Enhancing Patient Wellbeing Through Integration of Social Prescribing, Transitional Care, and Place-based Care in Community Hospitals Settings

September 27, 2026 updated by: Lee Kheng Hock, SingHealth Community Hospitals

The study aims to find out whether placed-based care (PBC), helps patients receive better support when they return home after leaving the community hospital, compared with the usual care provided.

Study Overview

Status

Not yet recruiting

Conditions

Intervention / Treatment

Detailed Description

This study addresses the critical need for a rigorous evaluation of PBC as an integrated model of care within community hospital settings. By employing a pragmatic parallel cluster randomised controlled trial design, the study will generate robust evidence on the effectiveness of PBC in real-world practice while minimising contamination at the ward level. The cluster-based design is appropriate given that the intervention is delivered at the ward level and cannot be implemented at the individual patient level without risk of spillover effects.

The use of validated outcome measures, including the CTM-15 as the primary outcome, will enable comprehensive assessment of care transition quality alongside broader outcomes related to patient wellbeing and healthcare utilisation. In addition, the study incorporates a mixed-methods approach, guided by the Practical, Robust Implementation and Sustainability Model (PRISM), to provide insights into implementation processes, mechanisms of action, and contextual factors influencing effectiveness (McCreight et al., 2019; Rabin et al., 2022).

Findings from this study will inform policy and service planning decisions regarding the scaling and sustainability of integrated social prescribing models within Singapore's healthcare system and contribute to the international evidence base on complex transitional care interventions.

Study Type

Interventional

Enrollment (Estimated)

720

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Contact

Study Locations

  • Singapore
      • Singapore, Singapore
        • Outram Community Hospital
      • Singapore, Singapore
        • Sengkang Community Hospital

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

50 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • Participant is (male or female) ≥ 50 years of age at Recruitment.
  • Participant is expected to discharge to the community.
  • Participant is able to converse in either English, Mandarin, or Malay
  • Participant is able to sign the written informed consent.
  • Participant is considered reliable and capable of adhering to the protocol.
  • Participant is able to complete all the questionnaires.

Exclusion Criteria:

  • Participant is planned for hospice discharge.
  • Participant is planned for nursing home placement, transitional shelter or care facilities

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Health Services Research
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Active Comparator: SCH Place-based Care Intervention Ward

SingHealth Community Hospitals Place-based Care model will be utilised in the ward on top of standard of care treatment.
Other: SingHealth Community Hospitals Place-based Care

Place-based Care (PBC) at SingHealth Community Hospitals represents a significant evolution of these approaches, addressing the limitations of fragmented care by integrating social prescribing with structured transitional care. Within community hospital settings, PBC encompasses five core domains: coordinated specialist outpatient follow-ups, linkage to community resources, medication adherence support, primary care transition planning, and caregiver education and self-care empowerment.

This integrated model shifts the conventional discharge process from a primarily episodic and medically driven approach to a comprehensive, person-centred care pathway that incorporates both clinical and social assessment, coordinated care planning, supported transition, and structured follow-up. By embedding social prescribing within the continuum of care, PBC aims to improve both clinical outcomes and patient experience during vulnerable transition periods.
No Intervention: SCH Control Ward

Wards will have normal standard of care treatment.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Care Transition Quality (CTM-15)
Time Frame: T1: 21 Days Post-Discharge

The CTM-15 is the primary outcome measure for this study and aligns closely with the five core domains of the PBC intervention: specialist outpatient clinic (SOC) follow-up coordination, community resource linkage, medication adherence support, primary care transition planning, and caregiver and self-care capability. The CTM-15 is a validated 15-item instrument that assesses the quality-of-care transitions from the patient's perspective, capturing key domains such as medication management, understanding of the care plan, preparation for self-care, and coordination across healthcare settings.
T1: 21 Days Post-Discharge

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

SingHealth Community Hospitals

Investigators

  • Principal Investigator: Kheng Hock Lee, SingHealth Community Hospitals

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Estimated)

November 17, 2026

Primary Completion (Estimated)

July 31, 2027

Study Completion (Estimated)

January 31, 2028

Study Registration Dates

First Submitted

September 27, 2026

First Submitted That Met QC Criteria

September 27, 2026

First Posted (Actual)

October 2, 2026

Study Record Updates

Last Update Posted (Actual)

October 2, 2026

Last Update Submitted That Met QC Criteria

September 27, 2026

Last Verified

September 1, 2026

More Information

Terms related to this study

Keywords

Other Study ID Numbers

  • 2026-1373
  • SHF-SCH/26/IFC1-6/01 (Other Identifier: SCH Health Fund)

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

NO

Drug and device information, study documents

Studies a U.S. FDA-regulated drug product

No

Studies a U.S. FDA-regulated device product

No

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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