Community Hospital Patients Discharging to the CommunityNCT07856030
Enhancing Patient Wellbeing Through Integration of Social Prescribing, Transitional Care, and Place-based Care in Community Hospitals Settings
A study testing SingHealth Community Hospitals Place-based Care in people with Community Hospital Patients Discharging to the Community, run by SingHealth Community Hospitals at 2 sites in Singapore.
Trial summary
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. Read more about this study
- Who is it for?
- Ages 50 years and older
- Conditions the study is for
- Community Hospital Patients Discharging to the Community
- What is being tested?
- SingHealth Community Hospitals Place-based Care
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 720 participants
- Where
- 2 sitesSingapore
- Study dates
- 17 Nov 2026to 31 Jan 2028
- Phase
- Interventional
- Are there results?
- Not yet: the study is under way
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 50 years and older
- All sexes
- No healthy volunteers
- Adult, Older adult
Who may be able to join
- 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.
Who cannot join
- Participant is planned for hospice discharge.
- Participant is planned for nursing home placement, transitional shelter or care facilities
Trial locations and contacts
2 sites in 1 country. Contact the study team or a site near you to ask about taking part.
Singapore2 sites
Outram Community Hospital
Singapore
Sengkang Community Hospital
Singapore
About this study
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.
Read the 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.
- Being tested
- SingHealth Community Hospitals Place-based Care
- Keywords
- Community Hospital, Social Prescribing, Placed Based Care
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
SingHealth Community Hospitals Place-based CareOther
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.
| Study group | Role | What they receive |
|---|---|---|
| SCH Place-based Care Intervention Ward | Active comparator | SingHealth Community Hospitals Place-based Care model will be utilised in the ward on top of standard of care treatment. Receives: Other: SingHealth Community Hospitals Place-based Care |
| SCH Control Ward | No intervention | Wards will have normal standard of care treatment. |
What is being measured
The primary outcome is the main question the study is designed to answer.
Care Transition Quality (CTM-15)
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.
Measured: T1: 21 Days Post-Discharge
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted2 Oct 2026
- Study start17 Nov 2026 (estimated)
- Primary completion31 Jul 2027 (estimated)
- Study completion31 Jan 2028 (estimated)
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Other trials for Community Hospital Patients Discharging to the CommunityStudies of the same condition, open and under way.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Primary purpose
- Health services research
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- None (open label)
- Enrolment
- 720 participants (estimated)
Sponsor and investigators
- Lead sponsor
- SingHealth Community Hospitals
- Sponsor type
- University, hospital or other
- Responsible party
- Principal investigator, Lee Kheng Hock, SingHealth Community Hospitals
- Investigators
- Kheng Hock Lee, Principal investigator, SingHealth Community Hospitals
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT07856030
- Sponsor's protocol ID
- 2026-1373
- Other IDs
- SHF-SCH/26/IFC1-6/01
- Status last verified
- Sep 2026
- First submitted
- 27 Sep 2026
- Last updated
- 2 Oct 2026
- Results posted
- No
- Data monitoring committee
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- No
Study at a glance
From the registry record, last updated by the sponsor on 2 Oct 2026. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Enhancing Patient Wellbeing Through Integration of Social Prescribing, Transitional Care, and Place-based Care in Community Hospitals Settings
- ClinicalTrials.gov ID
- NCT07856030
- Acronym / sponsor ID
- 2026-1373
- Keywords
- Community Hospital, Social Prescribing, Placed Based Care
- Study type
- Interventional
- Recruitment status
- Not yet recruiting
- Enrolment
- 720 participants (estimated)
- Lead sponsor
- SingHealth Community HospitalsUniversity, hospital or other
- Study start
- 17 Nov 2026 (estimated)
- Primary completion
- 31 Jul 2027 (estimated)
- Study completion
- 31 Jan 2028 (estimated)
- First posted
- 2 Oct 2026 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
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.
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 design
- Primary purpose
- Health services research
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- None (open label)
- Number of arms
- 2
| Arm | Type | Receives |
|---|---|---|
| SCH Place-based Care Intervention Ward | Active comparator | Other: SingHealth Community Hospitals Place-based CareSingHealth Community Hospitals Place-based Care model will be utilised in the ward on top of standard of care treatment. |
| SCH Control Ward | No intervention | –Wards will have normal standard of care treatment. |
Who may qualify
- Ages
- 50 years and older
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
Key inclusion criteria (6 listed)
- 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.
Key exclusion criteria (2 listed)
- Participant is planned for hospice discharge.
- Participant is planned for nursing home placement, transitional shelter or care facilities
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| SingHealth Community Hospitals Place-based CarePlace-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. | Other | SCH Place-based Care Intervention Ward |
Primary outcome
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.
Results and safety
This study is still under way. Results are not available in the source record yet.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 2 Oct 2026.
- Individual participant dataSharing planned: No
Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part.
Kheng Hock Lee principal investigator
SingHealth Community Hospitals
2 sites in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A study testing SingHealth Community Hospitals Place-based Care in people with Community Hospital Patients Discharging to the Community, run by SingHealth Community Hospitals at 2 sites in Singapore.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 6 inclusion and 2 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: opening soon, as of the sponsor's last update on 2 Oct 2026. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 2 sites in Singapore. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
This study is still under way. Results are not available in the source record yet.
How can a doctor refer a patient or contact the research team?
Contact A/Prof Lee Kheng Hock (69703201, lee.kheng.hock@singhealth.com.sg), or a site near the patient. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Care Transition Quality (CTM-15) (time frame: T1: 21 Days Post-Discharge). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 2 Oct 2026.