One-Rehab: Enabling shared care across the patient rehabilitation journey

The National One-Rehab Framework (One-Rehab) is a nationwide initiative to enhance patients’ rehabilitation journeys and outcomes by ensuring that harmonised outcomes, conditions and pathways are tracked through a common IT system. Senior Minister of State Dr Janil Puthucheary had announced One-Rehab at MOH Committee of Supply debate in 2021.

To enable the implementation of One-Rehab, the Ministry of Health (MOH) collaborated with rehabilitation service providers across all three healthcare clusters, community rehabilitation service providers, Agency for Integrated Care (AIC), MOH Office for Healthcare Transformation (MOHT), Integrated Health Information Systems (IHiS) and Singapore Institute of Technology (SIT) to co-develop models of care. To support the models of care, enablers such as a common IT system, training on the use of harmonised clinical outcomes and financial incentives were introduced to right-site rehab care. One-Rehab is also the first implementation of at-scale clinical data sharing across hospitals, polyclinics, and community service providers.

OneRehab Usability Session with St Luke’s ElderCare therapists

The One-Rehab IT System was launched in Aug 2022. The system enables an end-to-end view of a patient’s rehabilitation care journey and supports the tracking of a harmonised set of rehabilitation outcomes to improve patient care. It aims to enable seamless shared care across Public Healthcare Institutions (PHIs) and community rehabilitation partners in four ways:

Firstly, the One-Rehab IT System enables the rehabilitation team – clinicians, physiotherapists, occupational therapists and speech therapists – to formulate care based on the harmonised, structured information collected through the One-Rehab Care Plan.

Next, the One-Rehab IT System provides an end-to-end view of patients’ rehabilitation outcomes across their care journey, which helps to facilitate informed and shared decision-making by providers from acute hospitals to community settings. The single page view allows providers to see a snapshot of the patient’s rehabilitation journey – records with past and current rehabilitation providers.

Thirdly, the data collected from One-Rehab Care Plan will support MOH, PHIs and community rehabilitation partners to track rehabilitation service delivery across all care settings and at a national level. It will provide insights to inform future service improvement and policy formulation.

Finally, the One-Rehab IT System provides opportunities for future learning. The team can re-use many components of the IT system for similar use cases involving collaboration across care settings.

This is the first of a multi-part series. Stay tuned for further posts where the One-Rehab team will share about the challenges and takeaways of our journey in creating the One-Rehab IT System.

Special mention to the One-Rehab colleagues from all PHIs, Community Service Providers, AIC, MOH and IHiS for making this happen.

Lakshman Murugappan – Integrated General Hospital programme

At MOHT, I value the autonomy to think critically, try new ideas and help bridge the ground’s needs and management’s aspirations. I function as a change agent, explore unchartered waters and ask (and face) tough questions. I also get to challenge usual practice norms, and that is how iConnect and subsequently One-Rehab got going.

With One-Rehab, I hope that our work will lead to greater things in the space of care collaboration across care settings. We can start a new movement in digital collaboration – the data collected can allow us to track, compare and benchmark rehab service quality and delivery, and the data will continue to grow as we expand to more conditions and use-cases that are protocolisable.