• Community of Care programme provides home-based multidisciplinary care and social support for more than 260 seniors at risk of repeated hospital admissions

Singapore, 26 April 2017 – SingHealth Regional Health System (RHS) and Kreta Ayer-Kim Seng constituency today launched a community care programme aimed at enhancing health and social care for elderly residents in Chin Swee Road and Banda Street. The programme will complement existing services run by community partners in the vicinity to provide holistic care for seniors. This forms a strong community support network to cater to the different care needs of seniors. Key partners include the Agency for Integrated Care, Kreta Ayer Seniors Activity Centre and general practitioners in Chinatown. 

“Community and grassroots volunteers are often in the best position to identify residents’ real needs and mobilise community-based resources to meet them. With the medical expertise from SingHealth, we are better equipped to help our elderly residents lead independent lives and age in place confidently, among a supportive network of friends and familiar faces,” said Dr Lily Neo, MP for Jalan Besar GRC (KRETA AYER-KIM SENG).

Under the new programme, a multi-disciplinary care team comprising family medicine physicians, nurses, medical social workers, physiotherapists and occupational therapists from Singapore General Hospital first identifies patients at risk before they are discharged from the hospital. In particular they look out for elderly patients who have complex medical conditions that need close monitoring, and face social issues such as loneliness, lack of caregiver support and financial difficulties. 

To ensure that these seniors are cared for adequately at home and in the community, the care team assesses their post-discharge needs and works with Temasek Foundation Cares – Care Close to Home team to put together a personalised care plan. Depending on each individual’s needs, the plan would cover medical and social support services such as home and day care, psychosocial support, financial assistance, interim caregiving, and meals-on-wheels.

Seamless Transition from Hospital to Home

“Patients have emotional and social needs, beyond the medical issues that we’re helping to address. By working closely with grassroots organisations, community partners and GPs, we can strengthen the post-discharge care support system for this group of elderly residents, spot complications early and intervene before their condition worsens. This will help to ensure that residents who are at-risk of frequent hospital admissions do not fall through the gaps when they transit from one care setting to another,” said Professor Fong Kok Yong, Deputy Group CEO (Regional Health and Medical), SingHealth.  

Once the senior is discharged from SGH, the care team conducts home visits for those with more complex medical needs and calls them regularly to ensure they are coping well. They also hold weekly meetings with Care Close to Home team at the Kreta Ayer Seniors Activity Centre to review the senior’s wellbeing, share relevant medical records and discharge summaries and flag out social and medical issues that require attention. As at 26 April 2017, 263 elderly residents are enrolled in the programme. 

“This model of integrated care piloted at SGH has shown to be effective in reducing readmissions to hospital as well as length of stay. Chinatown has a sizeable proportion of vulnerable elderly with little or no caregiving support. We plan to reach out to more residents by end of this year,” said Associate Professor Lee Kheng Hock, Director, Office of Integrated Care, SGH.