SGH pulls together organisations in the community as partners in health. Together, they create a strong net for residents and patients, ensuring they stay healthy and age well at home.

A 90-year old breaks his hip and is admitted to hospital for surgery. He stays a week and is then discharged to a community hospital to recuperate. There, he is taught to walk with an aid. When he goes home, he will need someone to keep an eye on him if he doesn’t have a carer. Even if he has family help and goes straight home aft er discharge, he still will need some support like someone to teach his caregiver to dress his wounds and help him in daily activities.

If such post-hospital help is not forthcoming, including long-term support, chances are the nonagenarian will be back in hospital in no time. So how and who should provide these post-hospital services, ensuring that his recovery is smooth and uneventful?

For Singapore General Hospital (SGH), one way is in the partnerships that it forms with community welfare services. Another are the nurses that it stations in the community.

Back at SGH, two other classes of nurses ensure that patients going home are well supported, and if they aren’t, referrals to a care facility are offered. Together they provide an important link in medical care post-discharge.

“We play a key role in coordinating care in the community, between SingHealth institutions and community care partners,” said Dr Low Lian Leng, Director, SingHealth Office of Regional Health, SGH Campus.

“What is increasingly important is our regional role, where we are responsible for the health of the residents in the communities around us. For instance, SGH tends to the needs of residents in areas like Bukit Merah, Telok Blangah, Tiong Bahru, Outram and Henderson. We take responsibility for the complete care and health of not just our patients but residents in our areas.”

Under the Ministry of Health’s regional health system initiative, the island is carved up by geographical area, with care and the health of people coming under the responsibility of Singapore Health Services (SingHealth), the National Healthcare Group and the National University Health System. SingHealth’s three major hospital groups – SGH, Changi General Hospital and Sengkang General Hospital – further subdivide the region for care.

For the SGH Campus cluster, medical care is supported by not just SGH but also the campus-based national disease centres like the National Cancer Centre Singapore and the Singapore National Eye Centre, KK Women’s and Children’s Hospital, and SingHealth Polyclinics, as well as private general practitioners.

According to Dr Low, the focus of care and the programmes that each campus sets up depend largely on the population mix of the area. SGH has an older population – 18 per cent of residents in its areas are at least 65 years old – while Sengkang has a younger demographic – just 7 per cent are elderly. Changi’s demographic, meanwhile, is more in line with the 12 per cent national average of the aged.

“At SGH, we focus more on the ageing population – for example, in the prevention of frailty, and how to better integrate health and social care  for our older adults who have more complex care needs,” said Dr Low. He is also Consultant, Department of Family Medicine and Continuing Care, SGH.


Brave new world of community nursing

Despite the challenges, nurses are enthusiastic about providing healthcare services within the community. They build close bonds with residents and are part of the neighbourhood.

In community nursing, it’s a brave new world where anything can happen.

Whether running a neighbourhood nursing post or visiting patients at home, community nurses often need to draw on their ingenuity and creativity. They often have to make quick, independent decisions. Unlike at a hospital or other healthcare facility, resources are limited and, if needed, nurses often have to make do with what’s available.

For these nurses, however, the rewards are immeasurable. Whatever role they play, be they community patient navigators (PNs), hospital-to-home (H2H) or community-based nurses, they share a warm and close bond with the community they serve. For those running community nurse posts, in particular, they are often recognised and treated with respect by residents.


PNs and H2H nurses
When an SGH patient is admitted and requires close management and care coordination because of complex needs, a PN will look at what he needs and draws up a post-discharge care plan. This can include a transfer to community hospitals or other care facilities, meal deliveries by welfare organisations if the patients have little home support, and transitional care services such as the H2H programme.

“We are the link between hospital and home to make certain the patient’s condition doesn’t deteriorate after discharge, and that caregivers are well supported,” said Dr Rachel Towle, Senior Nurse Clinician (Advanced Practice Nurse), SGH.

“For instance, someone with pneumonia may stay a week or two at SGH before being discharged. When he returns home, he can become very frail, making him prone to falls. If he does, he will have to come back to the hospital.”

If he had a post-discharge plan, the patient might have gone onto SGH’s H2H programme, where a nurse checks on him regularly at home to make sure he is taking his medication regularly and that his condition is improving. The nurse ensures his carer understands what to do, like how to dress his wounds, and take his temperature and blood pressure. The nurse also addresses any problems that the patient and his carer might have during the visit.

Dr Towle, who leads a team of 63 nurses – 21 of whom are PNs and the rest H2H nurses – said the H2H service runs for as long as six months, after which the patient is “transited to a community care provider for long-term care and follow-up”. These may include community care partners like NTUC, Home Nursing Foundation, Senior Activity Centres (SACs), Thye Hua Kuan Moral Charities and Montfort Care.


Community nurses
Community-based nurses are ensconced in familiar senior activity and family service centres that residents frequent, playing the part that family and caregivers might: keeping a close tab on the well-being of elderly residents, checking their blood pressure, making sure they take their medications correctly, and just being available for seemingly small questions like “Do I have a fever and need to see a doctor?”

“We want our community nurses to be part of the community, to be actively involved in their neighbourhood. We don’t want them to be ‘guests’,” said Dr Lim Su Fee, Assistant Director, Nursing (Advanced Practice Nurse), SGH.

“The reason is that we want them to be accessible to residents. They are always with the residents, so they know them and their conditions well. That way, they can follow up quickly if residents feel unwell or have any other problem.”

She leads a team of 29 community nurses who, like their PN and H2H counterparts, are senior healthcare professionals. They need to work independently, and draw on not just their nursing but also  organisational and clinical decision-making skills.

“Residents go to the SACs almost daily. They may have concerns but don’t want to go to a clinic because they aren’t really ill. They just want some advice or to be assessed. So the nurse on site assesses and advises whether they need to see a doctor,” said Dr Lim.

The nurses can’t prescribe medicine or treatment, but have the multidisciplinary resources of SGH and the SingHealth Group to refer patients to.
“Community-based nursing is patient care that extends beyond the hospital. At the hospital, the focus is on treating sickness. In community nursing, the focus is on prevention and maintenance,” said Dr Lim.

“If we manage residents’ chronic diseases well, they might not have to visit the A&E as frequently. They can be managed at the polyclinics and see community nurses in between their regular visits.”


Much of the feedback that we received on our Al-Amin Mosque-SingHealth community nursing programme has been positive and complimentary. Residents can easily walk from their homes to see the healthcare team, with whom they have built a good rapport. The mass health screening and talk held at our mosque have benefited our elderly, not just Muslims but also residents of other faiths. We thank the SingHealth team for being our partner in this programme to address the health concerns of our community, and to empower them to take greater ownership of their health. We hope that this partnership will bring the mosque and the multiracial community closer together.



The community nurses who are based in the Montfort Care office make up for our social service providers’ lack of medical expertise. We visit residents together so we get a better perspective of their social needs, and how to design new programmes. For instance, following nurses’ feedback, we are looking into adding physical activities for more frail residents. Having community nurses in the neighbourhood allows residents to know the nurses well, and this allows them to discuss health-related issues in an open and safe environment.




The residents and I have built up a strong relationship of trust. They listen to what I tell them, such as the importance of keeping their medical appointments and taking their prescribed medications. Some residents have pet names for me. I am touched when they say I am like family instead of nurse to them.



My elderly patient is in her late 80s, suffers from multiple long-term conditions, and is constantly in pain. She lives with her maid in a four-room flat. She didn’t want to take her medicine because she wanted God to take her away and not be a burden to her married children. But as I spent more time with her, I managed to lift her spirits and persuade her to take her medication.




One of my patients needed a hospital bed and other equipment because she had bed sores and amputated limbs, and also needed assistance with breathing. So before her discharge after a long hospital stay, I discussed with her family her care at home, their needs and concerns. I coordinated with them to ensure that everything she needed was ready at home before her discharge. I even organised things as seemingly simple as putting the vendors’ contacts within easy reach during an emergency.



Many of my H2H patients live in rental flats, so their finances and resources are often very tight. When I teach a patient how to administer his diabetes injections at home, for instance, I wouldn’t insist that alcohol swabs be used to sterilize the injection site. Instead, he can use a clean wet tissue to clean his skin and let it dry before injecting the insulin. Having a chronic disease already affects them financially, psychologically and emotionally, so I don’t want to add to their stress.