially when working with frail and vulnerable populations like low-SES older people;
  4. Devising creative and safety-conscious measures to encourage older people to continue to engage with research during health emergencies;
  5. Adapting methods of data collection to the literacy, educational and technological capabilities of the target population (e.g., avoiding digital data collection methods with a still largely digitally illiterate older population); and Key Performance Indicators
  6. Placing participants’ needs, their safety and well-being above Key Performance Indicators or other metrics for research success during health emergencies.

Global implications

The COVID-19 pandemic has highlighted the importance of continual efforts to ensure that the experiences and voices of vulnerable older people are heard before, during and after health emergencies. Lessons learnt from this study can be adapted in diverse country contexts to ensure that research on vulnerable older populations can be conducted safely and ethically during the current and future pandemic and other health emergencies. The key message is that participant safety is paramount and research should be terminated if it is deemed the best course to protect participant safety, irrespective of research success considerations.

Implications for Kansai

The practical advice offered by the research team based on their experiences may be useful for local researchers and institutions in the Kansai region that also conduct research on older people. The insights gained from this study can improve local research about health issues among older people even during health emergencies. This can help ensure a continuous, safe and ethical stream of relevant information to help inform and adjust local policies and programmes. 


Maulod A, Rouse S, Lee A, Ravindran M, Mohamad H, Goh V, Azman D, Low LL, Malhotra R, Chan A. Ethics of Participation and Social Inclusion of Older Persons in Research: Lessons learnt from the Covid-19 Pandemic in Singapore. – Health Research Policy and Systems. Supplement issue. (Under review)




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