FACTORS ASSOCIATED WITH REHABILITATION OUTCOMES, NURSING HOME PLACEMENT AND SURVIVAL OF PATIENTS IN SINGAPORE COMMUNITY HOSPITALS CHEN HUIJUN CYNTHIA (BSc (Hons.), MSc, NUS) A THESIS SUBMITTED FOR THE DEGREE OF DOCTOR OF PHILOSOPHY SAW SWEE HOCK SCHOOL OF PUBLIC HEALTH NATIONAL UNIVERSITY OF SINGAPORE 2014 |Page DECLARATION I hereby declare that this thesis is my original work and it has been written by me in its entirety. I have duly acknowledged all the sources of information which have been used in the thesis. This thesis has also not been submitted for any degree in any university previously. ______________________________________ Chen Huijun, Cynthia 30 October 2014 |Page ACKNOWLEDGEMENT I am grateful to God for His abundant grace thoughout my entire PhD journey. I would like to extend my deepest gratitude to my thesis supervisors, Dr Koh ChoonHuat Gerald and Dr Teo Yik Ying, for their never ending patience and support. Without their guidance, this thesis and the scientific papers would not have been possible. Thank you also for giving me the flexibility of working at my own pace. I’ve been truly blest with two of the best supervisors that a student can ever ask for. Special thanks also to Professor Chia Kee Seng, Dean of Saw Swee Hock School of Public Health for teaching me the concepts of Epidemiology and for giving me many opportunities to explore research in various areas. This has been exceptionally beneficial as I learn to apply different models and gain different perspectives. Thanks to Dr Tai Bee Choo and Dr Tan Chuen Seng for their patience in guiding me in the statistical modelling. Thanks to all my teachers who have taught me during my modules; and my classmates and colleagues who I have the privilege to encounter, especially to Nasheen Naidoo who has encouraged and guided me in scientific writing since the start of my PhD. I would like to thank the staff of Ang Mo Kio Thye Hua Kwan Hospital, St Luke’s Hospital, St Andrew’s Community Hospital and Bright Vision Hospital for assisting in the study. Also my heartfelt appreciation to the National University of Singapore (NUS) who has sponsored my PhD studies through the Research Scholarship. Lastly, my heartfelt thanks and gratitude to my family for their never ending support, encouragement and understanding, especially my dearest sister Cindy Tan. |Page TABLE OF CONTENTS SUMMARY LIST OF TABLES . LIST OF FIGURES . LIST OF ABBREVIATIONS . 10 LIST OF PUBLICATIONS . 11 CHAPTER ONE: INTRODUCTION 12 1. Context and motivation . 12 2. Life expectancy . 13 3. Healthy life expectancy 14 4. Disability – Definitions and International Action Plans . 16 5. Epidemiology 18 5.1 Prevalence of Physical Disability in The Elderly . 18 5.2 Incidence of Physical Disability in The Elderly . 19 5.3 Disability prevalence in Singapore . 20 6. Evidence for Rehabilitation in The Elderly . 23 6.1 Various settings for Rehabilitation for The Elderly (Long-Term Care) . 23 6.2 Need for an Inter-Disciplinary Approach . 24 6.3 Ideal Timing of Initiation and Duration 24 6.4 Ideal Intensity 25 7. Rehabilitation in Singapore . 26 7.1 Organization of Rehabilitation Services in Singapore 26 7.2 Financing 27 7.3 Infrastructure of Rehabilitation and Healthcare in Community Hospitals 28 7.4 Patients receiving care at community hospitals 29 8. Rehabilitation for Adults in the Post-acute Phase of Illness . 32 9. Overview of Thesis . 34 9.1 Aim and Objectives . 34 9.2 Methodology . 35 9.2.1 Functional Assessment Instruments . 38 9.2.2 Barthel Index (BI) and its Validity and Reliability 38 9.2.3 Statistical Analysis . 40 9.2.4 Ethics 42 CHAPTER TWO: TRENDS IN PATIENT SOCIO-DEMOGRAPHIC, HEALTH AND FUNCTIONAL PROFILE AND REHABILITATION OUTCOMES BY HOSPITAL AND YEAR OF ADMISSION FROM 1996 TO 2005. . 43 2.1 Abstract 43 2.2 Background 45 2.3 Methods 46 2.4 Results . 51 2.5 Discussion . 55 CHAPTER THREE: FACTORS ASSOCIATED WITH NURSING HOME PLACEMENT 75 3.1 Abstract 75 3.2 Background 77 3.3 Methods 80 3.4 Results . 85 3.5 Discussion . 88 |Page CHAPTER FOUR: THE JOINT IMPACT OF COMORBIDITIES AND DISABILITY ON PATIENTS’ SURVIVAL. . 108 4.1 Abstract 108 4.2 Background 110 4.3 Methods 111 4.4 Results . 114 4.5 Discussion . 116 CHAPTER FIVE: THE INDIVIDUAL EFFECT OF 10 ACTIVITIES OF DAILY LIVING ON REHABILITATION OUTCOMES: PRINCIPAL COMPONENT ANALYSIS 132 5.1 Abstract 132 5.2 Background 134 5.3 Methods 134 5.4 Results . 140 5.5 Discussion . 145 CHAPTER SIX: DISCUSSION AND CONCLUSION 161 6.0 Summary 161 6.1 Trends in Patient Characteristics and Rehabilitation Outcomes from 1996 to 2005. . 161 6.2 Factors associated with Nursing Home Placement . 163 6.3 Joint Impact of Comorbidities and Disability on Patients’ Survival 164 6.4 Ten Activities of Daily Living on Rehabilitation Outcomes: Principal Component Analysis . 166 6.5 Public Health Implications: What it means to stakeholders? 167 6.5.1 “Forgotten” Stakeholders: The People . 168 6.5.2 “Fettered” Stakeholders: The Providers . 170 6.5.3 “Funding” Stakeholders: The Partial Payers 171 6.6 Future plans . 172 6.6.1 Linking database 172 6.6.2 Cost of rehabilitation by primary diagnosis groups . 173 6.6.3 Uninsured patients: Characteristics and household fund transfer 173 6.7 Strengths and limitations 174 6.8 Conclusion 175 REFERENCES . 176 APPENDIX . 190 Appendix 1. Shah Modified Barthel Index . 190 Appendix 2. Formula System for Charlson Co-Morbidity Index Score . 194 Appendix 3. Data Collection Form 196 |Page SUMMARY This summary lists the key findings of the thesis work on post-acute rehabilitation in Singapore. Rehabilitation outcomes of patients admitted to Singapore’s community hospitals have improved between 1996 and 2005 despite decreasing length of stay. There is an increasing trend in functional status at admission and discharge and an increase in effectiveness and efficiency of rehabilitation during this period. Discharge destinations have remained largely unchanged. The odds of nursing home placement are found to be increased in Chinese, males, single or widowed or separated/divorced, patients in high subsidy wards for hospital care, patients with dementia, without caregivers, lower functional scores at admission, lower rehabilitation effectiveness or efficiency at discharge and primary diagnosis groups such as fractures, lower limb amputation and falls in comparison to strokes. Social factors are the most important factors in predicting nursing home placement and accounted for 50% of the explained variation. This is followed by rehabilitation factors. Comorbidity and disability are independent predictors of mortality risks in patients after discharge from acute hospitalizations. In addition to widowhood and institutionalization, we also found a novel synergistic interaction effect of the comorbidity-disability complex independent on mortality risk. Most rehabilitation studies use admission functional scores as a total of 10 activities of daily living (ADLs) due to its simplicity. The final study showed that using a total score accounted for 64% of initial variation in the 10 ADLs. In order to capture 90% of the |Page information, only principal components are needed. The different ADL clusters, including bowel and bladder control, ambulation and feeding were independent predictors of rehabilitation outcomes (length of stay, discharge functional status and destination, and/or survival), even after adjustment of admission BI scores. Although these ADL clusters were significant predictors of rehabilitation outcomes, the additional information explained in the multivariate models were marginal. |Page LIST OF TABLES Table 1. Post-Acute Rehabilitation in Singapore . 30 Table 2. Demographic characteristics for rehabilitation patients by principal diagnosis for all admissions from 1996 to 2005 59 Table 3. Comparison between those with both BI scores available and those with missing Barthel scores . 61 Table 4. Overall outcome measures for rehabilitation patients by principal diagnosis for all admissions from 1996 to 2005 63 Table 5. Beta coefficients for trend in rehabilitation outcomes by principal diagnosis for all admissions from 1996 to 2005 64 Table 6. Beta coefficient of trends of discharge destination by principal diagnosis for all admissions from 1996 to 2005 . 68 Table 7. Descriptive table by primary diagnosis at admission to Singapore community hospitals from 1996 to 2005. . 95 Table 8. Odd ratios of nursing home placement by primary diagnosis at admission in Singapore community hospitals from 1996 to 2005 (univariate analysis) 99 Table 9. Odd ratios of nursing home placement by primary diagnosis at admission in Singapore community hospitals from 1996 to 2005 (multivariate analyses) 103 Table 10. Percentage variation explained by predictors in the overall model. 105 Table 11. Model summary . 106 Table 12. Social demographics by discharge disability . 120 Table 13. Social demographics by death status at time of censoring and bivariate model of all-cause mortality for hazard ratio 123 Table 14. Multivariate model of all-cause mortality in patients admitted to Singapore community hospitals from 1996 to 2005 . 126 Table 15. Discharge destinations and mortality status by admission characteristics of rehabilitation inpatients admitted to Singapore community hospitals from 1996 to 2005. 151 Table 16. Factors-loading matrix for admission Barthel Index (BI) items identified by principal components (PC) analysis . 153 Table 17. Regression coefficient (95% confidence interval) of predictors on response variables: rehabilitation outcomes, discharge destinations and mortality 154 Table 18. Percentage variation explained (R-square) by variables in the overall model. 155 |Page LIST OF FIGURES Figure 1. Life expectancy at birth (both genders) in year 1990, 2000 and 2012 by WHO regions and Singapore (Source: World health statistics 2012, WHO) . 13 Figure 2. Singapore life expectancy and healthy life expectancy at birth (by gender) in year 1990 and 2010. Dotted boxes are the remainder unhealthy life expectancy. (Lancet 2012) 15 Figure 3. Percentage of Population Aged >75 Years with Impaired Mobility (1983, 1995, 2005 and 2011) (Source: National Survey of Senior Citizens) 21 Figure 4. Percentage of Population Aged >75 Years with ADL Dependency (1983, 1995, 2005 and 2011) (Source: National Survey of Senior Citizens) 22 Figure 5. Mean admission Barthel Index score by principal diagnosis for admission across years from 1996 to 2005 . 70 Figure 6. Mean discharge Barthel Index score by principal diagnosis for admission across years from 1996 to 2005 . 70 Figure 7. Median length of stay (days) by principal diagnosis for admission across years from 1996 to 2005 71 Figure 8. Median Rehabilitation Effectiveness (%) by principal diagnosis for admission across years from 1996 to 2005 . 71 Figure 9. Median Rehabilitation Efficiency (units per month) by principal diagnosis for admission across years from 1996 to 2005 72 Figure 10. Median Relative Functional Efficiency (% per month) by principal diagnosis for admission across years from 1996 to 2005 72 Figure 11. Percentage (%) of those discharged home by principal diagnosis for admission across years from 1996 to 2005 73 Figure 12. Percentage (%)discharged to nursing or sheltered home by principal diagnosis for admission across years from 1996 to 2005 73 Figure 13. Percentage (%) of those discharged to acute hospital by principal diagnosis for admission across years from 1996 to 2005 74 Figure 14. Flowchart of selection criteria 127 Figure 15. Kaplan-Meier survival curve by comorbidity burden, discharge disability and discharge destination 128 Figure 16. Kaplan-Meier survival curves stratified by comorbidity and discharge disability. 129 Figure 17. Multiplicative interaction effect of comorbidity and disability in patients admitted to Singapore community hospitals from 1996 to 2005 . 130 Figure 18. Frequency of patients by ten activities of daily living . 156 Figure 19. Spearman correlation (lower triangle), scatterplot matrix (upper triangle) and histogram (diagnoal) of Admission BI scores with individual BI components. 158 Figure 20. Pearson correlation (lower triangle), scatterplot matrix (upper triangle) and histogram (diagnoal) of Admission BI scores with principal components. . 159 Figure 21. Screeplot of principal components. 160 |Page LIST OF ABBREVIATIONS ADL aBeta AbsoluteFG aHR Aic AIC AMKTHKH ANOVA aOR BI BIC BVH CI FI FIM FS IADL ICF ICIDH ILTC IQR IRB LL LOS MeSH MOH NUS NUS-IRB PC PCA PH PRT RCCH R-effectiveness R-efficiency Relative-FE SACH SD SES SLH VWO WHO Activity of Daily Living adjusted beta Absolute Functional Gain adjusted hazard ratio Agency for Integrated Care Akaike information criterion Ang Mo Kio Thye Hua Kwan Hospital Analysis of variance adjusted odds ratio Barthel Index Bayesian information criterion Bright Vision Hospital Confidence Interval Frailty Index Functional Independence Measure Frailty Scale Instrumental Activity of Daily Living International Classification of Functioning, Disability and Health International Classification of Impairments, Disability and Handicaps Intermediate and Long-Term Care Interquartile range (25% - 75%) Institutional Review Board Lower Limb Length of Stay Medical Subject Headings Ministry of Health (Singapore) National University of Singapore National University of Singapore Institutional Review Board Principal component Principal component analysis Proportional-hazards Progressive resistance training Ren Ci Community Hospital Rehabilitation Effectiveness Rehabilitation Efficiency Relative Functional Efficiency St Andrew’s Community Hospital Standard Deviation Socioeconomic status St Luke’s Hospital Voluntary Welfare Organization World Health Organization | P a g e 10 149. 150. 151. 152. 153. 154. 155. 156. 157. 158. 159. 160. 161. 162. 163. 164. 165. 166. 167. 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MOH 2012 Committee of Supply Speech Healthcare 2020: Improving Accessibility, Quality and Affordability for Tomorrow’s Challenges (Part of 2). 2012 [cited 2014 13 Aug]; Available from: http://www.moh.gov.sg/content/moh_web/home/pressRoom/speeches_d/2012/ moh_2012_committeeofsupplyspeechhealthcare2020improvingaccessibi.html. Ministry of Health. Costs and Financing. 2013 [cited 2014 12 Aug]; Available from: http://www.moh.gov.sg/content/moh_web/home/costs_and_financing.html. Ministry of health. Together, Better Healthcare for All. MediShield Life. 2013 [cited 2014 12 Aug]; Available from: http://www.moh.gov.sg/content/moh_web/home/pressRoom/Current_Issues/2 013/national-day-rally-2013/medishield.html. | P a g e 189 APPENDIX Appendix 1. Shah Modified Barthel Index No. 1. Activities of Daily Living (ADL) Personal Hygiene Scale Points Points The patient is unable to attend to personal hygiene and is dependent in all aspects. Assistance is required in all steps of personal hygiene. Some assistance is required in one or more steps of personal hygiene. Patient is able to conduct his/her own personal hygiene but requires minimal assistance before and/or after the activity. The patient can wash his/her hands and face, comb hair, clean teeth and shave. A male patient may use any kind of razor but must insert the blade, or plug in the razor without help, as well as retrieve it from the drawer or cabinet. A female patient must apply her own make-up, if used, but need not braid or style her hair. 2. Bathing Total dependence in bathing self. Assistance required with either transfer to shower/bath or with washing or drying; including inability to complete a task because of condition or disease, etc. Supervision is required for safety in adjusting the water temperature, or in the transfer. The patient may use a bath tub, a shower, or take a complete sponge bath. The patient must be able to all the steps of whichever methods is employed without another person being present. Dressing Assistance required in all aspects of bathing. 3. The patient is dependent in all aspects of dressing and is unable to participate in the activity. The patient is able to participate to some degree, but is dependent in all aspects of dressing. Assistance is needed in putting on, and/or removing any clothing. Only minimal assistance is required with fastening clothing, such as buttons, zips, bra, shoes, etc. The patient is able to put on, remove, and fasten clothing, tie shoelaces, or put on, fasten, remove corset, braces, as prescribed. 10 | P a g e 190 4. Feeding Dependent in all aspects and needs to be fed. Can manipulate an eating device, usually a spoon but someone must provide active assistance during the meal. Able to feed self with supervision. Assistance is required with associated tasks, such as putting milk/sugar into tea, salt, pepper, spreading butter, turning a plate or other “set-up” activities. Independence in feeding with prepared tray except assistance may be required to cut meat, open milk carton, jar lid, etc. Presence of another person is not required. The patient can feed self from a tray or table when someone puts food within reach, The patient must be able to put on assistive device if needed, cut the food, and if desired, use salt and pepper, spread butter, etc. 5. Toileting Fully dependent in toileting. 10 Assistance may be required with management of clothing, transferring, or washing hands. Supervision may be required for safety with normal toilet. A commode may be used at night but assistance is required for emptying and cleaning. The patient is able to get on and off the toilet, fasten and unfasten clothes, prevent soiling of clothes and use toilet paper without help. If necessary, the patient may use bad pan or commode, or urinal at night, but must be able to empty it and clean it. Bowel Control & Management Assistance required in all aspects of toileting. 6. The patient is bowel incontinent. 10 The patient needs help to assume appropriate position, and with bowel movement facilitatory techniques. The patient can assume appropriate position, but cannot use facilitatory techniques, or clean self without assistance and has frequent accidents. Assistance is required with incontinence aids such as pads, etc. The patient may require supervision with the use of suppository or enema and has occasional accidents. The patient can control bowels and has no accidents, can use suppository, or take an enema when necessary. 10 | P a g e 191 7. 8. Bladder Control & Management Transferring The patient is dependent in bladder management, is incontinent, or has indwelling catheter. The patient is incontinent but is able to assist with the application of an internal or external device. The patient is generally dry by day and not at night, and needs some assistance with the devices. The patient is generally dry by day and night, but may have an occasional accident, or need minimal assistance with internal or external devices. The patient is able to control bladder day and night, and/or is independent with internal or external devices. 10 Unable to participate in transfer. Two attendants are required to transfer the patient with or without a mechanical device. Able to participate but maximum assistance of one other person is required in all aspects of the transfer. The transfer requires the assistance of one other person. Assistance may be required in any aspect of the transfer. The presence of another person is required either as a confidence measure or to provide supervision for safety. 12 The patient can safely approach the bed in a wheelchair, lock the brakes, lift the footrests, move safely to bed, lie down, come to a sitting position on the side of the bed, change the position of the wheelchair, transfer back into it safely. The patient must be independent in all phases of this activity. 9a. Mobility (Ambulation) Dependent in ambulation. 15 Constant presence of one or more assistants is required during ambulation. Assistance is required with reaching aids and/or their manipulation. One person is required to offer assistance. The patient is independent in ambulation but unable to walk 50 metres without help, or supervision is needed for confidence or safety in hazardous situations. The patient must be able to wear braces if required, lock and unlock these braces, assume standing position, sit down, and place the necessary aids into position for use. The patient must be able to use crutches, canes or a walking frame, and walk 50 metres without help or supervision. | P a g e 192 12 15 9b. Wheelchair Ambulation [Only use this item if the patient scored ‘0’ for mobility (ambulation), and then only if the patient has been trained in wheelchair management] 10. Stairs Dependent in wheelchair management. Patient can propel self short distances on flat surfaces, but assistance is required for all other steps of wheelchair management. Presence of one person is necessary and constant assistance is required to manipulate chair to table, bed, etc. The patient can propel self for a reasonable duration over regularly encountered terrain. Minimal assistance may still be required in “tight corners”. To propel wheelchair independently, the patient must be able to go around corners, turn around, manoeuvre the chair to a table, bed, toilet, etc. The patient must be able to push a wheelchair at least 50 metres. The patient is unable to climb stairs. Assistance is required in all aspects of stair-climbing, including assistance with walking aids. The patient is able to ascend/descend but is unable to carry walking aids, and needs supervision and guidance. Generally no assistance is required. At times, supervision is required for safety due to morning stiffness, shortness of breath, etc. The patient is able to go up and down a flight of stairs safely without help or supervision. The patient is able to use hand rails, cane, or crutches when needed and is able to carry these devices as he/she ascends or descends. Overall Score Dependency Level – 24 25 – 49 50 – 74 75 – 90 91 – 99 100 Total Severe Moderate Mild Minimal Independent | P a g e 193 10 Appendix 2. Formula System for Charlson Co-Morbidity Index Score The Charlson Co-Morbidity Index (CCMI) contains 19 categories of co-morbidity. Each category has an associated weight which is based on the adjusted risk of oneyear mortality. The overall CCMI score is the sum of the weighted scores and it reflects the cumulative disease burden: the higher the score, the greater the burden of co-morbidity. Charlson’s original 19 categories of co-morbidity and their assigned weights were as follows: The minimum and maximum score for CCMI is zero and 35 respectively. For this study, the conditions ‘diabetes’ and ‘diabetes with end organ damage” was collapsed into one category but with the original Charlson weights retained. This was similarly done for liver disease and tumour. The following below presents the above data in alphabetical order and with the collapsed categories. | P a g e 194 Co-Morbidity Charlson Weights AIDS No = 0, Yes = Connective tissue disease No = 0, Yes = Cerebrovascular disease No = 0, Yes = Chronic pulmonary disease No = 0, Yes = Congestive heart failure No = 0, Yes = Dementia No = 0, Yes = Diabetes Mellitus* • • • Hemiplegia No = 0, Yes = Leukemia No = 0, Yes = Liver Disease* • • • Lymphoma No = 0, Yes = Myocardial infarct No = 0, Yes = Ulcer disease No = 0, Yes = Peripheral vascular disease No = 0, Yes = Renal disease • • No or mild = Moderate or severe = Solid tumour* • • • No = Yes (non-metastatic) = Yes (metastatic) = No = Without end organ damage = With end organ damage = No = Mild = Moderate or severe = * Coded as separate variables in original CCMI. | P a g e 195 Appendix 3. Data Collection Form | P a g e 196 | P a g e 197 | P a g e 198 | P a g e 199 [...]... subsidy if income is below S$700.[52] In 2011, Singapore had 60 nursing homes (private and VWO) with a total of 9,300 beds with a minority offering skilled inpatient rehabilitation The number of beds will rise to 14,000 in the next decade after the building of two new homes and upgrading and relocation of four others.[53] In addition, rehabilitation services are also offered in non-residential day rehabilitation. .. care at community hospitals Our local Ministry of Health recommends that rehabilitation units in acute hospitals cater to younger patients with the goal of returning patients back to the workforce while rehabilitation in community hospitals cater to older patients with the goal of returning patients to their homes.[56] As a result, staff in rehabilitation units in acute hospitals are trained in specialized... and facilitate placement of elderly sick in nursing homes and chronic sick units, discharge planning and facilitating transition of patients Aic enhances and integrates care, and monitors patient health outcomes within the ILTC sector which includes community hospitals. [48] Since rehabilitation is a primary function and role of the ILTC sector, Aic has been tasked to measure and monitor trends on rehabilitation. .. Class B2 7.3 Infrastructure of Rehabilitation and Healthcare in Community Hospitals Singapore s community hospitals are required to provide frequent physician involvement (a doctor’s review at least every 2 days), 24-hour rehabilitation nursing, therapy given twice a day in the morning and afternoon with a maximum length of stay of 90 days per episode of illness All community hospitals in Singapore provide... mean age of community hospital patients from 1995 to 2005 was 73.2 years [58] In our ageing population with increasing disability and comorbidity, it is crucial to improve our understanding about geriatric inpatient rehabilitation in Singapore which is provided mainly in the community hospitals Table 1 provides a summary of the postacute rehabilitation setting in Singapore Table 1 Post-Acute Rehabilitation. .. understanding of the factors affecting rehabilitation outcomes, identify high and low performing rehabilitation centres so that support can be given to improve their standards of care, and monitor the trends of rehabilitation outcomes with time, given our increasing ageing population with disability Little is known about trends in geriatric rehabilitation and its association with discharge destination and. .. outcomes within community hospitals Historical data on rehabilitation outcomes will be useful to Aic and MOH to review the quality of rehabilitation and national prevalence of disability and care planning needs in the light of our ageing population 7.2 Financing Provision and selection of participants for rehabilitation are often determined by the funding mechanisms and healthcare system Our inpatient rehabilitation. .. functioning and performance of simple and complex activities in older adults.[46] Another meta-analysis of randomized controlled trials found that higher PRT intensities were superior to lower PRT intensities in improving maximal strength and functional performance in older adults.[47] | P a g e 25 7 Rehabilitation in Singapore 7.1 Organization of Rehabilitation Services in Singapore In Singapore, inpatient... research was to investigate the trends in functional outcomes, the factors associated with nursing home placement and survival in a retrospective national database of elderly admitted for inpatient rehabilitation to all community hospitals in Singapore from 1996 to 2005 (10 years) The four chapters are: 1 Chapter 2: Trends in patient socio-demographic, health and functional profiles and rehabilitation. .. condition requiring rehabilitation The common principal diagnoses for admission include stroke, hip fractures, joint replacement, amputations and falls Most patients are directly admitted from acute hospitals and receive inpatient rehabilitation during their stay According to Ministry of Health guidelines, initial functional assessment and rehabilitation should be initiated within two days of community hospital . | Page 1 FACTORS ASSOCIATED WITH REHABILITATION OUTCOMES, NURSING HOME PLACEMENT AND SURVIVAL OF PATIENTS IN SINGAPORE COMMUNITY HOSPITALS CHEN HUIJUN CYNTHIA. Rehabilitation in Singapore 26 7.1 Organization of Rehabilitation Services in Singapore 26 7.2 Financing 27 7.3 Infrastructure of Rehabilitation and Healthcare in Community Hospitals 28 7.4 Patients. Lee KK, Ng YS, Teo YY, Koh CHG. Factors associated with nursing home placement of all patients admitted for inpatient rehabilitation in Singapore community hospitals from 1996 to 2005: a disease