Singapore, 17 May 2024 – SingHealth, together with its institutions and community partners from the eastern region of Singapore, came together today at its annual Community Forum to showcase service innovation collaborations which aim to enhance care and support for residents and patients in the community. Themed ‘Innovations to Improve Care Delivery and Quality of Life’, the forum explored the ways innovation can be harnessed to enhance social-health integration while promoting holistic person-centred care. In addition, it highlighted the importance of close collaboration with partners to achieve synergy in care delivery and ultimately, a good quality of life for residents. The SingHealth Community Forum 2024 was held at the Sengkang General Hospital auditorium and was graced by Guest of Honour, Dr Janil Puthucheary, Senior Minister of State, Ministry of Communications and Information & Ministry of Health, who delivered the opening speech. 

Two service innovation collaborations between SingHealth institutions, namely the National Heart Centre Singapore (NHCS) and the National Neuroscience Institute (NNI), and their respective community partners were highlighted at the forum today, among others. These illustrate the positive impact of innovations when partners from the healthcare and social service sectors with different expertise synergise their strengths in pursuit of a common goal − to  support our residents with the relevant healthcare and community resources within the community and enable them to take charge of their own wellbeing. These service innovations augment SingHealth’s ongoing population health efforts in line with the nation’s Healthier SG and Age Well SG initiatives. 

Local Area Coordination and Empowerment by NHCS 

Local Area Coordination and Empowerment (LACE) is a person-centred model of care driven by Medical Social Workers (MSW) from the NHCS through which heart failure patients are prompted along their health journey with three simple yet thought-provoking questions:

LACE’s key components were developed by adapting Local Area Coordination (LAC), a "strengths-based" approach from Australia that involves walking alongside individuals, nurturing, and leveraging their gifts, strengths and talents to contribute to their communities. This approach reduces dependence on healthcare and formal support services. It enhances resilience by developing locally owned and sustainable solutions within community networks and capabilities. Recognising the importance of empowerment as key to steering patients into action, the NHCS MSW team came up with the unique LACE model of person-centred care that is relationship-driven to empower and activate individuals and communities, serving as contributors to health and social care by building social capital and community capability. 

Results of a pilot programme utilising LACE from 2020 to 2023 saw a reduction of 58 per cent in readmissions and average length of stay by two days. Over 90 per cent of the 208 community partners, community nurses and cardiac doctors, who attended the training workshops on "Good Life" conversations with LACE principles, found the training useful and reported an increased confidence in providing cardiac community care. To-date, with the help of LACE, over 95 per cent of patients reported feeling more in control of their lives. In addition, many have changed their perspectives on life and have even initiated activities to support and empower one another. For instance, an interest group was formed by the patients to curate healthy recipes for one another, and another group came together to produce podcasts to share their stories of empowerment and activation. 

“A person-centric approach like LACE brings greater involvement of patients and the community in the care process. This holistic approach can improve the quality of life of patients and potentially help to delay the progression of heart disease. While a medical diagnosis cannot be changed, we can empower our patients to transform their experience of living with the condition and at the same time, effect positive downstream changes to their overall health and mental wellbeing,” shared Prof Yeo Khung Keong, Chief Executive Officer, NHCS. 

Neuroscience Network Integration in Community Health by NNI

People living with neurodegenerative conditions, such as Parkinson’s disease, dementia, motor neuron disease and multiple sclerosis, often have complex medical and psychosocial needs requiring follow-up with a multi-disciplinary healthcare team. However, these conditions also significantly impact a person’s mobility and cognitive function, making it challenging for patients to attend review appointments at specialist outpatient clinics (SOC). 

To provide more support and closer monitoring, NNI has formed the Neuroscience Network Integration in Community Health (NNI Community Health) – a collaboration with community partners such as Home Nursing Foundation, Touch Community Services and Tsao Foundation − to bring care into the homes of patients living with neurodegenerative conditions who require close follow-up. Under NNI Community Health, neurologists, specialist nurses and allied health professionals train community care partners to assess persons with neurodegenerative conditions in their homes and conduct caregiver training. The NNI team receives updates after each home visit, and if new or worsening symptoms are detected, appropriate treatment plans and referrals are made. 

Between July 2020 and November 2023, 203 patients joined the programme. To date, 89 of these patients have spent one year on the programme and their SOC visits were reduced by 42 per cent on average as compared to the previous year, while caregiver burden reduced by 14 per cent. Other benefits included improved medication compliance amongst patients and an increased understanding amongst caregivers on the disease and caregiving issues. With such benefits, it is not surprising that 93 per cent of patients and caregivers under this programme were happy with the service and found it helpful. Plans are afoot to multiply the benefits of this service innovation by scaling up this model of care to patients with neurodegenerative conditions seen at the Singapore General Hospital and other SingHealth institutions.

“At NNI, we put patients and their caregivers at the heart of all we do, because conditions such as Parkinson’s disease and dementia have such an impact on both parties,” said Li Wei, Senior Nurse Clinician – Advance Practice Nurse, NNI. “Through the NNI-Community Health programme, our patients and caregivers can receive care and support to manage their conditions as much as possible in the comfort of their homes, thus avoiding waiting  at the SOCs and the hassle and expense of booking transport.” 

 

These service innovations are testament to the benefits to patients and residents when like-minded organisations collaborate to meet their needs in innovative ways and to integrate social and healthcare resources. “At SingHealth, we centre care on our patients and residents and strive to continually enhance care for our residents through service innovations, technology and collaboration with our community partners. Through these efforts, we empower our residents and patients to get well, live well and keep well in the community. I look forward to more collaborative efforts, engaging, learning and innovating together with our community partners to support our residents and patients,” said Professor Lee Chien Earn, Deputy Group CEO, Regional Health System, SingHealth.