The Geriatric Services Hub is a new community initiative to help the frail elderly age safely.

 

Despite having severe constipation and intense abdominal pain for almost a week, 78-year-old Mr Leong Hoong Tat was too afraid of hospitals to go to emergency services for treatment.

But his assigned community nurses were able to coax him to have his condition — faecal impaction — seen to, thanks to the strong bond and friendship that they had built up with him.

“His daughter tried asking him to go to the Emergency Department but he refused. After I explained to him the dangers of faecal impaction, I managed to convince him,” said Ms Jovin Ang, Senior Staff Nurse (Community Nurse), RHS – Community Nursing, Singapore General Hospital (SGH).

Ms Ang is also the Nurse Lead for Geriatric Services Hub (GSH), a new initiative under SGH’s Population Health and Integrated Care Office’s (PHICO) community-based nursing programme, and funded by the Ministry of Health’s (MOH) Health Services Development Programme. 

GSH places SGH nurses in neighbourhood Senior Activity Centres and Family Service Centres. They keep an eye on residents’ health, and help them with issues such as medication and healthcare appointments.

Since 2018, the community nurses have become a popular fixture in the Bukit Merah, Telok Blangah, Chinatown, and Tiong Bahru neighbourhoods, caring for the health and well-being of residents as part of SingHealth’s efforts to strengthen community care beyond hospital walls. The GSH initiative, which began in 2019, is more focused, actively identifying and enrolling people who are at least 65 years of age and are moderately frail.

<< Ms Ang came up with an emergency phone number chart, which includes the contact numbers of family members and service providers, in large fonts. Mr Leong and Mdm Leong can easily call these people when they have to urgently reach them.

A resident on GSH gets up to three funded consultations, including a comprehensive geriatric assessment to determine his physical and cognitive status. Then the team designs a care plan that considers his needs. This typically includes a home-based exercise programme to enhance balance and strength; advice on nutrition, home safety, and lifestyle; and referrals to health and social care services in the community.

A referral may be made to day care, day rehabilitation services, or an appropriate specialist if needed.

“GSH fills an existing gap for frail seniors in the community. Frail seniors often have complex medical conditions or geriatric syndromes, and are at risk of falls, disability, and hospitalisation,”
said Ms Julian Lee, Nurse Clinician, Speciality Nursing (Geriatric Medicine), SGH. She is part of the GSH team that also includes six geriatric-trained community nurses, a family medicine doctor,
a physiotherapist, and an occupational therapist.

“Identifying frail seniors early and providing prompt intervention can result in better functional status and health outcomes. The GSH ensures that seniors receive proper health and social care in
the community so that they can continue to stay in place and age gracefully in the comfort of their neighbourhoods,” Ms Lee added.

Community partners

Social and health issues faced by the elderly are closely linked, said Mr Alan Yong, Care Manager, NTUC Health. He is part of the care management team that serves about 300 seniors living in Bukit Merah.

“Seniors are referred to us for help with daily living or medicine compliance. For instance, they can become socially isolated after a fall at home,” said Mr Yong. To help them live independently, the
team offers all-rounded care, including connecting them to financial assistance and welfare services. The team also shares information about the elderly with GSH to better care for them in the community.
 
Under the programme, Ms Ang checks in regularly on Mr Leong in his one-bedroom rental flat at Bukit Merah. It was on one of her regular visits that Ms Ang noticed his symptoms. X-rays confirmed a mass of hard, dry stools had become stuck in his colon. Left alone, complications, such as dehydration, agitation and delirium, can occur.

<< Mr Kwan Ah San (above, with Ms Yiong) exercises safely at home.

Mr Leong has children but lived alone until his sister, Mdm Leong Yoke Hing, moved in last year to provide support. In her late 60s, she also suffers from various ailments, including knee  steoarthritis. Like her brother, Mdm Leong has grown very fond of Ms Ang and the other community nurses.

“They don’t treat us like patients, but like friends and loved ones. I feel that they have a lot of patience, love, and respect for the elderly,” said Mdm Leong.

Mr Kwan Ah San, a Bukit Merah resident with diabetes and kidney ailment, is another GSH beneficiary. After a fall last year, the GSH team drew up an exercise plan to improve the 88-year-old’s balance and strength. Since then, Mr Kwan has not had another fall.

Mr Kwan, who exercises at least five times a week, said: “The exercises have helped with my leg weakness and cramps. I feel stronger now.”

An estimated 18 per cent of Singapore’s population aged 65 years and above are living in the south-east region. Together with partners like NTUC, the GSH programme hopes to support up to 2,250 seniors in the region. It has enrolled more than 200 seniors.

<< The GSH partners Thye Hua Kwan Moral Society to provide elderly residents with nutritious meals through
a food delivery service called Meals-on-Wheels.

Another community partner that the GSH team works with is Thye Hua Kwan Moral Society (THK), which provides residents like the Leong siblings with nutritious meals through its Meals-on-Wheels service. The Leongs also use THK’s weekly home cleaning service.

Not many residents or their families are aware of services like Meals-on-Wheels. Before the service was offered to a 78-year old woman, her daughter had to deliver food to her every day. The elderly  resident, who suffers from depression, anxiety and severe eczema, refuses to leave her home and has not seen a doctor for years.

The team also referred her to a home care medical service to manage her skin and mental health  problems, and an occupational therapist to sort out her balance issues, said Ms Ang. “[The daughter] did not know of such services for seniors, but felt that her mother is now being better cared for under the GSH initiative,” Ms Ang said.

GSH target group

At least 65 years old
• Mildly frail: need help for daily activities, such as housework and taking medication
• Moderately frail: need help to bathe or get dressed, or when outside the home
• Severely frail: in stable medical condition but are completely dependent on others for most activities
• Live in Bukit Merah, Tiong Bahru, Telok Blangah, or Chinatown

For more information on the GSH programme, call 6377 8503 or email community.integration@sgh.com.sg.