A home-based palliative care program for terminally ill patients with end-stage organ failure and severe frailty in Singapore has been shown to improve symptom control and honour the patients’ end-of-life preferences while reducing acute healthcare use and its associated costs.
Known as Programme IMPACT, the program provides 24/7 home-based palliative care to terminally ill non-cancer patients using a multidisciplinary approach integrated into acute care. The multidisciplinary team consisting of doctors, nurses, and medical social workers provides round-the-clock support, including medical and nursing care, symptom assessments, and psychosocial support.
Care is delivered primarily through scheduled home visits, with additional visits prompted by symptom exacerbations. Patients could be admitted to the acute inpatient ward for treatment of potentially reversible conditions. Between visits, patients and caregivers had access to telephone support via a 24/7 on-call system, which facilitates timely clinical advice or urgent home visits.
A single-arm prospective cohort study to evaluate the Programme IMPACT included 387 patients. The mean age of the patients was 82.3 years, 56.1 percent were men, and 88.1 percent were Chinese. Of the patients, 39.3 percent had end-stage respiratory failure, 24.8 percent had end-stage heart failure, 16.3 percent had end-stage chronic obstructive pulmonary disorder (COPD), 11.1 percent were severely frail at end of life, and 8.5 percent had end-stage non-COPD respiratory diseases.
Programme IMPACT was associated with improved palliative outcomes. Mean symptom scores on the Edmonton Symptom Assessment Scale increased by 2.5 points, and 58.8 percent of episodes with exacerbations improved by a subsequent visit. [BMC Palliat Care 2026;doi:10.1186/s12904-026-02137-6]
Over a mean of 3.5 months from enrolment, 281 patients died, of which 165 had formally documented advance care plan (ACP). The ACP indicated that 64 percent preferred to die at home, 98.2 percent opted for do-not-resuscitate (DNR) orders, 83 percent preferred limited intervention, and 15.8 percent favoured comfort-focused care.
Concordance between preferences and outcomes was high for CPR status (94.8 percent), medical interventions (96.3 percent), and place of death (89.1 percent).
“Discordance for CPR and medical intervention stemmed from the reversal of decisions by caregiver or next-of-kin during crisis events or the healthcare staff’s unawareness of care preferences. For the place of death, the primary reason for discordance was dying in the hospital,” the authors noted.
Lower healthcare expenditure
To evaluate healthcare use and costs, the authors conducted a retrospective analysis using data from the Programme IMPACT and administrative database. The analysis included 148 Programme IMPACT patients and 853 control decedents, with the mean age at death being 82.3 and 77.2 years, respectively.
Relative to controls, Programme IMPACT decedents had significantly reduced hospital admissions and length of stay (rate ratio [RR], 0.65–0.85; p<0.005), admission-related and total costs (mean ratio [MR], 0.56–0.75; p<0.001), and emergency department visits and costs (RR and MR, 0.69–0.81; p<0.008).
Programme IMPACT decedents also had 16-fold greater odds of dying at home compared with control decedents (odds ratio, 16.6, 95 percent confidence interval, 10.2–27.0; p<0.001).
“While these findings are largely positive, it is important to acknowledge variation across patient subgroups. Respiratory failure patients had significantly longer inpatient length of stay compared with controls, likely reflecting the inherent complexity of managing acute respiratory crises and the time required for adequate symptom stabilization and caregiver preparation,” the authors pointed out.
“Collectively, these findings highlight the potential value of structured home palliative care programs in facilitating improved end-of-life care, enabling home death as per the patient’s preference, and reducing healthcare cost and utilization, though the intensity of resource requirements may vary across different patient subgroups,” they added.