The focus of population health is to empower our communities to keep well, get well and live well at home and with their loved ones.

Many factors such as lifestyle, culture, age, genetics and the environment in which we live can impact the common health conditions faced by a population. Studies into population health can provide vital insights that can be harnessed to build systems that promote health and prevent disease among the population.

One such system is the SingHealth Regional Health System (RHS) which was formed in 2013. The RHS looks at how we can move care outside the healthcare institutions and keep our population healthy for as long as possible, with access to right care at the right place.

The RHS aims to empower individuals to keep well, get well and live well in their own communities and homes. To achieve this, SingHealth and our network of partners across health and social care sectors collaborate to identify population health needs, promote behaviour changes and develop sustainable programmes. 

“Essentially, what we want to do is to keep people healthy for as long as possible,” explains Ms Stephanie Teo, Director, Community Nursing, SingHealth Office of Regional Health, and Deputy Group Chief Nurse (Care Integration and Community Nursing), SingHealth.

Moving beyond hospital walls

When the health of a population starts to decline, it can lead to a higher utilisation of healthcare resources such as accident & emergency services and hospital beds, leading to increasing healthcare costs. Therefore, the strategy of RHS is to tackle this ‘unhealthy’ problem upstream by working with patients and the communities before they enter the healthcare system.

“We need to support the present and future healthcare needs of Singaporeans by preparing the next generation to remain healthy and building preventive health,” shared Ms Teo.

“Preventive health is a very big part of our work here at RHS. How do we prevent someone from being admitted or readmitted to the hospital? This is where we move beyond the hospital walls into the community. For example, our community nurses who work in communities with a large aged population ensure that the pre-frail and elderly there are ageing well. The community nurses also provide other services like health screening, falls and frailty assessments and home visits so that the elderly can receive timely intervention through appropriate referral and be kept well at home, minimising unnecessary visits to the hospital.”

Ms Teo added, “Because the environment and psychosocial factors play a big part in one’s well-being, we work closely with community partners to support our elderly’s ability to continue to live in their own homes and communities safely, independently and comfortably.”

Philanthropy and Population Health

Philanthropic partners have empowered much of these efforts. One example is the Temasek Foundation Parkinson's disease Community Care Programme (TFPDCCP) which provides holistic care in the community for patients with moderate to advanced Parkinson's disease (PD) and their caregivers, to improve their wellbeing and reduce the need for hospitalisation. Care is provided by trained community nurses from Singapore General Hospital (SGH), supported by a multidisciplinary care team specialised in PD. This initiative is funded by Temasek Foundation till April 2023, with no costs incurred by eligible patients and their caregivers.

COVID-19 has also accelerated the need to offer new ways of care delivery, such as teleconsultations to complement physical visits to the doctor. This reduces the risk of the elderly being exposed to the virus. In October 2020, the SingHealth Telehealth Pilot for Seniors in the Community was launched. This programme was made possible by a generous $200,000 gift from the Asian Medical Foundation Silver Care Fund to help fund manpower and equipment cost.

Instead of going to the polyclinic for a doctor’s appointment, eligible elderly patients can now measure their vital signs using the telehealth kit sent to them, and see the doctor virtually.

66-year-old Mdm Lee (not her real name), who is enrolled in this programme, has benefitted from this arrangement. She suffers from multiple chronic diseases that are poorly controlled. Under this programme, she is able to have a video consultation at a nearby Senior Activity Centre with a community nurse and a doctor. This also allows the community nurse to better understand Mdm Lee’s living environment and conditions, and thereafter, refer her to a medical social worker to assist with her social and financial concerns.  Medication top-up via home delivery was also arranged.

To date, RHS has seen more than 100 seniors enrolled in this programme, with close to 200 video consultations completed. However, the initial funding to kickstart this progamme is expected to run out by early next year.

“Our programmes have been reaping some good outcomes. We are beginning to see some reduction in the readmission rate and Emergency Department visits as our patients manage their conditions well enough with the assessment and advice from our Community Nurses,” shared Ms Teo. “With the population landscape changing, we want to try out new ways of caring for patients without adding on to the increasing healthcare costs. Support from like-minded donors can help us continue the work that we do to enable more people to enjoy a better quality of life even as they age!”