SingHealth Regional Health System teams up with community partners to provide medical and social support for vulnerable elderly in their own homes

Associate Professor Lee Kheng Hock, Director of SGH's Office of Integrated Care, remembers one of his patients vividly.

"When I was a young doctor working in the polyclinic, I remembered one elderly patient who came to see me for his multiple medical conditions. From the corner of my eye, I noticed little black specks moving on his clothes.  I took a closer look and realised they were bed bugs. He was probably living in very poor conditions." recounted Prof Lee.

"I made adjustments to his medication, but I was afraid that it wouldn't help much because his chronic health issues could be affected by his living conditions and lack of social support. 

"I wanted to refer him to a medical social worker for assistance but he refused, and I didn't have other resources on hand. I felt helpless trying to help my patient." 

More elderly living alone

As Singapore's population ages, an increasing number of people above 65 years old live alone. In 2014, the number was reported to be about 42,000.  

These elderly are also likely to have multiple chronic conditions, such as diabetes, high-blood pressure and stroke that require daily medication and regular follow-ups at polyclinics or GP clinics.

Those who lack adequate support and care at home tend to fall into a vicious cycle of frequent hospital readmissions due to poorly managed conditions.

Community of Care in Chinatown

As medical and social needs are intertwined, a person-centred care model is needed, where healthcare providers work closely with community partners to provide patients with adequate care at home and in the community.

The Community of Care programme in Chinatown is one such initiative. The programme, launched on 26 April 2017 by SingHealth Regional Health System (RHS) and Kreta Ayer-Kim Seng constituency, aims to enhance health and social care for elderly residents in Chin Swee Road and Banda Street, particularly those who have complex medical conditions post-discharge and face social issues such as loneliness and financial difficulty.

At-risk elderly patients are identified by an SGH care team before they are discharged from hospital. A personalised care plan is drawn up for each patient – providing them with medical and social support services such as caregiving, psychosocial support, meal delivery and financial assistance – with the help of community partners.

When they leave the hospital, the multidisciplinary team continues to monitor and care for them, working closely with a community case manager from the Temasek Foundation Cares – Care Close to Home programme.

The programme has shown to be effective in reducing unplanned hospital readmissions and attendances at the emergency  departments.

Many helping hands

Siti Hajar bte Ninhadi, Assistant Nurse Clinician is one of the Patient Navigators in the programme. Each Patient Navigator handles as many as fifteen home visits to patients daily.

"Home visits are an eye-opener for me. Because of the additional time I have with the patients, I get to understand why some are hospitalised repeatedly; having difficulty stabilising their condition or have frequent falls.

"Our role  as  Patient Navigators in the community is to empower patients to take care of themselves and I find it easier to do so when I have a good understanding of their social issues," shared Siti.

"I once spent close to two hours to sort out the piles of medication accumulated by an elderly resident from his multiple hospital stays and consultations. It may sound simple but it really mattered to him," she added.

Other key partners in the programme include the Agency for Integrated Care, Kreta Ayer Seniors Activity Centre and general practitioners in Chinatown. Various volunteer organisations also contribute in providing support to the residents.

Assoc Prof Lee, who oversees the Community of Care programme, believes that this is the way to integrate care across the continuum. The programme has shown to be effective in reducing unplanned hospital readmissions and attendances at the emergency departments.

Photo: The SGH care team with Temasek Foundation Cares – Care Close to Home team (in purple) at the official launch of the Community of Care programme

More in the pipeline

Beyond the 263 patients in Chin Swee Road and Banda Street, Prof Lee is planning to roll out the programme to Tiong Bahru, Bukit Merah and Telok Blangah in the next three years by teaming up with grassroots organisations and social care agencies who are already serving in these communities. The target is to bring Communities of Care to 5,000 elderly residents living in the vicinity of the SGH Campus.

Prof Lee believes that with many helping hands beyond the hospital walls, vulnerable elderly patients can be empowered to live confidently in their homes.

Thinking back to the elderly patient he saw years ago at the polyclinic, he said, "The most gratifying thing for me is that, if I should come across a similar patient today, there is so much more I can do to help. I am very confident that I will make a difference to his care and his quality of life."

Mr Wong Ah Ann (above, in wheelchair) is 67 years old. He lives in his one-room flat in Chin Swee Road with a domestic helper.  Last year, he was admitted to Singapore General Hospital (SGH) due to a fall.

After his discharge, an SGH care team together with a team from Temasek Foundation Cares – Care Close to Home programme check on him regularly to ensure he is coping well.

They perform health checks, pack his medications, help him with his Medifund application, provided caregiver training to his new helper, and referred him to the Singapore Association of the Visually Handicapped. A volunteer from Lion's Befrienders visits him weekly to chat with him. Social gatherings are organised daily at the Senior Activity Centre below his block. 

"I felt very safe when the doctors and nurses visited me at home after my discharge from hospital. Being able to recuperate at home means a lot to me," he shared.