SINGAPORE – A 71-year-old patient called Yishun Polyclinic twice in 2022, asking to refill her prescription for blood pressure medication.

During her third call in September that year, staff explained that she first needed to come in and be assessed by a doctor.

The patient, Ms Lee, then said she had not gone for medical appointments because of lingering pain from a fall earlier that year. She had suffered a thigh fracture and it was hard for her to get around.

The retired waitress, who wants to be known only by her surname, is single and lives alone, and could not arrange transport to the polyclinic.

She also hesitated to ask the community centre or social service agencies for help.

“I’m used to my independence,” she told The Straits Times. “I can take care of myself.”

Managing healthcare is complicated for people like Ms Lee. They may be socially isolated or otherwise strapped for resources, yet unwilling or unable to ask for assistance.

This is a concern, as incidence of chronic conditions is on the rise, according to the National Population Health Survey 2022.

For example, the crude prevalence of hypertension showed a significant increase from 2010 (19.8 per cent) to the 2021-2022 period (37 per cent).

Singapore will also become a super-aged society in 2026, with 21 per cent of the population aged 65 or older.

Many of these older people are likely to live alone or be socially isolated after retirement. Illness or accidents could limit their daily activities and ability to manage their own healthcare.

Ms Lee rarely sees her friends because they have families to care for. She spends her days watching television or enjoying short strolls in her neighbourhood.

She received care for her thigh fracture at Khoo Teck Puat Hospital, and had a nurse and community partner check in on her regularly for several months after that.

However, her fierce independence did not allow her to admit just how much the lingering pain affected her.

Pain and reduced mobility can restrict a person’s ability to manage his or her own chronic conditions. He or she may miss medical appointments. The chronic condition may also worsen, making it harder for one to stick to a healthcare regimen.

New role for healthcare bodies

In the past, a kampung network of extended family and friends might step in to help, say healthcare workers.

Now, hospitals and polyclinics are taking on this role.

By the end of 2022, weeks after Ms Lee’s third request to refill her prescription, a voluntary welfare organisation was taking her to medical appointments, thanks to the intervention of the polyclinic Care Coach.

As of October, all seven polyclinics under the National Healthcare Group Polyclinics (NHGP) have a Care Coach to assist with complex cases.

In complex cases, the patient’s management of a disease or chronic condition is affected by psychological and social challenges.

For example, he or she may be caregivers to others with chronic conditions, or unable to get to medical appointments, or just not take medicines regularly. He or she may have impaired cognition or complex medication regimens.

Care Coaches are non-clinical staff who create an individualised intervention plan for complex patients.

The role is a feature of NHGP’s relationship-based health and social integration programme, also known as Relate, to achieve better health outcomes in patients.

Relate was piloted at Ang Mo Kio Polyclinic in September 2020 and expanded to Yishun Polyclinic in early 2021.

Care Coaches spend time with the patients, assessing what their challenges and needs are, then devise solutions.

They help patients navigate the healthcare system and work with them on lifestyle changes and other factors that can help them manage chronic conditions.

Care Coaches also work with community care partners such as voluntary welfare organisations, community centres and the Agency for Integrated Care, which coordinates and supports caregiving in Singapore.

Partners might arrange transport to the polyclinic or offer care respite for patients who are also caregivers.

Dr Valerie Teo, family physician and consultant, who is programme lead for Relate, says: “The Care Coach is the bridge between the patient, polyclinic care team and our community partners, and will help support the patient until his or her situation improves or stabilises.”

Since Relate was launched, interventions have been carried out for more than 400 patients under NHGP.

Six months after their enrolment in Relate, medication compliance improved by 10 per cent and nearly half were visiting the polyclinics less frequently for medical care.

Those with poorly controlled diabetes also reduced their HbA1c level, which marks blood glucose levels over three months.

The idea is to reduce emergency department visits for crisis care and to improve the management of chronic diseases such as diabetes and hypertension, says Dr Teo, who is also head of Kallang Polyclinic.

The patient-centred approach is integral to improving health outcomes, she adds.

Not all elderly and socially isolated patients have poorly controlled chronic conditions, notes Dr Kung Jian Ming, a family physician and associate consultant at Yishun Polyclinic, who is co-programme lead for Relate. 

Relate targets those with poorly controlled chronic conditions who may not be able to monitor themselves. They may have dementia or be otherwise incapacitated.

Dr Kung Jian Ming is co-programme lead for Relate at the National Healthcare Group Polyclinics. Relate helps patients manage chronic conditions by addressing their unmet needs. PHOTO: NATIONAL HEALTHCARE GROUP POLYCLINICS

Beyond prescriptions and doctor visits

Helping patients manage chronic conditions extends beyond their doctor visits and medical prescriptions.

Tan Tock Seng Hospital sees mostly elderly patients with chronic conditions.

Dr Chen Wei Ting, assistant clinical director at the hospital’s Division for Central Health, says a Community Health Team helps patients transition from hospital to home after being warded.

The team also works with social service agencies and community care partners to ensure these patients are able to manage their conditions.

The hospital’s partners may arrange medical escort services to take patients to appointments, or support them through telehealth consultations, or even check in daily to ensure that they are taking their medication.

Similarly, the National University Health System’s (NUHS) Community Care Team monitors patients post-discharge and links them with social service care providers, if need be, to address non-clinical needs.

These may include befriending services, meals-on-wheels or homecare services such as medication reminders or medical escorts.

The team also offers chronic disease management and other health services with community partners.

The National University Health System’s Community Care Team monitors patients post-discharge and links them with social service care providers, if need be, to address non-clinical needs. PHOTO: NATIONAL UNIVERSITY HEALTH SYSTEM

Ms Joanne Yap, executive director of NUHS’ Regional Health System Office, says that in 2022, 5,600 patients were enrolled with the Community Care Team compared with 3,500 the previous year.

“We have observed a rising trend, likely due to successful outreach to residents who needed supportive care, engagement and empowerment in self-care and a healthy lifestyle,” she says. 

Changi General Hospital (CGH) started a 24-hour phone service called CareLine (tel: 6340-7054) in 2016, which checks on the well-being of vulnerable seniors and addresses their needs by linking them to healthcare or social services.

To date, the service has taken more than 1,000 calls for urgent assistance and services and reached 19,000 seniors, says Ms Pearline Lee, the hospital’s deputy director of homecare and safety.  

A CareLine service associate at work. The 24-hour phone service has taken more than 1,000 calls for urgent assistance and services and reached 19,000 seniors. PHOTO: CHANGI GENERAL HOSPITAL

Importance of community networks

Since 2013, CGH and the South East Community Development Council have run a Neighbours for Active Living Programme, where volunteer befrienders are matched with vulnerable seniors.

Volunteer befrienders remind seniors to take their medications and go for medical appointments. About 900 volunteers have been trained and 13,000 seniors supported.

The befrienders also alert a community care team if they notice health issues. The care team conducts home visits, creates care plans and works with community partners to address care needs and other challenges.

Eyes and ears on the ground are needed because patients are often unable to recognise that their lives could be made better.

Retired security guard Mohamed Waren, 58, had both legs amputated below the knee because of uncontrolled diabetes.

As his diabetes may have also affected his vision, it is harder for him to remember whether he has taken his medication.

He is also a caregiver to his sister, 57, who is bedridden and on dialysis for kidney disease.

As Mr Mohamed Waren’s diabetes may have also affected his vision, it is harder for him to remember whether or not he has taken his medication. ST PHOTO: AZMI ATHNI

Hospitals and polyclinics are seeing more caregivers like Mr Mohamed, who might be ageing and have their own healthcare woes while also needing to support another family member with chronic conditions.

Mr Mohamed is a patient at Singapore General Hospital (SGH) which, like other public hospitals here, has a medical social services division to help patients and their families cope with emotional, psychological, social and care problems arising from illness or trauma.

The hospital has more than a million patients a year and receives 1,850 referrals to the medical social services division each month. Between 20 and 30 per cent of these are complex cases.

After Mr Mohamed’s second amputation in January, SGH nurses who manage patients’ transition from hospital to home alerted the hospital’s medical social services division that he would need more help managing his care.

Principal medical social worker Tang Chyi Yueh learnt only then that Mr Mohamed was a caregiver as well as a patient.

When in better health, he could manage household chores such as laundry and cleaning, but he needed more assistance after the amputation.

The flat also needed repairs and modification. Light switches were not working, the toilet bowl was broken and there were no grab bars in the bathroom, which meant an increased risk of falls.

Ms Tang says: “Sometimes, people get used to a less than optimal standard of living. When we conduct home visits, we realise the extent of the challenges that they are facing.”

Mr Mohamed was referred to SGH Project GroomOver, an SGH annual volunteer programme that helped to clean and fix his home.

Ms Tang also coordinated with community partners to arrange transport for medical appointments; home nursing services to ensure he would take his medication; and others for financial assistance.

“We brought a kampung in to help him,” she says.

She also helped him claim payouts from his insurance.

Mr Mohamed says: “I’m very grateful for her help. She applied for everything and it was fruitful.”

While he was aware that he could have benefited earlier from various community schemes, he was hesitant to apply.

“I don’t like paperwork. It gives me stress,” he adds.

His fear of paperwork has also prevented him from applying for a long-term visit pass for his wife of 22 years, who visits regularly from Batam and wants to move here permanently to help him out.

Mr Mohamed has a stepson and three grandchildren, also in Batam.

His older brother, a ship’s captain, helps financially but is unable to assist with daily care. Their eldest brother is a taxi driver.

Mr Mohamed emphasises that his life “is not a sad story”. He enjoys going to the nearby foodcourt for his meals and chatting with other residents in his block of flats.

“People do what they can to help,” he says. “I’m thankful.”

This article has been edited for accuracy.