Care providers across the continuum work together to ensure patients’ total well-being.

Madam Teo Gek Hoon, 71, lives in a three-room flat with her 80-year-old husband. She enjoys going to the wet market in the mornings, chatting with her neighbours and cooking meals for her husband. During her free time, she sings karaoke and takes part in activities organised by her temple.
But behind her smiles and spritely personality, health is a constant worry. Her husband suffers from eye conditions and diabetes, while she battles with gout, diabetes, high cholesterol, blood pressure and kidney problems. She has a pacemaker and moves about with a quad-stick. Every other month, her outpatient follow-ups take her to multiple public healthcare institutions. [watch a video of Mdm Teo]
Mdm Teo is not alone, individuals with multiple chronic conditions are set to increase as our population ages. Beyond care in hospitals, these individuals often need follow-up care at home and yearn for easy access to healthcare when they need it.
"Meeting the medical and social needs of patients are the foundations of person-centred care."
– Prof Fong Kok Yong, Deputy Group CEO (Regional Health & Medical), SingHealth
In Sweden, the Jönköping County Council set up the “Esther Network” to do just that. The person-centred Network constantly seeks to answer the question, “What is best for Esther?” by putting the individual at the heart of all its work.
It coordinates the efforts of different providers across the care continuum to address the medical, as well as psychosocial needs of “Esther”, so she can live independently and confidently in the community, close to her loved ones.
Building a local “Esther Network"
“Meeting the medical and social needs of patients are the foundations of person-centred care. Traditionally, acute tertiary hospitals tend to focus more narrowly on a medical model of healthcare – a history and examination – followed by investigation and treatment, and finally clinical measures of successful outcome. This is changing,” said Professor Fong Kok Yong, Deputy Group CEO (Regional Health & Medical), SingHealth.
“The SingHealth Regional Health System (RHS) aims to look beyond our hospital walls for solutions and pool resources with our community partners, to enable our patients to be cared for adequately at home and in the community.”
Partnering the community
Community organisations such as Intermediate & Long-Term Care agencies, GPs, and Voluntary Welfare Organisations are critical partners in building a successful care network because of their familiarity and close links with the communities they serve.
Peh Kim Choo, Chief of Programmes at Tsao Foundation, agrees that forming an “Esther Network” can help formalise relationships between hospitals and community partners.
“We can work together to ensure that individuals do not fall through the gaps when they transit from one care setting to another. Building an ‘Esther Network’ is timely and does not necessarily require more money and manpower.”
(L-R) Peh Kim Choo, Chief of Programmes, Tsao Foundation; Esther Lim, Assistant Director, SingHealth RHS; Jess Ho, Centre Manager of Cluster Support @ Bukit Merah, NTUC Health
Joining the dots
Working on the ground, community agencies are often in the best position to identify patients’ real needs and mobilise communitybased resources to meet them. To ensure that health and social needs are effectively met, strong coordination between agencies that provide different types of services – from home care to day care and stay-in care – is needed.
Jess Ho, Centre Manager of Cluster Support @ Bukit Merah, NTUC Health, said, “We may be from different agencies but we can share a common goal – to help the individual
lead a healthy, dignified life. When the goal is clear, barriers break down and hopefully, there can be a seamless flow of information in the care continuum to help each of us serve our roles well.”
Empowering patients and caregivers
“Patients have emotional and social needs, beyond the medical issues that we’re helping to address. In the busy hospital setting, we sometimes neglect this fact. We need to take these needs into account when we involve them in their care decisions. When they feel empowered to take charge of their own well-being, they tend to be more committed to achieving the care goals set together with the care providers,” said Esther Lim, Assistant Director of SingHealth RHS and Head of Medical Social Work at SGH.
“In an ‘Esther Network’, caregivers are equally important as they help to ensure that patients are happy and well-supported at home. Healthcare professionals need to recognise that patients and caregivers are our partners in care, not merely recipients of care.”

Started in 1997, the Esther Network is made up of patients, caregivers, clinicians and community partners who work together to care for those with complex care needs in Jönköping county, Sweden. “Esther” is a symbolic 88-year-old person who requires the coordination and integration between different care settings to address her needs.
“The Esther Network is all about creating the best value for Esther by taking responsibility for her total well-being, regardless of where she is being cared for. Working closely together also makes the healthcare system more efficient and sustainable as a whole,” said Ms Nicoline Vackerberg, chairman and coordinator of the Esther Network.
Esther coach Kajsa Radonich elaborated: “In 2012, a hospital in Eksjo started to identify frail patients at risk of avoidable readmissions and A&E visits. Before such patients are discharged, staff go through a checklist with them to make sure they know what to expect at home and who to contact for help.”
Referrals are also sent to primary and social care. Within 72 hours, care partners follow up at the patient’s home to see that there is food in the fridge, security alarms are in place, and drugs and devices are present and correct.
“It was challenging to get different organisations to come on board, but the Esther Network held regular forums where people wanting to make changes could come together and pave the way for collaborations to take place,” said Kajsa.