27 July 2019
Tan Tock Seng Hospital brings together 70 partners to join up care within our neighbourhoods, supported by Community Health Teams
Singapore's largest population of older residents will soon have more support to age meaningfully in their neighbourhoods, supported by a new integrated care network and model of care that Tan Tock Seng Hospital (TTSH) is building with its partners.
The National Healthcare Group (NHG) is transforming care to go beyond treating illness to fostering the holistic health of the population. Its River of Life Population Health Framework1 is delivered in three population zones: Central, Yishun, and Woodlands, with Central being the largest with 1.4 million2 residents. Of these, 18% are older than 65 years3 – significantly higher than the national average of 14%. These elderly are either living with or will experience some level of frailty, which requires not only increased healthcare, but more support from the community to enable them to age in place safely and purposefully. This will help to reduce emergency visits and multiple admissions to hospital.
TTSH is expanding its mission to not just serve patients coming to the hospital, but to also care for the residents living in the Central population zone. Recognising this need to become a Hospital Without Walls serving the community, TTSH is working closely with 70 community partners across seven subzones4, transforming healthcare together for the future beyond patients to population.
Providing care in the community is not new to TTSH, which has had its roots in the community since its founding in 1844. The Hospital is collaborating with health and social care providers who operate in Central Singapore and know the community intimately, building a network of care providers and an integrated care model. (See Annex A for more information.)
Partners and supporting organisations came together to celebrate and reaffirm their commitment to this shared vision at TTSH's 175th Founder's Day dinner, which was graced by President Halimah Yacob.
Building partnerships for continuous care
The first step towards more integrated care is developing relationships with partners to join up more seamless care for patients, as well as develop capabilities in the community to deliver more specialised care for residents.
In November 2018, TTSH and Tsao Foundation's Community for Successful Ageing (ComSA) embarked on a pilot project to strengthen support and care for individuals known to both partners. ComSA is updated when their clients visit the TTSH Emergency Department, are admitted to the wards, and upon discharge. The hospital teams then work with the ComSA team to share information, provide early interventions and timely support to the patient and family, and potentially reduce unplanned readmissions. About 160 ComSA clients have benefited from this programme.
Dr Tan Sai Tiang, Senior Assistant Director, Hua Mei Clinic, ComSA Whampoa Centre said: "These active updates between ComSA and TTSH allow both care teams to share information that can make a difference to the patient and family, such as caregiver support at an earlier point in the patient's care journey. In some cases, we also work with the hospital's Community Health Teams to care for the patient and family after discharge."
Kwong Wai Shiu Hospital is setting up its Chronic Sick Unit, a new clinical service that will provide care management for their residents requiring more complex interventions such as tracheostomy management. Their healthcare staff will be trained by TTSH to be competent with these procedures, so that residents can receive appropriate care without leaving the nursing home to be sent to an acute hospital for non-emergency management.
Dr Richard Tan, Director, Clinical Services, Kwong Wai Shiu Hospital said: "We look forward to this collaboration as it further enhances our capability and competency to care for residents' complex needs with seamless transition of care. This gives our residents the confidence that we will always be professional and caring, knowing that they will not need to 3
be admitted to an acute hospital unnecessarily. Our ongoing efforts to upskill our care team will be enhanced with this training initiative."
To care for residents closer to home, primary care initiatives – Community Right-Siting Programme, Shared Care, and GPNext – allow suitable patients to be co-managed by General Practitioners, who are located near patients' homes and often can forge a closer doctor-family relationship. Since 2014, the number of GPs in this network has grown to 140, caring for more than 4,300 patients outside of the hospital.
When multiple service providers join up care for patients with highly specific needs, developing a shared and in-depth understanding of these needs is crucial for targeted health and social care interventions. Hougang Sheng Hong Family Service Centre collaborated with TTSH to support residents with stabilised mental health needs as they work towards meaningful personal recovery goals. The support and care rendered through this collaboration have enabled residents to reintegrate well back into the community.
Mrs Sara Tan, Executive Director, Hougang Sheng Hong Family Service Centre said: "Co-learning with TTSH, we held in-depth conversations to understand our residents' priorities, expectations, and what matters to them. Often, we think we know what's best for our residents and tend to prescribe solutions, but listening to them can often surprise us. These conversations then allowed us to work with them to create recovery and reintegration goals based on what is important to them, and to their personal situations and conditions, which embodies the key principle of the ESTHER Network."
Building care teams into the community
To support residents as they age in place, TTSH has set up a Community Health Team (CHT) within each of the seven subzones served by the Hospital. Comprising an inter-professional team of doctors, nurses, allied health professionals, pharmacists, health coaches, and operations staff, each CHT works with partners in their subzone to co-develop care plans for residents.
Mdm Muntamah, who lives in the Geylang subzone, first came to the CHT's attention when she was discharged from TTSH. A home visit and conversation made it clear to the CHT that Mdm Muntamah was unable to understand the medication that she was prescribed, resulting in her not taking any medication at all for her chronic conditions. The CHT nurse coordinated a care plan for Mdm Muntamah with several community partners to help her with monitoring 4
her blood sugar at the centre near her home, as well as packing her medication in a way that Mdm Muntamah could understand and follow confidently.
"I didn't want so many people coming to my house all the time," Mdm Muntamah explained. "But I know it's better if I get my blood sugar checked regularly, so it was convenient when the nurse found someone at the centre downstairs to check it for me."
The CHTs also operate Community Health Posts located within partners' premises for better access and communication. There are currently 80 posts across Central Singapore.
Many activity centres plan programmes for their elderly clients based on interest and aptitude, but together with partners, the CHTs create health programmes for participants to achieve specific health outcomes. From guided exercises and cooking workshops to group discussions and peer support, the Stronger Joints, Steadier You 12-week programme taught participants to understand the factors that lead to better health, and advocate for their own health.
The participants have seen measurable improvement in their fitness after the programme, and continue to exercise together even after completing the programme. The CHT's health coaches follow up regularly to check on their progress. One participant Mr Lim Soon Seng, who is recovering from a stroke, made significant progress in terms of his physical performance score. He said: "My left leg has been stiff and difficult to move since I had the stroke, but the exercises have helped so much – I feel lighter now. Having friends around to exercise with also encourages me to continue, whereas exercising alone would be boring and I'd be more likely to stop."
In addition, residents who require close monitoring of their medications may soon be supported in their neighbourhood by the CHT pharmacists. TTSH's first community pharmacist will begin scheduling sessions at Community Health Posts in Hougang, and the Hospital is working with major retail pharmacies in the heartlands to expand the base of community pharmacists – all for residents to receive help in medication reconciliation as close to home as possible.
Building an activated community of carers
While residents with complex care needs are supported by the CHT, there are also many residents with the ability and enthusiasm to help their neighbours. In partnership with Ang Mo Kio Family Service Centre, Bless Community Services, Care Community Services Society, Sengkang Women's Executive Committee, and The Frontier Women's Executive Committee, TTSH's Centre for Health Activation (CHA) has begun a programme – CHArge Up! – to train volunteer carers in para-clinical skills such as medication management, chronic disease management, and gait assessment.
Eighty carers have been trained so far, and about 30 of them now help to extend the reach of the CHTs in Ang Mo Kio and Serangoon, building relationships with residents and looking after their health and wellbeing. (See Annex B for more information.)
Trained carer Margaret Wong said: "The training opens our eyes to things that make a big difference to residents' lives and wellbeing; for example, I can now confidently advise them on the correct way to hold a walking stick for better support and less wrist or arm strain. This has even helped me as a caregiver myself, as I advise my own mother on walking aid use. We also regularly update the CHTs on the residents' conditions so that the resident is truly cared for by a community."
Building health together
Dr Eugene Fidelis Soh, Chief Executive Officer, TTSH and Central Health said: "The future hospital is neither one that waits for patients to fall ill and come to its doors, nor one that discharges patients and leaves them without support in the community. Healthcare must evolve from a facility-centric to person-centric model; from episodes of care to relationships in care. TTSH has served Singapore well for 175 years, and looking ahead with a fast-ageing population, we must bring care closer to our community by expanding our mission as a Hospital Without Walls. Central Singapore has a long history of strong community support by very dedicated people and organisations. TTSH has brought these organisations together in an inclusive network, so as to actively create an integrated care model for our communities and the residents we serve. We have embedded Community Health Teams across Central Singapore, whose roles are to build relationships with residents, assess the local health needs in our neighbourhoods, and to join up health and social care."
NHG's River of Life Population Health Framework includes five segments of care programmes: Living Well, Living with Illness, Crisis and Complex Care, Living with Frailty, and Leaving Well.
Source: Department of Statistics Singapore
Source: Department of Statistics Singapore
Ang Mo Kio, Bishan, Geylang, Hougang, Novena-Kallang-Rochor, Serangoon, and Toa Payoh (see Annex A for map)